Cardiac interventions in Switzerland in 1994

As in the previous seven years, a survey of cardiac invasive, interventional and surgical procedures among the 25 Swiss centers was carried out in 1994 by a detailed questionnaire. The resulting data are presented per individual center and per university, private or public sector. The outstanding findings of the 1994 survey are: There is an ongoing increase in the use of coronary angioplasty. The rapid evolution of coronary angioplasty is predominantly due to an extension of indications towards simple cases since the percentage of multivessel angioplasties has remained low. More than half of all angioplasties have been performed immediately after the respective coronary angiography (ad hoc angioplasty). The use of coronary stents has increased steeply over the past three years. Other new devices like directional coronary atherectomy, rotablation and transluminal extraction have lost further ground. PTCA for ongoing infarction has remained exceptional, probably due to logistical problems. Among the diagnostic tools, only coronary ultrasound has been used regularly. Coronary as well as non-coronary surgery seem to plateau. Percutaneous balloon valvuloplasties remained rather rare interventions. Catheter closure of congenital shunt defects has joined the routine interventional procedures. The majority of interventional catheter procedures have been performed at the five university centers whereas the majority of coronary artery bypass graft interventions have been carried out at private institutions.     

Heart interventions in Switzerland 1996

For the year 1996, as for the previous 11 years, a survey of cardiac invasive and surgical procedures in Switzerland was carried out by a standardised questionnaire. At the 25 Swiss centres (10 public non-university, 10 private and 5 university centres) a total of 12,183 coronary revascularisation procedures were performed, 60% by percutaneous transluminal coronary angioplasty (PTCA). Of all PTCAs, 88% were single vessel interventions. PTCA for ongoing infarction accounted for 6% of all PTCAs. The use of coronary stents has increased to 50% of all angioplasties. Other interventions like directional atherectomy and rotablations have lost ground (0.4%, 35 cases). Only 22 interventions (0.2%) with intracoronary laser devices were recorded. Among the new diagnostic tools, only coronary ultrasound (233 cases) and Flowire (147) have been used regularly. Percutaneous balloon valvuloplasties (60 cases) and catheter closure of congenital shunt defects (42 cases) remained rare. Procedure related mortality for PTCA was 0.6%, infarction occurred in 1.0% and emergency coronary artery bypass grafting (CABG) became necessary in 0.4%. The total number of CABGs (4,463) slightly decreased. Among the 2,677 non-coronary operations, 48% were performed for valve disease and 51% for congenital heart disease. Heart transplantation was performed in 41 patients (1%). Half of the interventional catheter procedures were performed at the 5 university centres whereas the majority of CABGs were carried out at private centres. Four centres performed diagnostic procedures, exclusively. In-house surgical stand-by for PTCA was available in 17 of the 21 interventional centres.     

Extending the C2 domain family: C2s in PKCs delta, epsilon, eta, theta, phospholipases, GAPs, and perforin

Percutaneous balloon angioplasty and endovascular stent placement are becoming common techniques intended to reduce the need for surgical bypass procedures that may be more expensive or have higher morbidity rates. Prophylactic antibiotics are not currently used before stent placement in most centers even when implanted via the femoral route. Infectious complications have been rare. In the case presented here an infected common iliac pseudoaneurysm occurred after percutaneous balloon angioplasty and stent placement. The literature is reviewed.     

Single dose medication vial packaging deficiencies

OBJECTIVES: Technical success and early outcome of modified surgical techniques integrating interventional procedures for iliac recanalisation performed through an incision in the groin. MATERIALS: Sixty-one consecutive iliac arteries in 59 patients with long occlusions in 16, occlusions of the common iliac in 11, occlusions of the external iliac in 24 and multiple stenoses of the iliac in 10 cases underwent semiclosed recanalisation through a groin incision. METHODS: Passage of the lesion by guidewire permits retrograde ring-stripper endarterectomy over the wire as a guiding splint or thrombectomy with a double lumen balloon catheter. Residual lesions are corrected by balloon or stent angioplasty. Adequate outflow is established by femoral patch plasty. RESULTS: Conversion to a standard operation was required in 10 limbs (failure to recanalise the lesion in nine, rupture after angioplasty in one). Initial technical success was achieved in the remaining 51 limbs (recanalisation by ring stripper endarterectomy in 36, thrombectomy in 14, both in six, additional intraoperative angioplasty in 42). Five postoperative thromboses were successfully treated by a combined surgical and interventional approach accounting for a 1-month 100% secondary patency. CONCLUSION: Iliac recanalisation through the groin by modified ring stripper endarterectomy or modified thrombectomy in combination with intraoperative angioplasty is a safe and effective procedure. Long-term results are required to evaluate the procedure.     

