ANZ JOURNAL OF SURGERY, Issue 2007
S. Kumar
Background Coronary revascularization surgery does not traditionally employ angiography to assess procedural success. Early graft failure is reported up to 30% in one year (JAMA Nov 2005) may relate to technical errors or conduit problems. We hypothesize that intra-operative assessment of graft by angiography identifies graft defects and may improve the long term graft survival. Methods We have developed one of the first hybrid operation room in the USA. In one year period 203 consecutive patients (age:63+/,16, M/F:126/39) underwent coronary revascularization with angiography before decannulation. Results Of 436 grafts, 72 angiographic defects were detected in 69 grafts (17% of total grafts). There were 11% conduit defects, 3% anastomotic defects, and 3% target vessel error. Of 72 defects, 25/72 defects required minor revision, 47/72 required either surgical or percutaneous intervention. Intra-operative angiography added an average 20+/,12 minutes to the surgery and 112+/,56 ml contrast. Renal function at 24hours and 48 hours after procedure did not vary significantly between patients who did vs. those did not have revisions. There were no significant differences in cardiopulmonary bypass time, aortic cross clamp time, and length of hospital stay for patients who underwent revision compared to those who did not. Renal function, bleeding complication, transfusion were similar in patients with percutaneous vs. surgical revision. Conclusions Intraoperative graft angiography performed at the time of CABG identifies graft defects, allowing for immediate surgical or percutaneous revision. Long-term study is in progress to assess whether intra-operative completion angiography decreases the rate of early graft failure. [source]

DAMAGE CONTROL SURGERY AND ANGIOGRAPHY IN CASES OF ACUTE MESENTERIC ISCHAEMIA

ANZ JOURNAL OF SURGERY, Issue 5 2005
Anthony J. Freeman
Background: Acute mesenteric arterial occlusion typically presents late and has an estimated mortality of 60,80%. This report examines the evolution of a novel management approach to this difficult surgical problem at a teaching hospital in rural Australia. Methods: A retrospective review of 20 consecutive cases that presented to Lismore Base Hospital, Lismore, New South Wales, between 1995 and 2003 was performed. Results: Of the 16 patients who were actively treated, 10 survived. Mortality was associated with attempting an emergency operative revascularisation and not performing a second-look laparotomy. All three patients who had a damage control approach at the initial operation survived and in four cases endovascular intervention successfully achieved reperfusion of acutely ischaemic bowel. Conclusions: Evidence from the series of patients described suggests that damage control surgery and early angiography improve survival in patients suffering acute mesenteric ischaemia. A damage control approach involves emergency resection of ischaemic bowel with no attempt to restore gastrointestinal continuity and formation of a laparostomy. Patients are stabilised in the intensive care unit (ICU) and angiography can be arranged to either plan a definitive bypass procedure or alternatively endovascular therapies can be carried out in an attempt to arrest gastrointestinal infarction. Definitive surgery is then considered after 2,3 days. This approach is particularly attractive if immediate specialist vascular expertise is not available. [source]

Arteries of the Hindfoot of the Llama (Lama glama)

ANATOMIA, HISTOLOGIA, EMBRYOLOGIA, Issue 5 2000
G. Graziotti
Summary The objective of this study was to describe the arterial distribution of the hindfoot of the llama (Lama glama). Ten adult llamas, preserved in 6% formalin solution at 0°C, were dissected. The arterial system was perfused with a solution of 14% coloured plaster; the venous system was perfused with a solution of 17% coloured industrial gelatine. Angiographies were also obtained. In the llama, the arterial distribution is of the saphenous type and this simple sort of irrigation could be used as a didactic model. The caudal branch of the saphenous artery divides into the small lateral plantar artery and the larger medial plantar artery, which continues as the plantar common digital artery III, and it is the main blood supply of the hindfoot. The dorsal pedal artery is underdeveloped and the perforating tarsal artery does not exist in this species. The plantar common digital artery III divides into the plantar proper digital II, III and IV. Branches from the plantar proper digital artery III supply the digits. We compared the arterial distribution of the hindfoot of the llama with that of other domestic animals including the one-humped camel (Camelus dromedarius). [source]

Refractory Progression of Coronary Aneurysms, a Case of Delayed Onset Kawasaki Disease as Depicted by Cardiac Computed Tomography Angiography

CONGENITAL HEART DISEASE, Issue 3 2010
FACP, Shah Azmoon MD
ABSTRACT Background., Kawasaki disease (KD) is an immune-mediated vasculitis of unknown etiology with self-limited clinical course that was first described in 1967 by Dr. Tomisaku Kawasaki. It is a disease of early childhood and rare past late adulthood but one that can have detrimental consequences when there is a delay in diagnosis and treatment. Cardiovascular complications causing increased morbidity and mortality may include coronary artery aneurysms, myocardial infarction, heart failure, arrhythmias, and peripheral artery occlusion. Case Presentation., Here, we present an atypical case of delayed onset KD in a young teenager. DS had visited three different emergency departments during the course of 2 weeks for unrelenting fevers. Despite multiple treatment protocols including immunoglobulin, steroids, and tumor necrosis factor-alpha antagonists, he continued to have progression of cardiovascular complications. While echocardiographic findings were suspicious for cardiac complications, a cardiac computed tomography (CT) angiography was able to clearly distinguish giant coronary aneurysms. Conclusion., Without prompt therapy, fever and manifestations of acute inflammation can last for several weeks to months with increased risk toward complications. The incidence of coronary artery aneurysms has been noted to be 25% in untreated patients with a mortality rate of up to 2%. Using low-dose protocols along with high spatial and temporal resolution of cardiac CT angiography may provide a useful and complimentary imaging modality in accurate diagnosis and follow-up of patients with KD. [source]

