Clinical and Economic Outcomes of Embolic Complications and Strategies for Distal Embolic Protection during Percutaneous Coronary Intervention in Saphenous Vein Grafts
Background. Although distal embolic protection (DEP) is increasingly utilized in saphenous vein graft percutaneous coronary intervention (SVG PCI), the clinical and economic outcomes of different DEP strategies are unknown. Methods. We compared 3 DEP strategies (no DEP, routine DEP, selective DEP in high-risk cases) in 126 consecutive cases of SVG PCI performed without DEP in a single catheterization laboratory over a 4-year period. No SVG PCI was excluded. High risk was defined using 2 multivariate predictors of embolic complication previously validated by NCDR (graft age greater than or equal to 8 years and/or friable appearance with thrombus). Costs were determined by a ratio of cost-to-charges methodology and average cost of the two FDA-approved DEP devices ($1,350) with similar efficacy. Results. Without DEP, the incidence of embolic complications was 17% (22/126), resulting in major adverse coronary events (MACE) in 3.2% (4/126) of all cases: 2 deaths, 1 myocardial infarction, and 1 emergency coronary artery bypass. Embolic complications significantly increased both procedure costs by $2,725 (p < .001) and total hospital costs ~$2,800 (p < 0.05). Risk adjustment for selective DEP use correctly predicted 86% (19/22) of embolic complications, including all MACE, at an incremental cost of $684/patient for selective DEP versus $1,150/patient for routine DEP. Selective DEP would cost $43,127 per death prevented versus $72,461 using routine DEP during the index hospitalization. Conclusions. Embolic complications increase cost in excess of the cost of a DEP device. This risk adjustment model correctly predicted the majority of cases of embolic complication and all MACE, suggesting that selective DEP use may help reduce utilization of DEP by an almost 50% cost reduction compared to routine use.
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A Novel Use for a Distal Embolic Protection Device: Stent Retrieval
A Novel Use for a Distal Embolic Protection Device: Stent Retrieval CASE REPORTS: A Novel Use for a Distal Embolic Protection Device: Stent Retrieval - Pavel Guigauri, MD and Harold L. Dauerman, MD Stent embolization is an uncommon but potentially serious complication of percutaneous coronary intervention (PCI). the difficulty in utilizing snares and balloons for stent retrieval, we describe a new method of stent retrieval utilizing a distal embolic ...
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Randomized Trial of a Distal Embolic Protection Device During Percutaneous Intervention of Saphenous Vein Aorto-Coronary Bypass Grafts
Randomized Trial of a Distal Embolic Protection Device During Percutaneous Intervention of Saphenous Vein Aorto-Coronary Bypass Grafts Feature: Randomized Trial of a Distal Embolic Protection Device During Percutaneous Intervention of Saphenous Vein Aorto-Coronary Bypass Grafts - Donald S. Baim, MD, Dennis Wahr, MD, Barry George, MD, Martin B. Leon, MD, Joel Greenberg, MD, Donald E. Cutlip, MD, Unsal Kaya, MS, Jeffrey J. Popma, MD, Kalon K.L. Ho, ,MD, MSc, Richard E. Kuntz, MD, MSc; on behalf...
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Percusurge Guardwire Balloon-Associated Thrombus ? A Limitation of the Percusurge Distal Protection System
Saphenous vein graft interventions represent a challenge to interventional cardiologists because of the frequent and unpredictable incidence of distal embolization. Distal embolic protection devices have demonstrated a reduction in the incidence of this phenomenon. As the use of these devices becomes more frequent outside research protocols, the limitations of different devices will become apparent. Thrombus at the site of the distal occlusive balloon of the Percusurge distal embolic protection system was noted in the case described and represents a potential drawback of this form of distal protection.
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COMMENTARY: Can Distal Embolic Protection Yield Better Results in Acute Myocardial Infarction Treatment?
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Distal Embolic Protection ? Don't Cause a Stroke Trying to Prevent One!
Embolic Protection Device (ev3 Inc., Plymouth, Minnesota) provides further evidence of the merit of these newer-generation ? The earlier generation protection devices such as the PercuSurge device (Medtronic, Inc., Minneapolis, Minnesota), the Angiogard device (Cordis Corporation, Miami, Florida), and the Accunet? Soon after the introduction of embolic protection devices in U.S. trials, I found myself excessively manipulating the first-generation devices through many typical high-grade ...
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Contemporary Management of Vein Graft Disease
Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts. Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts: The Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts (RECOVERS) Trial. Clinical outcomes after sirolimus-eluting stent implantation for de novo saphenous vein graft lesions.
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Intragraft Nicardipine Prophylaxis to Prevent No-reflow in Triple-vessel Saphenous Vein Graft Intervention
ABSTRACT: Saphenous vein graft angioplasty and stenting has been associated with a relatively high risk of no-reflow and myocardial necrosis. The injectable dihydropyridine calcium channel blocker, nicardipine, is a highly potent arteriolar vasodilator, could be valuable as a prophylactic treatment to prevent no-reflow during SVG interventions. We examined the use of prophylactic, intracoronary (intra-graft) nicardipine, without distal protection, as a means to prevent no-reflow and myocardial necrosis in two consecutive patients undergoing 3-vessel, saphenous vein graft intervention. Following IC nicardipine injection, six stents were placed via direct stenting in the six degenerated SVGs. The average graft age was 13.5 years. Clinical, electrocardiographic, enzymatic (CPK and CPK-MB, troponin) and quantitative coronary angiographic methods were used to assess the safety and efficacy of this treatment in these two high-risk cases. There were no clinical, enzymatic or electrocardiographic signs of ischemia or injury after the use of nicardipine IC injection combined with direct stenting in these cases. Angiograph-ically, TIMI flow was 2.33 ± 0.52 prior to intervention, and improved to 3.0 ± 0.0 after intervention. The mean (TIMI) myocardial blush scores from the 6 SVG distributions improved from 1.82 ± 0.41 prior to intervention, to 2.67 ± 0.52 after intervention. The CPK peaks were 79 IU and 105 IU, respectively, in the two cases (upper limit normal = 190 IU). In summary, the dihydropyridine calcium channel blocker, nicardipine, may provide effective prophylaxis for no-reflow and myocardial necrosis, without the routine use of distal embolic protection devices, in SVG stent interventions. A larger prospective study is warranted to expand upon this preliminary observation.