Early operative intervention after thrombolytic therapy for primary subclavian vein thrombosis: an effective treatment approach

PURPOSE: Effective treatment of primary subclavian vein thrombosis focuses on restoration of venous patency, relief of intrinsic stenosis, and decompression of the thoracic inlet. The appropriate method and timing for surgery, however, have not been not well defined. We conducted a study to determine an acceptable treatment approach. METHODS: A retrospective review evaluated 11 patients seen at our institution in an 8-year period. Seven patients were male and four were female, with an average age of 30 years (range 15 to 54 years). Two patients who had symptomatic stenosis without occlusion were omitted from the study. All patients with occlusion received urokinase therapy and underwent surgical decompression within 5 days of thrombolytic therapy. Five percutaneous transluminal angioplasties were attempted before operative intervention. Eleven decompressions were performed, including nine first-rib resections and two scalenectomies. Five operative venous procedures, consisting of thrombectomy with patch closure (n = 3) and bypass (n = 2), and seven venolysis procedures were performed. All patients received coumadin for 3 to 6 months after the operation. RESULTS: Urokinase therapy established wide venous patency in nine of the 11 extremities treated, with the remaining two requiring thrombectomy for residual thrombus at the time of operation. One patient who underwent transluminal angioplasty before the operation had rethrombosis, and the remaining four showed no improvement in venous stenosis after the intervention. Eight of nine extremities treated by first-rib resection and one of two treated by scalenectomy were free of residual symptoms at follow-up. CONCLUSIONS: Preoperative use of percutaneous balloon angioplasty is ineffective and should be avoided in this setting. Surgical intervention within days of thrombolysis obviates the need for interim oral anticoagulation and enables patients to return to normal activity sooner.     

Evaluation of the systematic use of wide lumen 6 French guiding catheters in conventional coronary angioplasty

The aim of this study was to evaluate the results of systematic use of 6 French guiding catheters in conventional balloon coronary angioplasty without any restriction of indications apart from coronary lesions necessitating other techniques such as atherectomy. Therefore, after a learning period, 200 consecutive procedures performed between November 1993 and June 1994 for the treatment of 234 lesions were analysed prospectively. Fifty-one patients had stable and 70 unstable angina. In 79 cases, the angioplasty was performed on the culprit lesion of a myocardial infarction. An angiographic success was obtained for 206 lesions or 88% of cases which increased to 95% after exclusion of attempted recanalisation. There were 3 cases of damage to the ostium and 7 patients underwent implantation of a stent with the same catheter for occlusive or threatening dissection. There were 10 ischaemic complications (5%) (7 non-Q wave infarctions, 2 Q wave infarctions, 1 aorto-coronary bypass, no deaths) and 8 local complications at the site of arterial catheterisation during the hospital period. These results demonstrate the feasibility of coronary angioplasty with wide lumen 6 French guiding catheters and show that they amy be used in first intention for all conventional balloon angioplasty procedures.     

Gastroduodenal arterial aneurysm and chronic pancreatitis. A case and review of the literature

A case of pseudoaneurysm of the gastroduodenal artery due to chronic pancreatitis is reported. Pancreatitis causing splanchnic arterial aneurysm is more likely to affect the splenic artery than the gastroduodenal artery. Ten percent of cases of chronic pancreatitis are associated with splanchnic aneurysm. Hemorrhage occurs in 50% of cases. Color Doppler ultrasound is the best diagnostic tool, indicating the need for coeliac arteriography. In our case report, transcatheter embolization was performed with stainless steel coils and the pseudoaneurysm was successfully occluded.     