Vertebral artery fibromuscular dysplasia: an unusual cause of stroke in a 3-year-old child

DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY, Issue 10 2003
Ana Camacho MD
Fibromuscular dysplasia (FMD) is a systemic arteriopathy which tends to affect renal arteries followed by cervicocranial vessels. It can lead to cerebral infarction if cephalic arteries are involved. FMD is an unusual cause of stroke in childhood that generally affects the carotid area. Only four cases of vertebral FMD and subsequent stroke have been reported previously and we present the youngest patient of all. A healthy 3-year-old female was admitted to Hospital Doce de Octubre in Madrid, Spain with cerebellar infarction. Angiography disclosed basilar artery thrombosis and typical signs of FMD in both vertebral arteries. No other angiographic alteration was noted in the other vessels studied. Her phenotype and other investigations were unremarkable. The patient was treated with anti-aggregation therapy (aspirin) and the outcome was excellent. Investigation of the occurrence in childhood of this kind of arteriopathy may lead to clarification of its natural history and speculation about its unclear pathogenesis. [source]

Endoscopic Injection Sclerotherapy for the Treatment of Recurrent Esophageal Varices after Esophageal Transection

DIGESTIVE ENDOSCOPY, Issue 3 2002
Hiroshi Yoshida
Background: ,We examined the hemodynamic changes associated with recurrent esophageal varices after esophageal transection (ET) and evaluated the effectiveness of endoscopic injection sclerotherapy (EIS) as the treatment for these varices. Methods: ,Nineteen patients with recurrent esophageal varices after ET were treated by EIS. Endoscopic varicealography during injection sclerotherapy, following oral blockage of flow by a balloon, identified three patterns: (i) type 1: common type, continuous filling by the feeder vessel of the varix; (ii) type 2: retrograde-disappearing type, confirmed hepatofugal flow; and (iii) type 3: immediate washout type, immediate washout of contrast medium. Results: ,Angiography revealed that the hepatofugal feeder vessel was the right gastric vein in all cases. Fourteen patients (73.7%) were classified as type 1, 4 patients (21.1%) as type 2, and 1 patient (5.3%) as type 3. Fewer treatment sessions were required in type 1 than in type 2 (P < 0.005). Recurrent varices were completely eradicated in all patients except the patient with type 3 disease. Cumulative re-recurrence rates at 5 and 10 years were similar for types 1 and 2 (28.6 and 71.4%vs 25 and 25%, respectively). The cumulative survival rates after EIS at 5 and 10 years were also similar for types 1 and 2 (77.1 and 66.1%vs 66.7 and 66.7%). Conclusion: ,Endoscopic injection sclerotherapy is an effective treatment for recurrent esophageal varices after ET, except in type 3 disease. Our classification based on endoscopic varicealography during injection sclerotherapy provides knowledge of blood flow within the varices that helps to inform the treatment strategy. [source]

Measurement of Left Ventricular Ejection Fraction by Real Time 3D Echocardiography in Patients with Severe Systolic Dysfunction: Comparison with Radionuclide Angiography

ECHOCARDIOGRAPHY, Issue 1 2010
Hajo Müller M.D.
Aim: Measurement of left ventricular ejection fraction (LVEF) using real time 3D echocardiography (3DE) has been performed in subjects with preserved or modestly reduced systolic function. Our aim was to evaluate this technique in the subset of patients with severe systolic dysfunction. Methods and results: Consecutive patients with LVEF less than 0.35 at two-dimensional echocardiography were included. LVEF obtained by 3DE was compared to the value measured by radionuclide angiography (RNA). Real time full-volume 3DE was performed, with offline semiautomated measurement of LVEF using dedicated software (Cardioview RT, Tomtec) by a single observer blinded to the results of RNA. A total of 50 patients were evaluated, of whom 38 (76%, 27 males, age 69 ± 13 years) had a 3DE of sufficient quality for analysis. LVEF for this group was 0.21 ± 0.07 using 3DE and 0.27 ± 0.08 using RNA. The agreement between the two techniques was rather poor (r = 0.49; P < 0.001; 95% limits of agreements of ,0.20 to 0.09). Truncation of the apex was observed in 6 of 38 (16%) patients. Conclusion: In patients with severe systolic dysfunction, 3DE shows poor agreement for measurement of LVEF as compared to RNA. There may be underestimation of up to 20% in absolute terms by 3DE. Accordingly, the two methods are not interchangeable for the follow-up of LV function. A limitation of 3DE may, at least in part, be related to the incomplete incorporation of the apical region into the pyramidal image sector in patients with dilated hearts. (Echocardiography 2010;27:58-63) [source]

The Relation Between Mitral Annular Calcification and Mortality in Patients Undergoing Diagnostic Coronary Angiography

