Complication Of Percutaneous Coronary Intervention Research Articles

Heparin Versus Bivalirudin in Acute Myocardial Infarction: Unfractionated Heparin Monotherapy Elevated to Primary Treatment in Contemporary Percutaneous Coronary Intervention.

Bivalirudin, a direct thrombin inhibitor, was developed as an antithrombin agent for patients undergoing percutaneous coronary interventions (PCI) with the hypothesis that it would reduce bleeding complications without compromising the rate of ischemic events compared to heparin plus GP IIb/IIIa inhibitors. Although the cumulative evidence makes a strong argument for the use of bivalirudin rather than heparin plus systematic GP IIb/IIIa inhibitors for the great majority of patients with acute myocardial infarction (AMI) undergoing PCI, the benefit observed with bivalirudin was achieved because of the major bleeding complications with the use of heparin plus GP IIb/IIIa inhibitors. When bivalirudin was compared with unfractionated heparin alone there was no benefit in ischemic complications with a decrease in major bleeding. However, in a recent large randomized controlled trial comparing bivalirudin with unfractionated heparin alone in AMI patients undergoing primary PCI, bivalirudin did not reduce bleeding complications and was associated with higher rates of stent thrombosis, myocardial reinfarction, and repeat revascularization compared with heparin. Moreover, a very recent meta-analysis shed more insights on the utilization of bivalirudin versus heparin regimens during PCI. Findings from this meta-analysis suggest that routine use of bivalirudin offers little advantage over heparin among PCI patients. In a detailed analysis of some randomized trials and observational studies with bivalirudin in AMI patients done by myself and published almost five years ago in this journal, I rendered some reflections on the future widespread use of bivalirudin. “In the setting of PCI in AMI patients, and in the absence of GP IIb/IIIa inhibitors, bivalirudin did not offer any beneficial effect in the incidence of the composite end points when compared with heparin alone. For now, in real world practice, one would probably choose a well known cheaper drug that has already passed the test of time, heparin. There may be reinforcement in the sole utilization of heparin confining GP IIb/IIIa inhibitors and other intravenous antithrombotics to bailout therapy for periprocedural PCI complications in AMI patients”. Therefore, instead of being the beginning of a new era with bivalirudin, it sure is a welcome back to an old friend, heparin. Indeed, after more than two decades, it is always good to welcome back an old friend, unfractionated heparin, as monotherapy and preferred anticoagulant regimen for contemporary PCI in AMI patients.

Rosuvastatin for Reduction of Myocardial Damage during Coronary Angioplasty - the Remedy Trial.

Periprocedural myocardial infarction (MI) is a frequent complication of percutaneous coronary intervention (PCI). Statins might reduce its incidence. The aims of the present studyare to assess whether such benefit is a class-effect or whether differences exist between various lipid-lowering strategies and whether cardioprotectionis exerted by increasing circulating endothelial progenitor cells (EPCs). The REMEDY study will enroll a total of 1080 patients submitted to elective PCI. Eligible patients will be randomized into 4 groups: 1) placebo; 2) atorvastatin (80mg+40mg before PCI); 3) rosuvastatin (40mg twice before PCI); and 4) rosuvastatin (5mg) and ezetimibe (10mg) twice before PCI. Peri-procedural MI is defined as an elevation of markers of cardiac injury (either CK-MB or troponin I or T) values >5x the upper reference limit estimated at the 99th percentile of the normal distribution, or a rise >20% in case of baseline values already elevated. EPCs will be assessed before, at 24h and - in a subset of diabetic patients - at 3months after PCI (EPC-substudies). The primary endpoint of the main REMEDY study is the rate of peri-procedural MI in each of the 4 treatment arms. Secondary endpoints are the combined occurrence of 1-month major adverse events (MACE, including death, MI, or the need for unplanned revascularization); and any post-procedural increase in serum creatinine. Endpoints of the EPC-substudies are the impact of tested regimens on 1) early (24-h) and 3-month EPC levels and functional activity; 2) stent strut re-endothelialization and neointimal hyperplasia; 3) 1-year MACE. REMEDY will add important information on the cardioprotective effects of statins after PCI.

