Complication Of Percutaneous Coronary Intervention Research Articles

C58. Management of Ellis Type V RV Branch Coronary Perforation Using Handmade Covered-stent: a case report

Abstract Coronary perforation is a rare but life-threatening complication of percutaneous coronary intervention (PCI) requiring urgent management including balloon inflation, thrombin, microcoils, fat embolization, autologous blood clots administration, heparin-reversing agent, covered-stent implantation, or surgery. We report a case of Ellis type V RV branch coronary artery perforation during PCI treated with a handmade covered-stent. A 69-year-old female presented with typical angina in three days. She was hemodynamically stable and no sign of congestion. Laboratory results showed leukocytosis, mild elevation of liver transaminase, elevated CK-MB level, mild hypoalbuminemia. ECG showed sinus rhythm with atrial bigeminy, late-onset inferoposterior and RV MI, and first-degree AV block. TTE revealed reduced LV systolic function (LVEF 45%), impaired LV relaxation, reduced RV function, marked LV hypokinetic in inferior, inferoseptal, apicoseptal, and inferolateral wall, and mild ischemic mitral regurgitation. DCA result showed 90 – 95% tubular stenosis in mid-LAD and total occlusion in proximal-RCA with grade V thrombus. She had an anomaly of RV branch angle that resembles the RCA so that the guidewire perforated the distal part of the RV branch artery. PCI was done using hydrophilic wire to distal RCA. Ellis type V perforation was found following multiple balloon inflation in RV branch. Perforation was managed with a handmade covered-stent using a Sirolimus-eluting stent with Tegaderm film. TIMI flow 3 was reached without thrombi or residual stenosis. In medical centers that have limited resources, handmade covered-stents can be used as an option after unsuccessful balloon inflation trial.

C58. Management of Ellis Type V RV Branch Coronary Perforation Using Handmade Covered-stent: a case report

Abstract Coronary perforation is a rare but life-threatening complication of percutaneous coronary intervention (PCI) requiring urgent management including balloon inflation, thrombin, microcoils, fat embolization, autologous blood clots administration, heparin-reversing agent, covered-stent implantation, or surgery. We report a case of Ellis type V RV branch coronary artery perforation during PCI treated with a handmade covered-stent. A 69-year-old female presented with typical angina in three days. She was hemodynamically stable and no sign of congestion. Laboratory results showed leukocytosis, mild elevation of liver transaminase, elevated CK-MB level, mild hypoalbuminemia. ECG showed sinus rhythm with atrial bigeminy, late-onset inferoposterior and RV MI, and first-degree AV block. TTE revealed reduced LV systolic function (LVEF 45%), impaired LV relaxation, reduced RV function, marked LV hypokinetic in inferior, inferoseptal, apicoseptal, and inferolateral wall, and mild ischemic mitral regurgitation. DCA result showed 90 – 95% tubular stenosis in mid-LAD and total occlusion in proximal-RCA with grade V thrombus. She had an anomaly of RV branch angle that resembles the RCA so that the guidewire perforated the distal part of the RV branch artery. PCI was done using hydrophilic wire to distal RCA. Ellis type V perforation was found following multiple balloon inflation in RV branch. Perforation was managed with a handmade covered-stent using a Sirolimus-eluting stent with Tegaderm film. TIMI flow 3 was reached without thrombi or residual stenosis. In medical centers that have limited resources, handmade covered-stents can be used as an option after unsuccessful balloon inflation trial.

Extremely Late Stent Thrombosis in a First Generation Drug- Eluting Stent 10 Years After Stent Deployment: A Case Report

Stent thrombosis is one of the gravest complications of percutaneous coronary intervention which usually manifest as ST-segment elevation myocardial infarction or sudden death. There are a very few case reports in the literature regarding extremely late stent thrombosis in a drug-eluting stent. Here we report a case of extremely late stent thrombosis in a first generation drug-eluting stent in a 54 year old gentleman. To the best of our knowledge, this is the first case report with the longest duration (10 years) after sirolimus eluting first-generation DES in Bangladesh. Bangladesh Heart Journal 2021; 36(2): 164-168

Stent-graft and double-guiding catheter technique to rescue iatrogenic coronary perforation.