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The Evolving Role of Glycoprotein (GP) IIb/IIIa Receptor Blockade During Percutaneous Coronary Intervention of Saphenous Vein Bypass Grafts
GP receptor blockade trials during SVGB intervention. B. Delayed SVBG intervention after pretreatment with a GP IIb/IIIa receptor blocker. D. Distal protection devices and GP IIb/IIIa receptor blockade.
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Massive Air Embolus Treated with Rheolytic Thrombectomy
ABSTRACT: The incidence of air embolism during diagnostic cardiac catheterization and percutaneous coronary intervention is reported at a rate of 0.84% and 0.24%. Although there is no optimal technique to restore blood flow after blockage by air emboli, treatment options include manual aspiration or forcefully injecting saline, with auxiliary supportive measures like 100% oxygen or an intra-aortic balloon pump. The AngioJet (Possis Medical, Inc., Minneapolis, Minnesota) device is a catheter-based device for thrombus removal in which high-velocity saline jets are used to create a localized low-pressure zone at the distal catheter tip (Bernoulli effect), resulting in the maceration and removal of thrombus through an exhaust lumen. The use of rheolytic thrombectomy has been studied in thrombus-containing native coronary arteries as well as saphenous vein graft lesions. We report a case of a massive air embolus that occurred after activation of an AngioJet catheter in a thrombus-laden right coronary artery (RCA). The AngioJet catheter was then utilized to effectively aspirate the air embolus with restoration of coronary blood flow. Use of a guiding catheter that is nonocclusive or with side holes to ensure continuous blood flow from the central aorta may help avoid entrainment of air into the coronary artery during activation of the AngioJet thrombectomy catheter. To our knowledge, this is the first reported case of such a potential complication. In the event of such a complication, the AngioJet catheter can be implemented to aspirate a coronary air embolus. J INVASIVE CARDIOL 2007;19:E182?E184
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 Electrophysiologic Perspective on the BIPOLAR RF EPICARDIAL ABLATION Procedure for Atrial Fibrillation
Complimentary Accredited Breakfast Symposium
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Location: The St. Regis San Francisco
125 3rd Street
San Francisco, CA 94103
3rd and Mission Streets
Gallery Ballroom, 2nd floor
This activity is supported by an educational grant from AtriCure, Inc.
This program is not part of the Heart Rhythm 2008 Official Scientific Sessions as planned by the Heart Rhythm Society Scientific Sessions Committee. This event is neither sponsored nor endorsed by the Heart Rhythm Society.
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 Newest Perspectives on Drug-Eluting Stents
Complimentary CME Accredited Dinner Meetings Click Here for More Info.
Miami, FL - Date: Friday, April 4, 2008 6:00pm EST -8:00 pm EST
Birmingham, AL - Date: Friday, May 9, 2008 6:00pm EST -8:00 pm EST
This activity is supported by an educational grant from Abbott Vascular.
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 CLINICAL EXPERIENCE WITH A NEW HYBRID CORONARY WIRE
On Demand Web Archive
Non-Accredited
This activity is supported by an educational grant from Terumo Medical Corporation.
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 Pharmacoinvasive Management of Acute Coronary Syndrome: Incorporating the 2007 ACC/AHA Guidelines
Complimentary Accredited CME Program
This activity is supported by an educational grant from Sanofi-Aventis.
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 Varicose Veins: Causes, Symptoms, Diagnosis and Treatment of Chronic Venous Insufficiency
A Complimentary Accredited ON-DEMAND Webcast
This activity is supported by an educational grant from Diomed, Inc.
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 Create a Successful Vena Cava Filter Practice
Accredited CD
This activity is supported by an educational grant from Cook Incorporated and has been designed for Interventional Cardiologists, Vascular Surgeons, Fellows and Interventional Cardiovascular Nurses and Technologists.
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Webcast and Web Archives |
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 Achieving Optimal Outcomes in Carotid Stenting: Lessons Learned from Recent Clinical Trials
Complimentary Accredited ON DEMAND Webcast
Topics
1. EVA-3S & Space-Bumps in the road
2. CAPTURE 3500-Lesion morphology & Predictors for Stroke
3. CAPTURE II vs. EXACT 1500-Does open or Closed Cell Stent design really matter?
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Neurologists, Interventional Nurses and Technologists with an interest in the diagnosis and treatment of peripheral artery disease. |
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 Anticoagulation Techniques for Peripheral Vascular Interventions
Complimentary Accredited ON DEMAND Webcast
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 New Treatment Strategies for the Endovascular Approach to Critical Limb Ischemia: ADVANCEMENTS IN LIMB SALVAGE MEDICINE
Complimentary Accredited ON DEMAND Webcast
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 Reducing the Incidence of CIN during Cardiac Catheterization and PCI
Complimentary Accredited ON DEMAND
Educational Web Archive
This activity has been developed for nurses and technologists. |
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March 2007 Supplement
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On-Demand Webcast
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Archived Webcast
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Release Date: December 8, 2006