Paratesticular sarcoma: apropos of a case with a 19-year evolution

In young children with renal artery stenosis the applicability of percutaneous transluminal angioplasty is limited by the small vessel size. We report our experience in a 15-month-old girl with severe hypertension, who underwent successful balloon dilatation of a tight renal artery stenosis caused by fibromuscular dysplasia. The procedure was performed using the guided co-axial balloon catheter technique with a 6 F right coronary Judkins catheter, a 0.014" guidewire and a 2 mm coronary artery balloon dilatation catheter. Antihypertensive medication was discontinued 6 weeks after the procedure. During a follow up period of 11 months, Doppler sonography revealed no evidence of recurrent renal artery stenosis. CONCLUSION: Percutaneous transluminal angioplasty of renal artery stenosis can be performed safely in young children using equipment originally designed for treatment of coronary artery stenosis in adults.     

Repair of femoral pseudoaneurysm after cardiac catheterization: utility of extraperitoneal iliac control

Femoral artery lesions may occur after cardiac catheterization or percutaneous transluminal coronary angioplasty (PTCA). The incidence of pseudoaneurysm following transfemoral catheterization ranges from 0.21 to 6.25%. Among 3162 cardiac catheterization procedures thirteen (0.41%) patients presented a femoral pseudoaneurysm requiring surgical repair. The Authors reported their technical consideration about the utility of extraperitoneal iliac control during surgical repair of femoral artery pseudoaneurysm due to cardiac catheterization.     

Identification of PhoP-PhoQ activated genes within a duplicated region of the Salmonella typhimurium chromosome

The treatment of occlusive lesions in the innominate, subclavian, and axillary arteries has, until recently, been entirely surgical. Recently, advances in endovascular technologies have provided an alternative means of therapy. The advent of balloon angioplasty has resulted in some turmoil between medical specialties regarding patient selection and acceptable applications. Innovations in imaging, guidewire, catheter, stent, and balloon technology allow one to obtain percutaneous access and perform therapeutic procedures in a relatively safe manner. However, the excellent and time-tested results of surgery remain a standard for developing new procedures. Despite the appeal of less invasive techniques, the morbidity, mortality, and durability of novel treatments must equal or exceed those standards set by surgical procedures. Proponents of the endovascular options must familiarize themselves with advantages and disadvantages of surgical procedures. In a similar manner, surgeons have an obligation to understand the less invasive technologies as well. The clinician must uphold the best interests of the patient as a fundamental factor in the determination of a particular form of therapy. This paradox is well illustrated by consideration of occlusive lesions in the upper extremity.     

Evaluation of in vivo and in vitro quality of apheresis-collected RBC stored for 42 days

Neonatal critical aortic valve stenosis is a life-threatening malformation if untreated. Before the late 1980s, the preferred treatment was surgical valvotomy; however, operative mortality was high. Early reports of transcatheter balloon dilation were encouraging, although femoral artery damage and aortic valve insufficiency were procedural limitations. With new balloon catheter technology, transumbilical, transvenous, and transcarotid approaches have been advocated, although a comparison with recent surgical results has not been performed. We compared all neonates who presented to our institution since 1985 with the diagnosis of critical aortic stenosis. Ten patients underwent surgical transventricular valvotomy and 13 patients underwent balloon valvuloplasty via a right carotid cutdown with continuous transesophageal echocardiographic guidance. Prior to intervention, all patients had either left ventricular dysfunction, an aortic valve gradient > 100 mmHg, significant mitral valve insufficiency, and/or ductal dependent systemic blood flow. All patients had successful relief of aortic valve obstruction with normalization of left ventricular function and successful discontinuation of prostaglandin E1. Use of continuous transesophageal echocardiographic guidance resulted in fluoroscopic exposure of only 12 +/- 8 minutes. At the latest follow-up, a similar proportion of patients has required additional aortic valve procedures (38% vs 25%) and overall mortality (20% vs 15%) is similar. In the transcarotid group, 9 of 13 patients (69%) have a normal appearing right carotid artery by Duplex imaging, and no neurologic events have been reported. Balloon aortic valvuloplasty via a right transcarotid approach is safe, simplifies crossing the valve, and is effective for the initial palliation of neonatal critical aortic stenosis. The use of transesophageal echocardiographic guidance reduces fluoroscopy exposure, enables accurate assessment of hemodynamics without catheter manipulation or angiography, and avoids femoral artery injury.     