Incidence and Clinical Features of Early Stent Thrombosis in the Era of New P2y12 Inhibitors (PLATIS-2).

Early stent thrombosis (EST) (≤ 30 days after stent implantation) is a relatively rare but deleterious complication of percutaneous coronary intervention (PCI). Administration of newer P2Y12 inhibitors (prasugrel and ticagrelor) combined with aspirin has been shown to reduce the incidence of sub-acute and late stent thrombosis, compared with clopidogrel. We investigated the “real life” incidence of EST in patients from a large acute coronary syndrome (ACS) national registry, where newer P2Y12 inhibitors are widely used. Patients were derived from the ACS Israeli Survey (ACSIS), conducted during 2006, 2008, 2010 and 2013. Major adverse cardiac events (MACE) at 30days were defined as all-cause death, recurrent ACS, EST and stroke.Of the 4717 ACS patients who underwent PCI and stenting, 83% received clopidogrel and 17% newer P2Y12 inhibitors. The rate of EST was similar in both groups (1.7% in the newer P2Y12 inhibitor group vs. 1.4% in the clopidogrel-treated patients, p = 0.42). Results were consistent after multivariate analysis (adjusted HR = 1.06 [p = 0.89]). MACE occurred in 6.4% in the newer P2Y12 inhibitor group compared with 9.2% in the clopidogrel group (P<0.01). However, multivariate logistic regression modeling showed that treatment with newer P2Y12 inhibitors was not significantly associated with the secondary endpoint of MACE when compared with clopidogrel therapy [OR = 1.26 95%CI (0.93–1.73), P = 0.136]. The incidence of "real life" EST at 1month is relatively low, and appears to be similar in patients who receive newer P2Y12 inhibitors as well as in those who receive clopidogrel.

Suppression of Bim by microRNA-19a may protect cardiomyocytes against hypoxia-induced cell death via autophagy activation.

Microvascular obstruction (MO), one of unfavorable complications of percutaneous coronary intervention (PCI), is responsible for the lost benefit of reperfusion therapy. Determination of microRNA-19a, a member of the miR-17-92 cluster, using quantitative real-time polymerase chain reaction (PCR) revealed notably down-regulated microRNA-19a, in myocardium with MO. Nonetheless, the role of miR-19a in MO and the underlying mechanism remains to be elucidated. To this end, an in vitro microembolization model in cardiomyocytes was used. Our data revealed that hypoxic exposure prompted cardiomyocyte apoptosis in a time-dependent manner accompanied by reduced miR-19a. miR-19a overexpression clearly ameliorated hypoxia-induced cell death (necrosis and apoptosis), at least in part, through switching on autophagy. Further dual-luciferase reporter assay and immunoblotting studies demonstrated that miR-19a-induced cytoprotection might be achieved in part through modulation of the specific target Bcl-2 interacting mediator of cell death, Bim, an apoptotic activator. Bim sufficiently interfered with miR-19a-induced LC3 conversion and increased cardiomyocyte apoptosis under hypoxia. Moreover, cardiomyocytes pretreated with 3-methyladenine conferred resistance to the cytoprotective effect of miR-19a and displayed notably increased TUNEL staining and caspase-3 activity. In conclusion, miR-19a protected cardiomyocytes against hypoxia-induced lethality at least in part via Bim suppression and subsequently autophagy activation.

Impact of coronary artery calcification on percutaneous coronary intervention and postprocedural complications

BackgroundExcessive coronary calcification can lead to adverse outcomes after percutaneous coronary intervention (PCI). We therefore evaluated the impact of coronary calcium score (CCS) measured by multidetector computed tomography (MDCT) on immediate complications of PCI and rate of restenosis. MethodsWe performed a single-center retrospective analysis of 84 patients with coronary stenosis diagnosed by MDCT who underwent PCI. The Agatston method was used to measure total, target-vessel, and segmental (stent deployment site) CCS. ResultsIn 108 PCI procedures, 32 lesions (29.5%) were American College of Cardiology/American Heart Association type A, 60 (55.5%) were type B, and 16 (15%) were type C. ANOVA showed significantly higher segmental CCS in type C than in type A lesions (29±51 vs. 214±162; p=0.03). Six patients (7.1%) had periprocedural complications and seven (8.3%) had in-stent restenosis and angina. Mean total, target-vessel, and segmental CCS was significantly higher in complicated than in successful PCI (199±325 vs. 816±624, p=0.001; 92±207 vs. 337±157, p=0.001; and 79±158 vs. 256±142, p=0.003, respectively), but there was no significant difference in CCS between successful PCI and PCI complicated by late restenosis. ConclusionsCCS measured by MDCT has an important role in predicting early, but not late, complications from PCI.