IntroductionCoronary artery perforation (CAP) is an infrequent, yet life-threatening complication of percutaneous coronary interventions, posing a major risk of cardiac tamponade and mortality.MethodsWe report on effective management of Ellis type III CAP with use of double-guiding catheter technique and stent-graft implantation.ResultsProlonged balloon inflation via the first guiding catheter allows for temporary closure of the bleeding site. At the same time, stent-graft is inserted via the second guiding catheter to seal the perforation. After rapid deflation of the balloon, the stent is immediately advanced and expanded.ConclusionsThe procedure minimises the time between deflation of the balloon and implantation of the stent-graft, allowing for successful bleeding cessation.

Multi-Center, Prospective, Nation-Wide Coronary Angioplasty Registry in Thailand (Thai PCI Registry): Registry Design and Rationale

Background: Coronary artery disease (CAD) is one of the most common causes of death worldwide. Percutaneous coronary intervention (PCI) is currently the main revascularization modality for these patients. The practice of PCI, outcomes and resource utilization varies in many parts of the world. Therefore, it is important to have local information regarding the patient demographics, pattern of PCI practice, and outcomes. Objective: To report the study design, protocol and rationale of the Thai PCI registry. Materials and Methods: Thai PCI Registry is a prospective, multi-center study which is an initiative project of the Cardiac Intervention Association of Thailand (CIAT). The study consisted of phase I for cross-sectional data registry and phase II for follow up study. The project was started in November 2015. All catheterization laboratories in Thailand were invited to participate in this nationwide registry. The details regarding patient characteristics, procedural details, equipment, and outcomes of PCI were prospectively collected using well-constructed case record form. The protocol of the registry has been approved by the Central Research Ethics Committee (CREC). The project received a research grant from the Health System Research Institute, The Ministry of Public Health, in Thailand, March 2017. Results: There were 39 hospitals from all areas of the country participated in the registration. The hospital type and size were varied and well represented of the PCI centers in Thailand. The registry planned to enroll all consecutive PCI patients at each hospital for approximately one year with the estimated number of PCI at 22,000 procedures. Initially, all patients were followed up for at least 6 and 12 months. Conclusion: The present study provides rationale, protocol, definition and study design of Thai PCI registry. The results of the Thai PCI registry would yield the essential information regarding the current real-world practice as well as the results and complications of PCI. Keywords: Coronary angioplasty; Nationwide registry; Percutaneous coronary intervention; Thailand; Real-world

Acute kidney injury definition following PCI and cardiovascular outcomes

Abstract Background Acute kidney injury (AKI) is a complication of percutaneous coronary intervention (PCI), known to increase rates of adverse medical events. We aimed to identify the optimal definition of AKI in predicting of adverse cardiovascular outcomes and mortality post PCI. Methods From a large registry of patients undergoing PCI between 2006–2018 (n=25,690) at two hospitals, consecutive patients were assessed for the presence of AKI according to four different definitions: a relative elevation of ≥25% or ≥50%; or an absolute elevation of ≥0.3 mg/dL or ≥0.5 mg/dL in serum creatinine at 48 hours post PCI. We assessed the calculated rates of AKI according to the different definitions. The discriminant capacity for 30-day and 1-year mortality and MACE (MACE: all-cause death, myocardial infarction, target-vessel revascularization and coronary artery bypass graft surgery) of each definition was calculated using ROC curves and AUCs. Results Data of 15,153 patients was available for final analysis. Rates of AKI were 12.1%, 3.2%, 8.1% and 3.9% according to the four definitions, respectively. The discriminant capacity of adverse outcomes was highest among those defined as AKI according to the third definition - an absolute elevation of ≥0.3 mg/dL in serum creatinine with an AUC of 0.82 (95% CI 0.80–0.84) for 30-day mortality (P value = 0.036) and an AUC of 0.78 (CI 0.76–0.79) for 30 days MACE. Conclusions An absolute elevation of ≥0.3 mg/dL in serum creatinine 48 hours post PCI predicts overall mortality and MACE most accurately. Funding Acknowledgement Type of funding sources: None.