Percutaneous suture closure of the femoral artery access after diagnostic heart catheter examination or coronary intervention

BACKGROUND AND OBJECTIVE: Alternative methods to the conventional one of external compression with a pressure bandage over the site of arterial puncture after percutaneous catheter introduction for coronary angiography or transluminal balloon coronary angioplasty have failed to reduce the rate of vascular complications. This study was undertaken to assess the complication rate of a percutaneously introduced suturing device (Techstar, Perclose). PATIENTS AND METHODS: To achieve immediate haemostasis and thus shorten post-interventional immobilisation the technique of percutaneous suturing of the femoral artery was used in 1030 consecutive patients (793 men, 237 women; mean age 58.6 years) without obstructive vascular disease or local vascular complications. RESULTS: Percutaneous suture closure with primary haemostasis was successful after 137 of 153 coronary angioplasties (89.5%) and after 786 of 977 left heart catheterisations (89.6%). Early mobilisation, after at most 4 hours, was possible in 923 patients with successful suture closure (89.6%). The overall complication rate was 0.78%. CONCLUSION: Percutaneous suture repair of the femoral artery after cardiac catheterisation is a safe and effective method to achieve immediate haemostasis. However, controlled studies are needed to demonstrate harmlessness of early mobilisation.     

Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas

Endovascular repair of peripheral arterial lesions was performed in 10 patients including two iliac aneurysms, two iliac anastomotic pseudoaneurysms, one subclavian pseudoaneurysm, one axillary anastomotic disruption, two prosthetic pseudoaneurysms, and two posttraumatic arteriovenous (AV) fistulas. The indications for repair were aneurysm size in five cases, massive hematoma in one, threatened prosthetic dialysis graft in two, venous hypertension with non-healing ulcer in one, and arm pain in one. Vascular access was obtained through surgical cutdown in all cases, via the femoral artery in five patients, the proximal brachial artery in three and a prosthetic graft in two. Stented prosthetic grafts were used in five cases (1 polyester and polytetrafluoroethylene 4 [PTFE]), and PTFE-covered stents in five cases. Concomitant procedures were done in four patients including two open repairs of a common femoral artery aneurysm, a transluminal dilatation of a proximal aortic anastomotic stenosis, and an iliac artery transluminal angioplasty. Eight of 10 cases were technically successful. Completion arteriography revealed complete exclusion of all lesions, except for one minimal proximal stented graft leak in a pseudoaneurysm, and an incomplete obliteration of an AV fistula. No complications occurred. Operative time ranged from 45 min to 5 hours. Postoperative hospital stay was 1 day in five patients, 2 days in three patients, and 4 days in two patients. Follow-up contrast CT scan, arteriography, or duplex scanning demonstrated complete exclusion of all lesions except an AV fistula, and decrease in size in three aneurysms. The proximal leak initially present in a stented graft resolved. All grafts and covered stents remained patent at 2-19 months of followup. Endovascular exclusion of peripheral arterial aneurysms, pseudoaneurysms, and AV fistulas can be done with a high degree of technical success, low morbidity, and short hospital stay. Short-term follow up is encouraging, however, long term follow up of these procedures is warranted to assess durability of the repair and absence of complications.     

Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty

PURPOSE: The purpose of this study was to explore the feasibility of iliofemoral endarterectomy performed through a single groin incision. METHODS: Thirty-two patients aged 34 to 75 years (mean age 63.4 years) with a male/female ratio of 20:12 underwent 36 lower extremity inflow reconstructions from July 1989 to September 1994. Surgical indications were for limb-threatening ischemia in 24 patients and for claudication in eight patients. The procedures were done for occlusive disease of the external iliac artery and common femoral artery with patients under either spinal (n = 24) or local (n = 12) anesthesia. Intraoperative balloon angioplasty with fluoroscopic guidance preceded open retrograde iliofemoral endarterectomy. Adjunctive procedures included 18 profundaplasties, eight femorofemoral, nine femoropopliteal, and one femorotibial bypasses. RESULTS: Thirty-three of the 36 cases were initially successful. The three failures were in patients with extensive calcification. The mean follow-up has been 36.4 months, and the patency rate was 80.5% at 3 and 4 years. The four failures noted on follow-up were caused by three common iliac artery stenoses and one iliac system occlusion. The former group was successfully treated with balloon angioplasty/stent, and the latter patient required an aortofemoral bypass. No operative deaths or limb loss occurred in this series. CONCLUSIONS: Retrograde iliofemoral endarterectomy facilitated by balloon angioplasty is a safe, easy-to-perform, and viable option for patients with combined external iliac artery and common femoral artery occlusive disease. Midterm results (36.4 months) are favorable, and most hemodynamic failures are easy to correct with standard endovascular techniques.     