ECHOCARDIOGRAPHY, Issue 9 2006
Howard J. Willens M.D.
To determine whether the observed association between mitral annular calcification (MAC) and mortality is independent of the severity of coronary artery disease (CAD), we analyzed data from 134 male veterans (age 63 ± 10 years) followed for 5 years who had undergone diagnostic coronary angiography and transthoracic echocardiography within 6 months of each other. Echocardiograms were retrospectively reviewed for the presence of MAC. The relation of MAC to all-cause mortality was analyzed using logistic regression, and odds ratios (OR) were calculated. MAC was present in 49 (37%) subjects. Over the 5-year follow-up period, 38 (28%) patients expired. Five-year survival was 80% for subjects without MAC and 56% for subjects with MAC (P = 0.003). MAC (OR = 3.16, 95% confidence interval [CI]= 1.43,6.96, P = 0.003), ejection fraction (OR = 0.76, 95% CI = 0.59,0.97, P = 0.02), and left main CAD (OR = 2.70, 95% CI = 1.11,6.57, P = 0.02) were significantly associated with mortality in univariate analysis. After adjusting for left ventricular ejection fraction, number of obstructed coronary arteries and the presence of left main coronary artery stenosis, MAC significantly predicted death (OR = 2.48, 95% CI = 1.09,5.68, P = 0.03). Similarly, after adjusting for predictors of MAC, including ejection fraction, age, diabetes, peripheral vascular disease, and heart failure, MAC remained a significant predictor of death (OR = 2.38, 95% CI = 1.02,5.58, P = 0.04). MAC also predicted death independent of smoking status, hypertension, serum creatinine, low density lipoprotein cholesterol, high density lipoprotein cholesterol, and C-reactive protein levels (OR = 3.98, 95% CI = 1.68,9.40, P = 0.001). MAC detected by two-dimensional echocardiography independently predicts mortality and may provide an easy-to-perform and inexpensive way to improve risk stratification. [source]

What Are the Unintended Consequences of Changing the Diagnostic Paradigm for Subarachnoid Hemorrhage After Brain Computed Tomography to Computed Tomographic Angiography in Place of Lumbar Puncture?

ACADEMIC EMERGENCY MEDICINE, Issue 9 2010
Jonathan A. Edlow MD
First page of article [source]

Successful angiographic embolization of recurrent elbow and knee joint bleeds in seven patients with severe haemophilia

HAEMOPHILIA, Issue 1 2009
R. KLAMROTH
Summary., In haemophilic joints with high-grade arthropathy, bleeds occur that do not respond to replacement therapy of the deficient coagulation factor. The reason may be pathologically reactive angiogenesis in chronic synovitis. Seven patients with severe haemophilia A or haemophilia B experienced recurrent massive bleeds of one elbow joint or knee joint in the absence of trauma. After initial application of factor VIII or IX (fVIII/fIX; 50 IU kg,1 bodyweight), there was only slow and never complete relief of symptoms. Despite intensive secondary prophylaxis maintaining the plasma level of factor concentrate at minimum 50%, new massive bleeds at the same location occurred. Vascular bleeding was suspected. Angiography of the arteries was performed via the femoral artery. Vessels identified as potential bleeding sources were embolized with embolization fluid (ONYX) in eight joints (six elbow and two knee joints). Under low-dose prophylactic treatment (15 IU fVIII or fIX per kg bodyweight for three times per week), no recurrent severe bleed unresponsive to coagulation factor replacement occurred after a mean observation time of 16 months after embolization. The consumption of factor concentrate decreased to one-third of the amount consumed before embolization. In conclusion, angiographic embolization with a non-adhesive liquid embolic agent might be considered as a promising therapeutic and coagulation factor saving option in joint bleeds not responding to replacement of coagulation factor to normal levels. [source]

Rupture of radiation-induced internal carotid artery pseudoaneurysm in a patient with nasopharyngeal carcinoma,Spontaneous occlusion of carotid artery due to long-term embolizing performance,

HEAD & NECK: JOURNAL FOR THE SCIENCES & SPECIALTIES OF THE HEAD AND NECK, Issue 8 2008
Kai-Yuan Cheng MD
Abstract Background Rupture of internal carotid artery (ICA) pseudoaneurysm is a lethal complication in patients with nasopharyngeal carcinoma (NPC). Angiography is the best diagnostic and treatment method. The aim of embolization is to block the pseudoaneurysm; but sometimes, total occlusion of great vessels is ineludible. We describe a case of NPC post-radiation therapy and with ruptured pseudoaneurysm treated by angio-embolization. Methods The patient had received embolization with numerous tools such as stent grafts, balloons, and bare stents with or without filter protection. Results After failing to pass through the narrow lumen by embolizing tools, the right ICA finally occluded spontaneously by self-thrombosis. Conclusion Although the angio-embolization is a good method to resolve the problems of ruptured pseudoaneurysm, there is still high mortality and morbidity. Being aware of the clinical presentations and the changes of images may alert us to predict the happening earlier. © 2008 Wiley Periodicals, Inc. Head Neck, 2008 [source]

Physician Referral Patterns and Race Differences in Receipt of Coronary Angiography