Fibrin clot formation and fibrinolysis in patients with a history of coronary stent thrombosis

IntroductionCoronary stent thrombosis is a devastating complication of percutaneous coronary intervention (PCI). Multiple factors underlie the pathophysiological mechanisms of stent thrombosis. Previous studies demonstrated that patients with stent thrombosis, compared to control PCI patients, formed denser fibrin clots in vitro which were more resistant to fibrinolysis, suggesting that altered fibrin clot properties may contribute to the pathophysiology of stent thrombosis. We assessed the plasma fibrin clot formation and fibrinolysis of patients with and without stent thrombosis. MethodsCases (patients with stent thrombosis) and matched controls (patients without stent thrombosis) were included for a matched case-control study. Matching was performed on indication and time of the index PCI (initial stent implantation) from the cases. Fibrin clot formation and fibrinolysis were assessed in vitro by turbidimetric assays, with human thrombin to initiate fibrin polymerization and tissue type plasminogen activator to initiate fibrinolysis. Lag time, maximal absorbance and clot lysis time were determined by these assays. ResultsIn total, 27 cases and 27 controls were included. No significant differences were observed between cases and controls in lag time (173 vs. 162s, p=0.18), maximal absorbance (0.78 vs. 0.83, p=0.36), and clot lysis time (69 vs. 71min, p=0.78). Fibrin clot formation and fibrinolysis were not associated with stent thrombosis. ConclusionsPlasma fibrin clot formation and fibrinolysis were not significantly different between patients with stent thrombosis and matched control patients, suggesting that fibrin clot formation and fibrinolysis play no significant role in the pathophysiology of stent thrombosis.

Coronary artery rupture during high-pressure post-dilatation of coronary stent in a heavily calcified lesion of an ectatic right coronary artery

Coronary artery perforation (CAP) is a rare but feared complication of percutaneous coronary intervention. With the use of novel instruments, including hydrophilic and ultrarigid guidewires, rotablator devices, and cutting balloons, the success rate of intervention for coronary artery chronic total occlusion (CTOs) and calcified lesions has increased. Along with these changes, the risk of CAP has also increased. In this case report, we present a tip III CAP due to high-pressure postdilatation of coronary stent in a heavily calcified lesion of an ectatic right coronary artery.

Bouncing Guide and a Lost Stent

Coronary artery dislodgment is a rare but potentially lethal complication of percutaneous coronary intervention. We describe a case of an elective radial access right coronary artery PCI complicated by stent dislodgment into the aortic root and its successful retrieval with En-snare system through femoral access.

A Randomized Study of SheathLess vs Standard Guiding Catheters for Transradial Percutaneous Coronary Interventions

BackgroundThe small diameter of radial arteries remains a major limitation of the transradial approach for percutaneous coronary intervention (PCI). Sheathless guiding catheters (GCs) might offer an advantage over standard GCs. MethodsBetween 2011 and 2013, we randomized 233 transradial PCIs performed in men with ostial or bifurcation lesions and in all women between standard GC (Medtronic Launcher; Minneapolis, MN) and the SheathLess Eaucath GC (Asahi Intecc, Aichi, Japan). ResultsSuccessful PCI using the transradial approach was not different between the groups (P = 0.74), however the rate of successful transradial PCI with the designated GC (ie, without crossover to the opposing GC) was superior in the SheathLess group compared with the standard GC group (96.5% vs 89.9%; P = 0.047). Safety end point (ie, absence of PCI complication, radial artery occlusion, perforation, pseudoaneurysm, and Early Discharge after Transradial Stenting of Coronary Arteries [EASY] hematoma grade ≥ 2) did not differ between the groups (60.5% in both groups). Mean PCI duration (45.1 minutes vs 45.9 minutes), fluoroscopy (20.1 minutes and 19.9 minutes), and cannulation times (3.6 minutes vs 3.7 minutes), contrast media volume (196 mL vs 187 mL) and conversion to transfemoral approach (1.8% vs 0.8%) were not different between the groups. Patients' subjective assessment revealed less arm pain during navigation of the SheathLess GC (1.9 ± 1.9 vs 4.8 ± 3.6; P < 0.001). Operators graded arm crossability as easier with the SheathLess GC (8.7 ± 1.5 vs 5.1 ± 3.5; P < 0.001). ConclusionsIn selected coronary lesions requiring large-bore catheters in men and in all lesions in women, the SheathLess GC was superior to the standard GC for successful transradial PCI with the designated GC. The SheathLess GC was also associated with easier arm navigation and less patient discomfort.