Estrogen differentially modulates nicotine-evoked dopamine release from the striatum of male and female rats

BACKGROUND: Transluminal balloon angioplasty offers advantages to patch angioplasty. We evaluated the primary patency of thrombosed hemodialysis grafts that had undergone balloon angioplasty versus patch angioplasty as a salvage method. METHODS: We reviewed our experience with 22 consecutive intraoperative balloon angioplasties that were done in a 6-months period. The balloons used were noncompliant high pressure balloons. The balloon results were compared with those of 22 patients who had undergone patch angioplasties by the same surgeons. Age, gender, average time between graft insertion and revision, and number of prior revisions were analyzed. The two groups (patch and balloon) had similar ages (57 versus 58 years, respectively), gender distribution (12 women, 11 men versus 11 women and 11 men), average time of revisions before that particular procedure (15 versus 12 months), and average times of revisions before that procedure. RESULTS: Primary patencies of the patch and balloon group were respectively 86% versus 77% at 1 month, 45% versus 40% at 3 months, and 17% versus 28% at 6 months. There was no statistically significant difference between the two groups. Complications were comparable in both groups. CONCLUSION: Balloon angioplasty offers advantages to patch angioplasty, and we have shown similar patency rates. We recommend balloon angioplasty as a comparable method to salvage dialysis access grafts.     

Feeding practices and nutrition recommendations for infants with cystic fibrosis

OBJECTIVES: To evaluate the frequency and nature of complications in patients undergoing diagnostic cardiac catheterisation and to assess the feasibility of a voluntary cooperative audit system. METHODS: 27 centres enrolled patients over a two year period. Each centre voluntarily reported numbers of patients catheterised every month. Complications were reported as they occurred. Feedback was provided in the form of newsletters and reports. RESULTS: 39,795 procedures were registered, of which 33,776 were diagnostic catheterisations in adults or adolescents, 1265 were paediatric catheter studies in patients under the age of 12 years, and 4754 were coronary angioplasties or balloon dilatation of valves. 83.3% of diagnostic catheter studies in adults were left heart studies with coronary arteriography. The overall complication rate for diagnostic studies was 0.80%, mortality rate 0.12%, emergency surgical intervention rate 0.08%. Complication rates varied between centres, but there was no correlation with case load. Different patterns of complication were associated with different technical approaches. CONCLUSIONS: Complication rates of diagnostic catheterisation are low but neither negligible nor irreducible. Voluntary audit of this kind has limitations, but it is useful and inexpensive.     

Intraarterial ethanol for the management of iatrogenic renal artery pseudoaneurysm

Intraarterial injection of absolute ethanol was employed for the management of a pseudoaneurysm following percutaneous nephrolithotomy. The ethanol was delivered selectively using a coronary angioplasty catheter. This seems to be a potentially useful method for the management of severe hematuria following percutaneous renal procedures.     

Balloon dilatation in acute myocardial infarct in routine clinical practice: results of the register of the Working Society of Leading Cardiologic Hospital Physicians in 4,625 patients