Efficacy and safety of local intracoronary drug delivery in the distal coronary bed as treatment of no-reflow phenomenon during percutaneous coronary intervention

Abstract Background No-reflow is a complication of percutaneous coronary interventions (PCI), which occurs in 0.6–5% of elective PCIs, but it may be observed in up to 50% of primary PCI cases, involving the treatment of thrombus-containing lesions. An optimal standard treatment of no-reflow (NR) has not yet been established. Intracoronary (IC) vasodilators are being administered for the treatment of NR via the guiding catheter, but sometimes distal flow restoration is not satisfactory especially in patients with TIMI 0 flow. Purpose To investigate the efficacy and safety of local IC drug delivery in the distal coronary bed via a microcatheter as a treatment option of NR phenomenon during PCI. Methods A retrospective analysis of 4606 PCI procedures done in our institution was conducted, to identify patients who suffered from NR during PCI (TIMI 0-I flow in the absence of mechanical obstruction). In patients with NR, local IC infusion of vasodilators (Nitroprusside 50–200 mcg, Adenosine 30–40 mcg) was infused, via a microcatheter or thrombus-aspiration catheter, distal to the angioplasty site. Repeated injections were done with both drugs at the operator's discretion, until best flow was achieved, but without exceeding the maximum recommended dose. If the patient was hypotensive and, thus, the administration of IC vasodilators for treating slow flow/NR was impeded, 100–200 mcg IV phenylephrine were administered, to increase blood pressure. Afterwards, IC vasodilators were infused. Results In 4606 conducted PCIs, 83 patients suffered from NR (1.8%). The age of patients with NR was 65.17±11.69 years. As for the sex, there were 10 female (12.1%) and 73 male (87.9%) patients. The mode of presentation was: 1) STEMI in 28 patients (33.7%), 2) NSTEMI-Unstable Angina in 21 patients (25.3%) and 3) stable angina in 34 patients (41%). NR was observed in 57 patients (68.7%) at post-stenting and in 26 patients (31,3%) at post-dilation. The affected vessel was LAD in 35 patients (42.2%), LCx artery in 16 patients (19.3%), RCA in 28 patients (33.7%) and SVG in 4 patients (4.8%). The IC-infused drug was adenosine in 21 patients and nitroprusside in 62 patients. The total number of infusions was 4.05±1.88. TIMI III flow was achieved in 90.3% of patients and MBG II/III was achieved in 89.1%. The combination of TIMI III flow with MBG II/III was achieved in 87.9% of the patients. In the subgroup of patients with STEMI, the combination of TIMI III flow with MBG II/III was achieved in 85,7% of the patients. As for the complications, a transient systolic pressure drop below 90 mmHg occurred in 4 patients, while there was one death, due to cardiogenic shock complicating acute anterior MI. Conclusion Local IC delivery of vasodilator drugs in the distal coronary bed via microcatheter during PCI is a safe and effective treatment of NR phenomenon, and it can enhance the myocardial perfusion, in addition to reducing infarct's size. Also, it may improve the post-PCI prognosis. Funding Acknowledgement Type of funding sources: None.