HEALTH SERVICES RESEARCH, Issue 4 2002
Thomas A. LaVeist
Objective. This study addresses the following research questions: (1) Is race a predictor of obtaining a referral for coronary angiography (CA) among patients who are appropriate candidates for the procedure? (2) Is there a race disparity in obtaining CA among patients who obtain a referral for the procedure? Study Setting. Three community hospitals in Baltimore, Maryland. Study Design. We abstracted hospital records of 7,927 patients from three hospitals to identify 2,653 patients who were candidates for CA. Patients were contacted by telephone to determine if they received a referral for CA. Logistic regression was used to assess whether racial differences in obtaining a referral were affected by adjustment for several potential confounders. A second set of analyses examined race differences in use of the procedure among a subsample of patients that obtained a referral. Principal Findings. After controlling for having been hospitalized at a hospital with in-house catheterization facilities, ACC/AHA (American College of Cardiology/American Heart Association) classification, sex, age, and health insurance status, race remained a significant determinant of referral (OR=3.0, p<.05). Additionally, we found no significant race differences in receipt of the procedure among patients who obtained a referral. Conclusions. Our results demonstrate that race differences in utilization of CA tend to occur during the process of determining the course of treatment. Once a referral is obtained, African American patients are not less likely than white patients to follow through with the procedure. Thus, future research should seek to better understand the process by which the decision is made to refer or not refer patients. [source]

Case report of a focal nodular hyperplasia-like nodule present in cirrhotic liver

HEPATOLOGY RESEARCH, Issue 5 2008
Sho Takahashi
An 81-year-old female was referred to Sapporo Medical University Hospital because of a nodular lesion 20 mm in diameter found in the liver S8 during follow-up for type C liver cirrhosis. Abdominal ultrasonography showed a capsule-like structure, and contrast computed tomography revealed hypervascularity at the early phase and inner pooling of the contrast medium with ring enhancement at the late phase. Magnetic resonance T2-weighted imaging (T2WI) demonstrated a hyperintensity nodule with further hyperintensity signals in some parts of the nodule, and the signal pattern differed from that of typical fibrosis. SPIO-magnetic resonance imaging showed partial hypointensity signals by T2WI, which indicated the presence of Kupffer cells. Angiography did not show a spoke-wheel pattern. The results by imaging modalities indicated that the nodule was atypical for hepatocellular carcinoma (HCC) and focal nodular hyperplasia (FNH), and liver nodule biopsy was performed for histological diagnosis. Compared with the background liver, the nodule revealed high cellular density, cellular dysplasia at the periphery, a pseudo-crypt structure and irregular hepatic cord arrangement in some parts of the nodule. Among them, there was immature fibrous tissue containing arterioles with muscular hypertrophy. There has been no report of well-differentiated HCC with a central scar, and this case was presumed to be an FNH-like nodule with dysplasia physically associated with cirrhotic tissue. [source]

Resection of renal metastases to the pancreas: a surgical challenge

HPB, Issue 3 2003
D Zacharoulis
Background Metastasis to the pancreas from renal cell carcinoma (RCC) is distinctly uncommon. Most cases are detected at an advanced stage of the disease and are thus unsuitable for resection. A solitary RCC metastasis to the head of pancreas is rarely encountered and, although it is potentially amenable to surgical resection, surgeons may be hesitant to perform pancreatoduodenectomy. Cases outlines Two patients with a solitary RCC metastasis to the head of pancreas were treated by pancreatoduodenectomy, while a third with multiple RCC metastases declined any treatment. Two of the patients were asymptomatic, and one presented with anaemia and mild abdominal pain. Computed tomography (CT) and angiography were used to exclude other metastases and to assess resectability of the pancreatic tumour. All three patients are still alive, those with resectable disease at 2 years and 9 years and the one with irresectable disease at 4 years. Discussion Isolated RCC metastasis to the pancreas is a rare event. Patients present either on follow-up imaging or with symptoms such as mild abdominal pain, weight loss, jaundice, anaemia or gastrointestinal bleeding (whether occult or overt). Dynamic spiral CT can visualise the tumour and exclude distant metastasis. Angiography often reveals a highly vascularised tumour and will help to assess resectability. In the absence of widespread disease, pancreatic resection can provide long-term survival in metastatic RCC, although few cases have been reported with lengthy follow-up. The prognosis is better than for pancreatic adenocarcinoma. [source]

Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute-onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

ACADEMIC EMERGENCY MEDICINE, Issue 4 2010
Robert F. McCormack MD
Abstract Objectives:, The primary goal of evaluation for acute-onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute-onset headache. Methods:, This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. Results:, SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). Conclusions:, CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute-onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%. ACADEMIC EMERGENCY MEDICINE 2010; 17:444,451 © 2010 by the Society for Academic Emergency Medicine [source]

In reply to Commentary: "What Are the Unintended Consequences of Changing the Diagnostic Paradigm for Subarachnoid Hemorrhage After Brain Computed Tomography to Computed Topographic Angiography in Place of Lumbar Puncture?"