Medicolegal implications of radial and femoral access for coronary angiography and intervention in 2016: Focus on retroperitoneal hemorrhage.

Retroperitoneal hemorrhage is a rare but serious complication of transfemoral approach (TFA) and TFA percutaneous coronary intervention (PCI). Radial approach for coronary angiography and intervention (transradial approach, TRA) is associated with lower access site complications and reduced blood transfusion rates. Retroperitoneal bleeding has not been described with TRA. This study sought to evaluate the relationship between femoral access for coronary angiography (TFA) and PCI-induced retroperitoneal hemorrhage and the resulting medical litigation in the United States. From 342 lawsuit claim records identified in LexisNexis database search, 17 cases of TFA and TFAPCI-related retroperitoneal hemorrhage decided between 1995 and 2015 were included in the study. Claims were thoroughly reviewed and information about the date the case was decided, patient outcome, the plaintiff, the defendant, the claim, and the trial outcome were extracted. The most common filled claim was medical malpractice (53% of the cases), followed by wrongful death (18%) and review of the Commissioner's decision to deny the application for supplemental security income (12%). Forty-seven percent of the cases were won by the defense, 29% by the plaintiff, and 24% were remanded for a new trial. In 82% of the cases, physicians were sued, but only 14% of the cases were won by the plaintiff. In 59% of the claims, the patient died; however, 70% of those cases were decided in favor of the defending physician and hospital. Retroperitoneal hemorrhage is an uncommon complication of TFA and TFA PCI and is associated with high mortality rates. Physicians should able to identify this complication early and address it in a timely manner based on the applicable standard of care. TRA and TRA PCI is a reliable alternative and may potentially reduce medicolegal liability related to access site choice.

PROSPECTIVE DECISION SUPPORT TOOL GUIDES USAGE OF VASCULAR CLOSURE DEVICES THAT REDUCE BLEEDING COMPLICATIONS, LENGTH OF STAY, AND VARIABLE COSTS IN HIGH BLEED RISK PATIENTS

Bleeding is a common complication in percutaneous coronary intervention (PCI) and increases length of stay (LOS), costs, and mortality. Designed for rapid hemostasis, vascular closure devices (VCDs) are beneficial cases with a high bleeding risk but are utilized less often in these cases. A real-

Successful treatment of coronary artery perforation using fat tissue embolization.