Comparative efficacy of fibrinolytics and glycoprotein IIb/IIIa inhibitors in preventing coronary no-reflow: a network meta-analysis

Abstract Background Coronary no-reflow is a potentially lethal complication of percutaneous coronary intervention (PCI). The optimal approach to preserve coronary reflow during primary PCI is still controversial. Purpose Therefore, we aimed to compare and rank the adjunctive use of fibrinolytic agents and glycoprotein IIb/IIIa inhibitors by network meta-analysis of randomized controlled trials. Methods Pairwise and network meta-analysis were performed using the random-effects model within a frequentist framework. The primary outcome was coronary TIMI flow grade immediately following the intervention. Results 82 studies with a total of 20666 participants were identified, including 7 multi-arm studies. This enabled 94 pairwise comparisons of 35 different adjunctive anticoagulant regimens, all administered in the context of primary PCI. Overall, risk of bias in these studies was rated moderate, and heterogeneity was low with a global I2 value of 20.8%. The figure shows the ranking of the interventions in relation to no adjunctive treatment (NON) and placebo (PLA). In particular, Tirofiban (TIR) alone or in combination with Adenosin (ADE) Nicorandil (NIC) was effective in preventing coronary no-reflow. The route of its administration, intravenous (IV) vs intracoronary (IC), did not matter much. However, its timing as an early IV injection upstream of primary PCI was not beneficial. Eptifibatide (EPT) given as IC bolus followed by continuous IV infusion had an effect comparable to TIR, as well as, among the fibrinolytics, Pamiteplase (PAM) given IV and Urokinase (URO) given IC. Conclusions This comprehensive comparison of fibrinolytics and glycoprotein IIb/IIIa inhibitors demonstrates that TIR, EPT, PAM, and URO can effectively and equally prevent coronary no-reflow in primary PCI. Funding Acknowledgement Type of funding sources: None.

A risk predictive model for coronary perforation in patients undergoing percutaneous coronary intervention – APOLLO-XI score

Abstract Background Coronary perforation (CP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). Although several variables are associated with the risk of coronary perforation, a cumulative risk predictive model has not been established yet. Purpose To assess an incidence, risk factors and to develop risk predictive model for coronary perforation following PCI. Methods A single center, retrospective study of patients who underwent PCI from March 2010 to December 2019. Multivariate regression analysis was performed to identify independent predictors of CP. A risk predictive model was constructed with incremental weights attributed to each component variable according to their beta coefficients. Results 10,671 PCI procedures were enrolled. The incidence of CP was 0.94%. Adverse in-hospital outcomes were significant higher in CP group, including death (odds ratio [OR]: 3.58), mechanical circulatory support; including IABP and ECMO (OR: 3.79) and urgent revascularization (OR: 7.35). Multivariable analysis identified seven independent risk factors for CP, which were age (OR: 1.02), insulin-treated diabetes (OR: 2.50), prior CABG (OR: 2.03), hydrophilic guidewire (OR: 1.62), rotational atherectomy (OR: 2.60), excimer laser coronary atherectomy (ELCA) (OR: 3.39) and chronic total occlusion PCI (OR: 4.21). Risk predictive model (APOLLO-XI score) was calculated from the total points of each variables as follows: age (1 point per 10-year increase), hydrophilic guidewire (2 points), prior CABG (3 points), insulin-treated diabetes or rotational atherectomy (4 points), ELCA (5 points) and chronic total occlusion PCI (6 points). Cumulative risk score more than 11 points had increased risk for coronary perforation more than 1%. The validation of the risk predictive model (C-statistic) was 0.75 (95% CI: 0.70–0.80). Conclusions Coronary perforation is a rare but lethal complication. Our study demonstrates the risk predictive model which could enhance cardiovascular team to precisely estimate risk of coronary perforation before complex PCI procedure. Funding Acknowledgement Type of funding sources: None. Baseline charecteristicsAPOLLO-XI score

Efficacy of Distal Intracoronary Epinephrine and Glycoprotein IIb/IIIa Inhibitors in the Treatment of No-reflow during Percutaneous