ACADEMIC EMERGENCY MEDICINE, Issue 9 2010
Robert F. McCormack MD
No abstract is available for this article. [source]

Leg ulcers and hydroxyurea: report of three cases with essential thrombocythemia

INTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 12 2002
Zeynep Demirçay MD
Case 1,A 65-year-old woman with essential thrombocythemia (ET) had been taking oral hydroxyurea (HU), 1000 mg daily, for 7 years. Six months ago, she developed an ulcer on the outer part of her left ankle, which healed spontaneously within 2 months. She presented with a new, tender, shallow ulcer, 2 cm × 2 cm in size, at the same site. Doppler examination revealed thrombosis of the left common femoral vein and a calcified atheroma plaque of the left common femoral artery. The dosage of HU was decreased to 500 mg daily when the platelet counts were found to be within normal levels. The ulcer completely healed within 2 months with occlusive wound dressings, and has not recurred within the follow-up period of 1 year. Case 2,A 56-year-old women presented with multiple, painful, leg ulcers of 1 year duration. She had been diagnosed as having ET and had been on HU therapy, 1500 mg/day, for the past 5 years. Interferon-,-2b was started 3 months ago, in addition to HU, which was tapered to 1000 mg daily. She had suffered from hypertension for 20 years treated with nifedipine and enalapril, and had recently been diagnosed with diabetes mellitus which was controlled by diet. Examination revealed three ulcers located on the lateral aspects of both ankles and right distal toe. Arterial and venous Doppler examinations were within normal limits. Histopathology of the ulcer revealed nonspecific changes with a mixed inflammatory cell infiltrate around dermal vessels. The ulcers completely healed within 10 weeks with topical hydrocolloid dressings. After healing, she was lost to follow-up. A year later, it was learned that she had developed a new ulcer at her right heel, 3 months after her last visit (by phone call). This ulcer persisted for 8 months until HU was withdrawn. Case 3,A 64-year-old woman with ET presented with a painful leg ulcer of 6 months' duration. She had been taking oral HU for 5 years. She had a 20-year history of hypertension treated with lisinopril. Examination revealed a punched-out ulcer of 2 cm × 2 cm over the right lateral malleolus (Fig. 1). Doppler examination of the veins revealed insufficiency of the right greater saphenous and femoral veins. Angiography showed multiple stenoses of the right popliteal and femoral arteries. As her platelet count remained high, HU was continued. During the follow-up period of 13 months, the ulcer showed only partial improvement with local wound care. Figure 1. Punched-out ulcer surrounded by an erythematous border over the right malleolus (Case 3) [source]

Limitations of Right Internal Thoracic Artery to Left Anterior Descending Artery Bypass: A Comparative Quantitative Study of Postoperative Angiography of the Bilateral Internal Thoracic Artery Bypass Grafts

JOURNAL OF CARDIAC SURGERY, Issue 4 2008
Mizuho Imamaki M.D.
Methods: The 111 subjects underwent graft angiography after bypass grafting of the left or right internal thoracic artery (ITA) to the LAD. The vascular caliber was measured at the origin of the ITA, at an ITA site adjacent to the anastomotic site, and at an LAD site immediately below the anastomotic site, regarding the outer diameter of the catheter as a reference. Results: The caliber of the ITA immediately above the anastomotic site of the LAD was significantly lower in the RITA group. In the left internal thoracic artery (LITA) group, no patient showed a caliber of less than 1.25 mm, but five patients (7.8%) did in the RITA group. The preoperative cardio-thoracic ratio was significantly higher than that in patients in whom the caliber of the ITA immediately above the anastomotic site was 1.25 mm or more, and the height was significantly lower. Conclusions: In many patients, the RITA is appropriate as a graft material to the LAD. However, in patients with a high cardio-thoracic ratio and those with a low height, the RITA may not reach the LAD in a favorable state, and the LITA should be anastomosed to the LAD in some patients. [source]

Multivessel Off-Pump Coronary Artery Bypass Grafting Can Be Taught to Trainee Surgeons

JOURNAL OF CARDIAC SURGERY, Issue 5 2003
David Jenkins F.R.C.S.
The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively. Methods: Registry data, notes, and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training program for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it had an established recent experience in performing nonselective OPCAB for all in-coming patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses. Results: The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed 17 satisfactory (100%) distal anastomoses. Conclusion: With appropriate training, it is possible for trainees to learn OPCAB and perform multivessel revascularization in relatively high-risk patients with good results. [source]

A Xiphoid Approach for Minimally Invasive Coronary Artery Bypass Surgery

JOURNAL OF CARDIAC SURGERY, Issue 4 2000
Federico Benetti M.D.
However, opening the pleura has been a limitation of using these approaches. Aim: We used the xiphoid approach as an alternative to opening the pleura and to minimize pain after minimally invasive coronary artery bypass surgery. Methods: We review our surgical experience in 55 patients who underwent minimally invasive direct coronary artery bypass (MIDCAB) surgery through a xiphoid approach between October 1997 and August 1999. Thoracoscopy (n = 31) or direct vision (n = 24) were used for internal mammary artery (IMA) harvesting. Mean patient age was 67 ± 10 years and 65% were men. The mean Parsonnet score was 23 ± 10. Performed anastomoses included left IMA (LIMA) to the left anterior descending (LAD) artery (n = 53), LIMA-to-LAD and saphenous vein graft from the LIMA to the right coronary artery (n = 1), and LIMA-to-LAD and right IMA (RIMA) to right coronary artery (n = 1). Results: Postoperative complications included atrial fibrillation (12%), acute noninfectious pericarditis (12%), and acute renal failure (5%). Mean postoperative length of stay was 4 ± 2 days. Angiography was performed in 16 patients and demonstrated excellent patency of the anastomoses. There was no operative mortality. Actuarial survival was 98% in a mean follow-up period of 11 ± 5 months. Conclusions: Minimally invasive coronary artery bypass can be performed safely through a xiphoid approach with low morbidity, mortality, and a relatively short hospital stay. [source]