Balloon angioplasty as the treatment of first choice in the setting of an acute myocardial infarction (AMI) is gaining widespread acceptance because of favourable results from specialised centres concerning high patency rates and low mortality. This study reports the results of angioplasty for AMI at large community hospitals during 1992-1995. 4625 procedures were performed at 68 centres of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhaus?rzte (ALKK). The age of the patients was 60.8 +/- 11.3 years, with 75.1% men. The infarct related artery was the left anterior descendent in 43%, the right coronary artery in 37%, the circumflex artery in 16%, a bypass graft in 2.3% and the left main stem in 1.4% of patients. The success rate (residual stenosis < 50%) of the intervention was 86%. There was a wide range of procedures per centre, with a median of 40 AMI angioplasties per year and centre. The amount of angioplasties for AMI in relation to all angioplasties performed during this period rose from 5.2% in 1992 to 5.9% in 1995 (p = 0.01). Local complications at the puncture site occurred in 3.2%, with the need for a surgical intervention in 1.1% of patients. In 273 (5.9%) of the patients a second angioplasty was performed during the hospital stay. Aortocoronary bypass surgery was performed in 3% of the patients. Hospital mortality was 9.5% (438/4625 patients). The mortality rate remained constant during the years investigated (1992: 10.6%; 1993: 8.6%; 1994: 9.7%; 1995: 9.8%; p = ns). Higher mortality was observed in older patients, patients with multiple vessel disease, the left anterior descending artery or a bypass graft as infarct related artery as well as in patients with failed reperfusion (residual stenoses > 50%). Hospitals with a case load of more than 40 angioplasties for AMI per year showed a lower mortality as compared to the others. In clinical practice at large community hospitals results of angioplasty for AMI concerning mortality, complications and technical success rate are comparable to those of highly specialised centres. The absolute numbers of angioplasties for AMI increased constantly over the years.     

Novel vascular sealing device for closure of percutaneous vascular access sites

To investigate the hemostatic capabilities of a novel vascular sealing device consisting of a balloon catheter and procoagulant, vascular sheaths were placed percutaneously in the femoral arteries of dogs. The sealing device was evaluated using the balloon catheter alone in six femoral arteries and with the addition of a procoagulant, in 21 femoral arteries. The balloon catheter alone was successfully deployed in six of six femoral arteries achieving immediate hemostasis. In a second study in which the procoagulant was delivered following balloon placement, the sealing device was successfully deployed and hemostasis was achieved in 20 of 21 attempts (95%) despite removal of the balloon catheter. In a subset of fully anticoagulated animals, hemostasis was achieved in the sealing device-treated arteries at 6.5+/-3.4 minutes, but in none of the controls (P < 0.001). This novel vascular sealing device successfully achieves rapid hemostasis in normal and anticoagulated dogs following percutaneous vascular procedures.     

Initial experience with the use of abciximab in the salvage treatment of acute coronary thrombosis in the Hemodynamics Laboratory

The optimal treatment of acute thrombotic complications in the Catheterization Laboratory has not been defined yet, due to the limited efficacy shown by various pharmacological regimens, even when associated to coronary angioplasty (PTCA). The aim of our study was therefore to evaluate the effects of abciximab (ReoPro), a new potent inhibitor of the platelet glycoprotein IIb/IIIa, when administered as a "rescue" treatment for acute thrombotic coronary occlusion during diagnostic or interventional procedures. Sixteen patients (12 males, 4 females, mean age 59.3 +/- 9.2 years, range 43-77 years), with unstable angina and consecutively treated with abciximab due to clinical instability attributable to coronary thrombosis angiographically proven during PTCA (9 cases) or diagnostic angiography (7 cases), were identified. The individual angiographic films and medical records were then reviewed in order to evaluate the effects of treatment on coronary flow, thrombus size and occurrence of in-hospital adverse events: death, non-fatal acute myocardial infarction (AMI), need for urgent myocardial revascularization and hemorrhage. The administration of abciximab, in association with PTCA (associated in turn with stent implantation in 8 cases), induced a significant increase of coronary TIMI flow grade (0.3 +/- 0.6 vs 2.4 +/- 0.9; p < 0.05) and a significant decrease of thrombus "score" (size) 2.4 +/- 0.9 vs 1.3 +/- 0.6; p < 0.01). No deaths nor need for urgent myocardial revascularization were observed; in 31% of cases (5 patients) evolution towards AMI occurred, while however 94% of cases (15 patients) had a coronary occlusion before treatment. No major hemorrhagic complications were observed, while in 12% of cases (2 patients) a groin hematoma associated with moderate hemoglobin drop, developed. In conclusion, the administration of abciximab, associated with the common "rescue" interventional procedures, in patients with acute thrombotic coronary occlusion in the Catheterization Laboratory, appears to be effective in restoring adequate coronary flow and reducing the thrombus size (limiting therefore the evolution towards AMI), and safe, not having been associated with significant hemorrhagic complications.