Background: No-reflow is considered a major percutaneous coronary intervention complication, especially in primary PCI. A variety of medications have been studied for no-reflow treatment, including intracoronary nitrates, verapamil, adenosine, glycoprotein IIb/IIIa inhibitors, and epinephrine. Glycoprotein IIb/IIIa inhibitors and epinephrine are the two most promising agents for the treatment of no-reflow. Aim of work: evaluating epinephrine and glycoprotein IIb/IIIa inhibitors efficacy in treating no-reflow through local distal intracoronary injection in comparison to traditional intracoronary administration in the guiding catheter. Subjects and methods: 30 patients undergoing PCI complicated by no-reflow phenomenon. Patients were randomized to either group I where they were treated by local distal intracoronary injection of GP IIb/IIIa inhibitor and epinephrine or to group II where they received the same medications via the traditional intracoronary injection. Primary outcomes were TIMI flow, corrected TIMI frame count and TMPG, and major adverse cardiac events within 48 hours was the secondary outcome. Results: Group I had significantly superior angiographic outcomes than group II. As regards TIMI II-III flow, 86.7% of patients achieved it in versus 53.3% in group II, CTFC was 8.2versus 9.9, and in group I, 80% of patients achieved TMPG II-III, compared to 46.7 % in group II. MACE was insignificantly different between both groups. Diabetes mellitus was found to be the only predictor to be negatively associated with TIMI flow. Conclusion: Distal coronary artery local injection of a combination of GP IIb/IIIa inhibitors and epinephrine achieved superior angiographic outcomes in the treatment of refractory no-reflow in comparison with traditional intracoronary administration of the same medications.

Management of Stent Thrombosis Post-Percutaneous Coronary Intervention and Associated Rare Complications

Stent thrombosis is a devastating complication of percutaneous coronary intervention (PCI) associated with significant morbidity and mortality. Progressive technical advancements from balloon angioplasty to bare-metal stent and drug-eluting stent placement have reduced the incidence of stent thrombosis. Definitive management and preventive methods are still negligible. Here, we describe two cases of definite subacute stent thrombosis of the right coronary complicated by pericarditis and very late left anterior descending stent thrombosis after the intervention in the right coronary artery. In both cases, antiplatelet treatment with clopidogrel showed excellent compliance. Therefore, after successful PCI, we switched both cases from clopidogrel to potentially more potent antiplatelet treatment, such as ticagrelor, to reduce the occurrence of stent thrombosis in the future.

The bleeding risk treatment paradox at the physician and hospital level: Implications for reducing bleeding in patients undergoing percutaneous coronary intervention

Bleeding is a common and costly complication of percutaneous coronary intervention (PCI). Bleeding avoidance strategies (BAS) are used paradoxically less in patients at high-risk of bleeding: "bleeding risk-treatment paradox" (RTP). We determined whether hospitals and physicians, who do not align BAS to PCI patients' bleeding risk (ie, exhibit a RTP) have higher bleeding rates. We examined 28,005 PCIs from the National Cardiovascular Data Registry CathPCI Registry for 7 hospitals comprising BJC HealthCare. BAS included transradial intervention, bivalirudin, and vascular closure devices. Patients' predicted bleeding risk was based on National Cardiovascular Data Registry CathPCI bleeding model and categorized as low (<2.0%), moderate (2.0%-6.4%), or high (≥6.5%) risk tertiles. BAS use was considered risk-concordant if: at least 1 BAS was used for moderate risk; 2 BAS were used for high risk and bivalirudin or vascular closure devices were not used for low risk. Absence of risk-concordant BAS use was defined as RTP. We analyzed inter-hospital and inter-physician variation in RTP, and the association of RTP with post-PCI bleeding. Amongst 28,005 patients undergoing PCI by 103 physicians at 7 hospitals, RTP was observed in 12,035 (43%) patients. RTP was independently associated with a higher likelihood of bleeding even after adjusting for predicted bleeding risk, mortality risk and potential sources of variation (OR 1.66, 95% CI 1.44-1.92, P < .001). A higher prevalence of RTP strongly and independently correlated with worse bleeding rates, both at the physician-level (Wilk's Lambda 0.9502, F-value 17.21, P < .0001) and the hospital-level (Wilk's Lambda 0.9899, F-value 35.68, P < .0001). All the results were similar in a subset of PCIs conducted since 2015 - a period more reflective of the contemporary practice. Bleeding RTP is a strong, independent predictor of bleeding. It exists at the level of physicians and hospitals: those with a higher rate of RTP had worse bleeding rates. These findings not only underscore the importance of recognizing bleeding risk upfront and using BAS in a risk-aligned manner, but also inform and motivate national efforts to reduce PCI-related bleeding.