Three-Dimensional Anatomy of the Left Atrium by Magnetic Resonance Angiography: Implications for Catheter Ablation for Atrial Fibrillation

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 7 2006
MOUSSA MANSOUR M.D.
Background: Pulmonary vein isolation (PVI) has become one of the primary treatments for symptomatic drug-refractory atrial fibrillation (AF). During this procedure, delivery of ablation lesions to certain regions of the left atrium can be technically challenging. Among the most challenging regions are the ridges separating the left pulmonary veins (LPV) from the left atrial appendage (LAA), and the right middle pulmonary vein (RMPV) from the right superior (RSPV) and right inferior (RIPV) pulmonary veins. A detailed anatomical characterization of these regions has not been previously reported. Methods: Magnetic resonance angiography (MRA) was performed in patients prior to undergoing PVI. Fifty consecutive patients with a RMPV identified by MRA were included in this study. Ridges associated with the left pulmonary veins were examined in an additional 30 patients who did not have a RMPV. Endoluminal views were reconstructed from the gadolinium-enhanced, breath-hold three-dimensional MRA data sets. Measurements were performed using electronic calipers. Results: The width of the ridge separating the LPV from the LAA was found to be 3.7 ± 1.1 mm at its narrowest point. The segment of this ridge with a width of 5 mm or less was 16.6 ± 6.4 mm long. The width of the ridges separating the RMPV from the RSPV and the RIPV was found to be 3.0 ±1.5 mm and 3.1 ±1.8 mm, respectively. There were no significant differences between LPV ridges for patients with versus without a RMPV. Conclusion: The width of the ridges of atrial tissue separating LPV from the LAA and the RMPV from its neighboring veins may explain the technical challenge in obtaining stable catheter positions in these areas. A detailed assessment of the anatomy of these regions may improve the safety and efficacy of catheter ablation at these sites. [source]

Characterization of a New Pulmonary Vein Variant Using Magnetic Resonance Angiography:

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 5 2004
Imaging, Incidence, Interventional Implications of the "Right Top Pulmonary Vein"
Introduction: Catheter ablation of the pulmonary veins (PVs) for prevention of recurrent atrial fibrillation requires precise anatomic information. We describe the characteristics of a new anatomic variant of PV anatomy using magnetic resonance angiography. Methods and Results: A 1.5-T magnetic resonance imaging system with a body coil or a torso phased-array coil was used before and after gadolinium injection. Magnetic resonance angiograms were acquired with a breath-hold three-dimensional fast spoiled gradient-echo imaging sequence in the coronal plane. Three-dimensional reconstruction with maximum intensity projections and multiplanar reformations was performed. A newly described variant PV ascending from the roof of the left atrium was found in 3 of 91 subjects. The mean ostial diameter of the roof PV was 7 ± 2 mm, the mean distance from the ostium to the first branching point was 22 ± 8.5 mm, and the mean distance to the right superior PV was 3.3 ± 0.6 mm. Conclusion: We refer to the newly described variant of PV anatomy as the "right top pulmonary vein." It is important to be aware of this anatomic pattern to avoid inadvertent catheter intubation, which can result in misleading mapping results and PV stenosis. (J Cardiovasc Electrophysiol, Vol. 15, pp. 538-543, May 2004) [source]

N -Acetylcysteine Added to Volume Expansion with Sodium Bicarbonate Does Not Further Prevent Contrast-Induced Nephropathy: Results from the Cardiac Angiography in Renally Impaired Patients Study

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2009
CEZAR S. STANILOAE M.D.
We reviewed data from the multicenter CARE (Cardiac Angiography in Renally Impaired Patients) study to see if benefit could be shown for N-acetylcysteine (NAC) in patients undergoing cardiac angiography who all received intravenous bicarbonate fluid expansion. Four hundred fourteen patients with moderate-to-severe chronic kidney disease were randomized to receive intra-arterial administration of iopamidol-370 or iodixanol-320. All patients were prehydrated with isotonic sodium bicarbonate solution. Each site chose whether or not to administer NAC 1,200 mg twice daily to all patients. Serum creatinine (SCr) levels and estimated glomerular filtration rate were assessed at baseline and 2,5 days after receiving contrast. The primary outcome was a postdose SCr increase 0.5 mg/dL (44.2 ,mol/L) over baseline. Secondary outcomes were a postdose SCr increase 25% and the mean peak change in SCr. The NAC group received significantly less hydration (892 ± 236 mL vs. 1016 ± 328 mL; P < 0.001) and more contrast volume (146 ± 74 mL vs. 127 ± 71 mL; P = 0.009) compared with no-NAC group. SCr increases 0.5 mg/dL occurred in 4.2% (7 of 168 patients) in NAC group and 6.5% (16 of 246 patients) in no-NAC group (P = 0.38); rates of SCr increases 25% were 11.9% and 10.6%, respectively (P = 0.75); mean post-SCr increases were 0.07 mg/dL in NAC group versus 0.11 mg/dL in no-NAC group (P = 0.14). In conclusion, addition of NAC to fluid expansion with sodium bicarbonate failed to reduce the rate of contrast-induced nephropathy (CIN) after the intra-arterial administration of iopamidol or iodixanol to high-risk patients with chronic kidney disease. [source]

Diagnostic Coronary Angiography in Patients with Peripheral Arterial Disease: A Sub-study of the Coronary Artery Revascularization Prophylaxis Trial