Coronary artery rupture is a rare complication of percutaneous coronary intervention (PCI) that may lead to pericardial effusion frequently accompanied by tamponade. It is one of the most serious complications with a relatively high mortality rate ranging from 7 to 17%. 1-3 We report a case of a 63-year-old patient with acute inferoposterolateral ST-segment elevation myocardial infarction presented 4 hours from the beginning of chest pain. An urgent coronarography with left radial access was done and a 3-vessel coronary artery disease was found with occlusion of strong first marginal branch (OM1). Following stenting of the OM1 with 2nd bare metal stent (BMS), a type III distal guidewire-induced coronary perforation was recognized with extravasation of contrast into the pericardial space. Hemostasis was immediately performed inflating the balloon from the stent and a conversion of heparin with 10.000 I.U. protamine was done. As prolonged balloon inflations were unsuccessful, we decided to do a peripheral embolization with subcutaneous fat. The first guiding catheter, wire and balloon were left in place to maintain hemostasis and we placed another working guiding catheter through the right femoral artery. Prior to placing the introducer, 5 cc of subcutaneous fat was harvested from the patient’s upper right thigh. A mixture of fat and saline was injected through the over-the-wire balloon distally of the balloon for hemostasis resulting in the immediate cessation of leakage at the site of perforation. However, immediately after, most likely due to leakage of the pro coagulant fat tissue from circumflex artery (Cx) to left anterior descending artery (LAD), occlusion of the LAD at the previously diagnosed significant stenosis occurred. The PCI of the LAD was immedi ately made with BMS implantation and clinical stabilization of the patient. At the end of the procedure Cx was sealed and there was no need for the pericardiocentesis or cardiac surgery. Echocardiography reveled a moderate posterolateral hypokinesia with left ventricular ejection fraction of 45% and a mild mitral regurgitation. After 21 days PCI of the right coronary artery with BMS was done. Subcutaneous fat tissue embolization is a simple technique available to all for the treatment of potentially fatal complications such as rupture of the coronary artery. Even though potential complications must be considered.

Complete recovery of the right ventricle from a large intramyocardial hematoma complicating percutaneous coronary intervention

Right ventricular (RV) intramyocardial hematoma is a potentially life-threatening condition that can complicate percutaneous coronary intervention (PCI). Natural course of RV hematoma and long-term recovery of the affected myocardium have not been described. We present a case of a 70-year-old male with large RV hematoma caused by distal guidewire perforation during PCI of the right coronary artery. Baseline multimodality imaging, serial echocardiography, and long-term follow-up using cardiac magnetic resonance (CMR) imaging were used to investigate the natural course of this rare condition. Despite its massive initial appearance, the hematoma was successfully managed conservatively. Serial echocardiographic examination showed slow gradual resorption of the hematoma. Follow-up CMR performed at 12 months was strikingly normal, showing no late gadolinium enhancement of the RV myocardium indicating lack of significant fibrotic scarring at the site of hematoma resorption.<Learning objective: Right ventricular (RV) free wall hematoma is a potentially life-threatening complication of percutaneous coronary intervention. Multimodality imaging combined with serial echocardiography is useful to study the extent of myocardial involvement and the slow resorption process of the hematoma. This case illustrates that even a sizeable RV intramyocardial hematoma can be managed conservatively if no acute hemodynamic compromise occurs and complete recovery of the myocardium can be expected.>

Right Coronary Artery Ostial Avulsion and Aortic Dissection during Right Coronary Artery Angioplasty in a Dwarf Woman, a Case Report

Iatrogenic aortocoronary dissection and ostial coronary avulsion are rare and devastating complications of Percutaneous Coronary Intervention (PCI), which mandate a challenging management. Herein, we described a case of right coronary ostial avulsion in a dwarf woman with chronic total occlusion of the vessel during PCI and discussed about the results and pitfalls.

Abstract 205: Minimizing Post Procedural Bleeding Complications - A Quality Improvement Initiative

Objectives: The primary purpose of this study is to implement the National Cardiovascular Data Registry (NCDR) CathPCI bleeding risk score pre-procedurally, in order to identify the patients who are at high risk for bleeding complications and secondly, to examine accurate documentation to decrease hemorrhagic complications among adult patients undergoing percutaneous coronary intervention (PCI). Background: Bleeding is one of the most common complications of PCI. The NCDR CathPCI bleeding risk score can predict patient risk for bleeding complications pre-procedurally. This tool is recognized as an assessment tool that can modify bleeding risk among adult patients undergoing PCI. This validated, individualized bleeding risk score (BRS) is useful in clinical decision making to promote quality of care, patient safety, and patient satisfaction and PCI outcomes. Specific outcomes evaluated in this project include number of blood transfusion and length of stay (LOS). Currently, this BRS tool is under utilized in the clinical setting. Methods: A cross sectional study design was implemented for this quality improvement project in a major medical center in the Northeast. Retrospective clinical data review was conducted for adult patients who underwent PCI prior to initiation of the NCDR CathPCI assessment tool. A data collection form was implemented to obtain this retrospective data related to bleeding complications. The NCDR CathPCI bleeding score tool was then implemented for adult patients who underwent PCI. Prospective data collection after implementing NCDR cathPCI bleeding risk tool is in progress. Results: The preliminary findings of the retrospective data review prior to implementation of the NCDR CathPCI bleeding score suggests that, 34.4% of the patients who received blood transfusions had documented bleeding complications (hematoma 15.6% (10 of 64); retro-peritoneal bleeding 9.4% (6 of 64); gastrointestinal bleeding 9.4% (6 of 64). Only 14.1% (9 of 64) of these patients had a drop in hemoglobin of 3grams from the baseline prior to transfusion. There was also a lack of documentation of hematoma size. Chronically anemic patients who received blood transfusion without bleeding complications accounted for 65.6% (42 of 64) of the patients reviewed in the retrospective data review. Average LOS of patients who required blood transfusion was an average of 1.34 days when compared with patients who did not develop bleeding complications. Final results of the prospective data analysis post implementation of the NCDR CathPCI assessment tool are pending. Conclusion: Pending.