Design and rationale of the EVOCATION trial: A prospective, randomized, exploratory study comparing the effect of evolocumab on coronary microvascular function after percutaneous coronary intervention in patients with stable coronary artery disease

Percutaneous coronary intervention (PCI) is a standard treatment in patients with stable coronary artery disease (CAD); however, periprocedural myocardial infarction (PMI) remains a common complication of PCI. Aggressive lipid-lowering therapy with statin has shown to reduce the incidence of PMI by preventing coronary microvascular dysfunction. It is unclear whether evolocumab, a potent lipid-lowering agent, could diminish microvascular damage after PCI. The EVOCATION trial (jRCTs051180022) is a multicenter, randomized, open-label, active-controlled, parallel-group, exploratory, investigator-initiated clinical study to evaluate whether pretreatment with evolocumab could decrease the index of microvascular resistance (IMR) after PCI in patients with stable CAD. This study population consists of 100 patients with stable CAD who will undergo PCI and have high low-density lipoprotein cholesterol levels despite administration of maximum tolerated dose of statins for at least 2 weeks. Eligible patients are randomized in a 1:1 ratio to receive either evolocumab 140 mg every 2 weeks in addition to standard of care treatment or standard of care treatment only for 2–6 weeks before PCI. The primary endpoint is IMR after PCI. The EVOCATION trial will evaluate whether pretreatment with evolocumab reduces periprocedural microvascular damage in patients with stable CAD undergoing PCI.

Midkine as an Early Biomarker of Contrast-induced Acute Kidney Injury in Chronic Kidney Disease Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome: A Single-center Prospective Study

Background: Contrast-induced acute kidney injury (CI-AKI), is an important complication of percutaneous coronary intervention (PCI). We aimed to study the role of serum midkine (MK) as an early biomarker of CI-AKI.&#x0D; Methods: We conducted a prospective observational cohort study. It includes 100 chronic kidney disease (CKD) patients with an estimated glomerular filtration rate (eGFR) &lt;60 ml/min/1.73m2. All patients were undergoing PCI for ACS. We measured serum midkine before, 2 and 24 hours after PCI. &#x0D; Results: The mean age of the patients was 70.32±3.62 years, 74% males. Twenty-seven patients developed CI-AKI. The CI-AKI group has a history of diabetes mellitus (DM) and/or dyslipidemia, history of diuretics, metformin and/or angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARBs) use. The CI-AKI patients have low left ventricular ejection fraction (LVEF) (EF &lt; 45%) and low Creatinine Clearance (CrCl) before PCI. The CI-AKI received more contrast volume, had a longer duration of PCI and had high Mehran risk score after PCI. Comparison between the two studied groups regarding serum MK showed that there was a statistically significant difference regarding serum MK 2 hours after PCI. Receiver operating characteristic (ROC) curve analysis for serum MK showed that serum MK measured 2 hours after PCI was statistically significant to predict CI-AKI.&#x0D; Conclusion: An early Serum MK after PCI can be used as an early predictor of CI-AKI in ACS patients.