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2008
SANTIAGO GARCIA M.D.
Background: Although patients in need of elective vascular surgery are often considered candidates for diagnostic coronary angiography, the safety of this invasive study has not been systematically studied in a large cohort of patients scheduled for an elective vascular operation. The goal of this sub-study of the Coronary Artery Revascularization Prophylaxis (CARP) trial was to assess the safety of coronary angiography in patients with peripheral vascular disease. Methods: The CARP trial tested the long-term benefit of coronary artery revascularization prior to elective vascular operations. Among those patients who underwent diagnostic coronary angiography during screening for the trial, the associated complications were determined at 24 hours following the diagnostic procedure. Results: Over 5,000 patients were screened during a 4-year recruitment period at 18 major VA medical centers and the present cohort consists of 1,298 patients who underwent preoperative coronary angiography. Surgical indications for vascular surgery included an expanding aortic aneurysm (AAA) (n = 446; 34.4%) or arterial occlusive disease with either claudication (n = 457; 35.2%) or rest pain (n = 395; 30.4%). A total of 39 patients had a confirmed complication with a major complication identified in 17 patients (1.3%). Complication rates were higher in patients with arterial occlusive symptoms compared with expanding aneurysms (1.8% vs. 0.5%; P = 0.07) and were not dissimilar with femoral (2.8%) versus nonfemoral (4.7%) access sites (P = 0.42). Conclusions: Coronary angiography is safe in patients with peripheral arterial disease undergoing preoperative coronary angiography. The complication rate is higher in patients with symptoms of arterial occlusive disease. [source]

CT Coronary Angiography Predicts the Outcome of Percutaneous Coronary Intervention of Chronic Total Occlusion

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2007
F.R.A.C.P., KEAN H. SOON M.B.B.S.
Background: The success rate of percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) is relatively low. Further evaluation of CTO lesion with CT coronary angiography (CT-CA) may help to better select patients that would benefit from percutaneous revascularization. We aimed to test the possible association between failed PCI and transluminal calcification of CTO as assessed by CT-CA. Methods: Patients with CTO awaiting PCI were scanned with a 16-slice CT. A cardiologist and a radiologist assessed transluminal calcification of CTO lesions on CT images while an interventional cardiologist at a core laboratory assessed conventional variables of invasive fluoroscopic coronary angiography (FCA) associated with failed PCI of CTO. The significance of CT and FCA variables in association with failed PCI were analyzed. Results: In a cohort of 39 patients with 43 CTO lesions, 24 lesions were successfully revascularized. Transluminal calcification ,50% as assessed on CT-CA was strongly associated with failed PCI (odds ratio [OR] of PCI success = 0.10, 95% confidence interval [CI]: 0.02,0.47, P = 0.003). Blunt stump as seen on FCA was also associated with failed PCI (OR of PCI success = 0.24, 95% CI: 0.07,0.86, P = 0.029). There was no significant evidence to support that the duration of CTO, presence of side branch and bridging collaterals, and the absence of microchannels as assessed with FCA were associated with failed PCI. On multivariate analysis, transluminal calcification ,50% on CT-CA was the only significant predictor of failed PCI. Conclusions: Heavy transluminal calcification as assessed with CT-CA is an independent predictor of failed PCI of CTO. CT-CA may have a role in the work-up of CTO patients prior to PCI. [source]

Safety, Efficacy, and Cost Advantages of Combined Coronary Angiography and Angioplasty

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 3 2003
CLAUDE LE FEUVRE M.D., F.E.S.C.
Aim: The safety and efficacy of ad hoc PTCA has been previously reported and this approach is performed in many angioplasty centers as a routine procedure. The aim of this study is to examine whether this approach reduces the length, and cost of hospital stay. Methods and results: To determine the hospital costs we studied 2,440 PTCAs over 11 years in our institution (1990,2000). Urgent PTCA for acute coronary syndromes refractory to medical treatment were excluded. In 1809 patients (74%) angioplasty was performed immediately after coronary angiography, while separate procedures were performed in 631 patients. Indication for PTCA was unstable angina in 1342 patients (55%). In the ad hoc PTCA group, 92% of the culprit lesions were successfully treated; complications included myocardial infarction (2%), urgent bypass surgery (0.6%) and death (0.9%). The rate of combined procedure progressively increased from 54% in 1990 to 88% in 2000, with a significant decrease in the rate of complications. After adjusting for clinical and angiographic differences between combined and separate procedures, angiographic success and complication rates were not statistically different in the two groups. Mean length of hospital stay decreased all along the years, and was 45% less in the ad hoc PTCA group (11.4 ± 6.9vs18.2 ± 7.7in 1990,5.4 ± 4.3vs10.8 ± 5.7in 2000,P < 0.0001). The cost was 40% lower in the ad hoc PTCA group. For patients with stable angina, the savings were 49%, and for those with unstable angina, they were 29%. Conclusion: In the era of coronary stenting, ad hoc PTCA can be performed in most of the patients as safely and successfully as a separate procedure. It reduces the length, and the cost of hospital stay in patients with stable or unstable angina. (J Interven Cardiol 2003;16:195,199) [source]

Application of a Cardiac Arrest Score in Patients with Sudden Death and ST Segment Elevation for Triage to Angiography and Intervention