Public Reporting of Mortality After PCI in Cardiac Arrest and Cardiogenic Shock: An Opinion From the Interventional Council and the Board of Governors of the American College of Cardiology.

Current reporting standards imply that death after percutaneous coronary intervention (PCI) in a patient with cardiac arrest or cardiogenic shock is a PCI complication for the hospital and the interventionist [(1)][1]. However, in many cases, PCI is a bystander event, and most of the mortality in

Contrast-Induced Acute Kidney Injury: An Update.

Contrast-induced acute kidney injury (CI-AKI) is defined as an abrupt deterioration in renal function associated with the administration of iodinated contrast media. This type of acute kidney injury is frequently encountered as a complication of percutaneous coronary intervention (PCI) and is associated with adverse short- and long-term outcomes including mainly mortality, cardiovascular morbidity and prolongation of hospitalization. The incidence of CI-AKI after PCI ranges from 2 to 20% according to baseline kidney function. It may also range according to the clinical setting, being higher after emergency PCI. The primary manifestation is a small decline in kidney function, occurring 1 to 3days after the procedure. Kidney function usually returns to preexisting levels within 7days. Incidence of acute renal failure requiring dialysis following PCI is rare (<1%). The present article aims to review up-to-date published data concerning diagnosis, definition, epidemiology and prognosis of this novel in-hospital epidemic.

Balloon rupture during stent postdilation: Lesson from a movie

Balloon rupture (BR) is an infrequent complication of percutaneous coronary intervention (PCI) and can lead to vessel injury. The present article describes a case in which PCI for a lesion that did not appear to be severely calcified on angiography was complicated by BR during stent postdilation. Balloon rupture went unrecognized, with resultant coronary dissection. The presence of sharp calcium spicules – which could not be detected by angiography – is highlighted as the likely cause of BR. Vigilance for BR during every step of PCI, particularly in calcified lesions, is also emphasized along with the need for prompt recognition of BR to avoid or minimize coronary wall trauma.

DETECTING PAINLESS MYOCARDIAL ISCHEMIA IN A PATIENT WITH RESTENOSIS AFTER PERCUTANEOUS CORONARY INTERVENTION

Restenosis is a complication of percutaneous coronary interventions which results in the destabilization of coronary heart disease. Presents a clinical case of detection of restenosis using stress Echocardiography one year after percutaneous coronary intervention.

Extraction of a Fully Deployed Coronary Stent during Retrieval of Another Dislodged Stent.

Coronary stent dislodgement is a rare and serious complication of percutaneous coronary intervention and is associated with major adverse cardiac events. Successful retrieval of the stent is recommended in this situation because it is important for the prognosis. Recently, a patient was referred to our hospital with a dislodged coronary stent. When attempting to percutaneously extract the dislodged stent, a challenging situation was encountered, as the stent was entrapped and tightly entangled with another fully deployed coronary stent. Extraction of a fully deployed stent is generally prohibited as it may result in severe complications. Nevertheless, we extracted both the dislodged stent and the fully deployed stent, as a last resort. Herein, we report about this case. Our case highlights if the operator had a thorough understanding of the surrounding circumstances regarding the fully deployed coronary stent, successful extraction of the fully deployed coronary stent without any complications could be possible.