Timing of AKI after urgent percutaneous coronary intervention and clinical outcomes: a high-dimensional propensity score analysis

IntroductionAcute kidney injury is a common complication of percutaneous coronary intervention and has been associated with an increased risk of death and progressive chronic kidney disease. However, whether the timing of acute kidney injury after urgent percutaneous coronary intervention could be used to improve patient risk stratification is not known.MethodsWe conducted a retrospective cohort study in adults surviving an urgent percutaneous coronary intervention between 2008 and 2013 within Kaiser Permanente Northern California, a large integrated healthcare delivery system, to evaluate the impact of acute kidney injury during hospitalization at 12 (±6), 24 (±6) and 48 (±6) hours after urgent percutaneous coronary intervention and subsequent risks of adverse outcomes within the first year after discharge. We used multivariable Cox proportional hazards models with adjustment for a high-dimensional propensity score for developing acute kidney injury after percutaneous coronary intervention to examine the associations between acute kidney injury timing and all-cause death and worsening chronic kidney disease.ResultsAmong 7250 eligible adults undergoing urgent percutaneous coronary intervention, 306 (4.2%) had acute kidney injury at one or more of the examined time periods after percutaneous coronary intervention. After adjustment, acute kidney injury at 12 (±6) hours was independently associated with higher risks of death (adjusted hazard ratio [aHR] 3.55, 95% confidence interval [CI] 2.19–5.75) and worsening kidney function (aHR 2.40, 95% CI:1.24–4.63). Similar results were observed for acute kidney injury at 24 (±6) hours and death (aHR 3.90, 95% CI:2.29–6.66) and worsening chronic kidney disease (aHR 4.77, 95% CI:2.46–9.23). Acute kidney injury at 48 (±6) hours was associated with excess mortality (aHR 1.97, 95% CI:1.19–3.26) but was not significantly associated with worsening kidney function (aHR 0.91, 95% CI:0.42–1.98).ConclusionsTiming of acute kidney injury after urgent percutaneous coronary intervention may be differentially associated with subsequent risk of worsening kidney function but not death.

Rare Complication in The Coronary Angiography Laboratory: Stent Stripping

Although foreign body embolization is a rare complication of percutaneous coronary intervention, the increase in the number of procedures results in this problem being more frequently encountered by interventional cardiologists. Contemporary case studies have reported the rate of stent stripping to be below 1%. Interventional cardiologists attend to a considerable number of cases in everyday practice and witness a diverse spectrum of complications. Stent stripping can result in severe complications such as emergency coronary bypass surgery, coronary thrombosis, myocardial infarction, cerebrovascular event and death. Thus, the proper management of stent stripping is important for reducing the risk of mortality and morbidity. In this article, we present a case of left main coronary artery stent stripping; we discuss the removal procedure and the complications that arose.

Analysis of clinical efficacy and incidence of complications of percutaneous coronary intervention in the treatment of angina pectoris in elderly patients with coronary heart disease.

article: Analysis of clinical efficacy and incidence of complications of percutaneous coronary intervention in the treatment of angina pectoris in elderly patients with coronary heart disease - Minerva Surgery 2021 Aug 03 - Minerva Medica - Journals

Relationship between Lp-PLA2 and in-stent restenosis after coronary stenting: a 3-year follow-up study.

Coronary in-stent restenosis (ISR) is an important complication of percutaneous coronary intervention (PCI). However, the relationship between lipoprotein associated phospholipase A2 (Lp-PLA2) level and ISR after PCI is rarely reported. This study aims to explore the relationship between Lp-PLA2 and the occurrence of ISR at post-PCI and its predictive value for ISR. Plasma Lp-PLA2 mass were measured in 847 patients planting 1262 stents and evaluated along with known risk indicators. One-year angiographic follow-up showed that baseline elevated Lp-PLA2 mass was strongly associated with early restenosis (95% CI = 1.062-3.050, P < 0.05). Beyond the first year, the occurrence of late restenosis (95% CI = 1.043-3.214, P < 0.05) was significantly larger in the elevated Lp-PLA2 group. Kaplan-Meier analysis after three-year clinical follow up suggested that Lp-PLA2 mass did add the positive effect on the occurrence of major adverse cardiovascular events (MACEs). In conclusion, increased baseline plasma Lp-PLA2 predicts increased risks of re-stenosis and MACEs, which may be a novel biomarker for predicting ISR and MACEs.