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 4 2002
PETER A. MCCULLOUGH M.D.
The aim of this study was to test a previously validated, prognostic, cardiac arrest score in patients with ST segment elevation acute myocardial infarction (AMI) who suffereda witnessed cardiac arrest and survived to emergency department admission. A consecutive series constructed retrospectively from a sudden death database (n= 22) of patients with ST segment elevation AMI resuscitated from cardiac arrest underwent angiography and angioplasty of the culprit vessel within 24 hours of presentation. A cardiac arrest score was assigned to each case by explicit criteria present on evaluation. Primary outcomes were survival to hospital discharge and the degree of neurological recovery during the hospitalization. All patients underwent successful coronary angioplasty and 77% received adjunctive intraaortic balloon counterpulsation. The overall rate of survival to discharge was 41%. For cardiac arrest scores of 0, 1, 2, and 3, respectively, the rates of neurologic recovery were 0 (0%) of 4 (95% CI 0,53%), 3 (50%) of 6 (95% CI 15,85%), 2 (67%) of 3 (95% CI 13,98%), and 9 (100%) of 9 (95% CI 72,100%), and the rates of survival to discharge were 0(0%) of 4, (95% CI 0,53%), 2 (33%) of 6 (95% CI 6,74%), 2 (67%) of 3 (95% CI 13,98%), and 9 (100%) of 9 (95% CI 72,100%), P<0.01 for both outcomes over ascending scores. These results suggest appropriate patients for primary angioplasty after cardiac arrest are those with ST segment elevation AMI and an emergency department cardiac arrest score of ,2, thus predicting a11 (92%) of 12 (95% CI 65,100%) chance of survival to discharge. [source]

A Time-to-Treatment Analysis in the Medicine Versus Angiography in Thrombolytic Exclusion (MATE) Trial

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 4 2001
F.A.C.C., F.A.C.P, M.P.H., PETER A. MCCULLOUGH M.D.
Patients with acute coronary syndromes who are considered ineligible for thrombolytic therapy are at high risk of recurrent ischemia and death. This trial randomized 201 patients to triage angiography in the first 24 hours of hospital admission versus conventional medical care. Of the 165 patients who underwent angiography that was either protocol-driven or on the basis of physician preference, those who underwent angiography within 6 hours of symptom onset had a reduction in early and late adverse events. The rates of in-hospital recurrent ischemia were 15.4%, 15.4%, 17.5%, 32.4%, and 38.5%, respectively (P = 0.01 for trend), and rates of cumulative recurrent myocardial infarction or death were 0%, 12.8%, 10.0%, 11.8%, and 7.7%, respectively (P = 0.48 for trend) for patients who underwent angiography at 0,6, 6,12, 12,24, 24,48, and over 48 hours, respectively from symptom onset. Future trials of invasive versus conservative therapy should focus on performing angiography within 6 hours of symptom onset. [source]

A Novel Automated Injection System for Angiography

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2001
JAMES A. GOLDSTEIN M.D.
The present method of performing manual coronary angiography requires repetitive manipulation of a cumbersome stopcock-manifold system and contrast injection by hand syringe. This study reports a novel mechanical contrast injector with automated manifold that provides finger touch operator-controlled contrast injections. The ACIST Injection System components include a software-controlled syringe injector, a disposable automated manifold without stopcocks, a disposable hand controller, and a touch screen control panel. The ACIST system was evaluated in 50 patients undergoing diagnostic coronary angiography (n = 37) or coronary interventions (n = 13). In all cases, the system was easy to use and provided excellent quality images even with four catheters, as well as imaging during stent positioning with 6Fr guides. This mechanical injector facilitates precision operator-controlled angiographic injections, provides superb high quality coronary images even with very small lumen catheters, and expedites ventriculography during angiographic procedures. (J Interven Cardiol 2001;14:147,152) [source]

Coronary Artery Stenting in Vessels with Reference Diameter < 3 MM

JOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 5 2000
ALFRIED GERMING M.D.
The study included 220 consecutive patients with coronary artery stenting. In 128 patients (60.8 ± 10.2 years, 68% men), a total of 184 stents were placed in coronary vessels with a reference diameter < 3 mm (group S). One hundred thirty-four stents were implanted in 92 patients (62.9 ± 9.8 years, 82.6% men) in vessels > 3 mm (group L). There was no significant difference according to clinical baseline characteristics. The primary end point of this retrospective study was the rate of periinterventional complications (death, stent thrombosis, myocardial infarction, urgent angioplasty, or surgical revascularization). The, secondary end point was the clinical and angiographic follow-ups (restenosis, recurrent angina, further revascularization) after 3 months. Cardiac complications occurred in group S in two (1.6%) patients, two stent thromboses with urgent angioplasty, one Q-wave and one non-Q-wave infarction. There was one (1.1%) event in group L, a stent thrombosis with Q-wave infarction and urgent angioplasty. Angiography at 3-month follow-up was performed in 148 patients. Restenosis occurred in group S in 31.8% and in group L in 21.7% (NS). Data according recurrent angina and recommended surgical revascularization did not differ between both groups. In group S, significantly more angioplasties of the stented lesion were performed (23/60 patients) compared to group L (6/88) (P = 0,015). Coronary artery stenting in vessels with a reference diameter < 3 mm can be performed without a high rate of periinterventional complications. Restenosis tends to be more frequent in the small vessel group, a higher rate of reangioplasties have to be expected. The clinical follow-up is comparable to a control group. [source]