The Definition of “Acute Kidney Injury” Following Percutaneous Coronary Intervention and Cardiovascular Outcomes

Acute kidney injury (AKI) is a complication of percutaneous coronary intervention (PCI), known to increase rates of adverse medical events. We aimed to identify the optimal definition of AKI in predicting adverse cardiovascular outcomes and mortality post PCI. From a large registry of patients undergoing PCI between 2006-2018 (n = 25,690) at our medical center, consecutive patients were assessed for the presence of AKI according to four different definitions: a relative elevation of ≥25% or ≥50%; or an absolute elevation of ≥0.3 mg/dL or ≥0.5 mg/dL in serum creatinine at 48 hours post PCI. We assessed the calculated rates of AKI according to the different definitions. The discriminant capacity for 30-day and 1-year mortality and MACE (MACE: all-cause death, myocardial infarction, target-vessel revascularization and coronary artery bypass graft surgery) of each definition was calculated using ROC curves and AUCs. Data of 15,153 patients was available for the final analysis. Rates of AKI were 12.1%, 3.2%, 8.1% and 3.9% according to the four definitions, respectively. The discriminant capacity of adverse outcomes was highest among those defined as AKI according to the third definition - an absolute elevation of ≥0.3 mg/dL in serum creatinine with an AUC of 0.82 (95% CI 0.80-0.84) for 30-day mortality (P value = 0.036) and an AUC of 0.78 (CI 0.76-0.79) for 30-day MACE. In conclusion, an absolute elevation of ≥ 0.3 mg/dL in serum creatinine 48 hours post PCI predicts overall mortality and MACE most accurately.

Evidence-to-Practice Gap for Preventing Procedure-Related Acute Kidney Injury in Patients Undergoing Percutaneous Coronary Intervention.

BackgroundAcute kidney injury (AKI) is a common complication of percutaneous coronary intervention. This risk can be minimized with reduction of contrast volume via preprocedural risk assessment. We aimed to identify quality gaps for implementing the available risk scores introduced to facilitate more judicious use of contrast volume.Methods and ResultsWe grouped 14 702 patients who underwent percutaneous coronary intervention according to the calculated NCDR (National Cardiovascular Data Registry) AKI risk score quartiles (Q1 [lowest]–Q4 [highest]). We compared the used contrast volume by the baseline renal function and NCDR AKI risk score quartiles. Factors associated with increased contrast volume usage were determined using multivariable linear regression analysis. The overall incidence of AKI was 8.9%. The used contrast volume decreased in relation to the stages of chronic kidney disease (168 mL [SD, 73.8 mL], 161 mL [SD, 75.0 mL], 140 mL [SD, 70.0 mL], and 120 mL [SD, 73.7 mL] for no, mild, moderate, and severe chronic kidney disease, respectively; P<0.001), albeit no significant correlation was observed with the calculated NCDR AKI risk quartiles. Of the variables included in the NCDR AKI risk score, anemia (7.31 mL [1.76–12.9 mL], P=0.01), heart failure on admission (10.2 mL [6.05–14.3 mL], P<0.001), acute coronary syndrome presentation (10.3 mL [7.87–12.7 mL], P<0.001), and use of an intra‐aortic balloon pump (17.7 mL [3.9–31.5 mL], P=0.012) were associated with increased contrast volume.ConclusionsThe contrast volume was largely determined according to the baseline renal function, not the patients' overall AKI risk. These findings highlight the importance of comprehensive risk assessment to minimize the contrast volume used in susceptible patients.