The superiority of low-molecular weight heparin (LMWH) over unfractionated heparin (UFH) in the management of acute coronary syndrome (ACS) patients was demonstrated in the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE)1 and Thrombolysis in Myocardial Infarction (TIMI) 11B2 trials, and since then, LMWH has become a mainstay of management for these patients. However, LMWH has not become a preferred anticoagulant in the context of percutaneous coronary intervention (PCI), in part because the Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial3 did not show any difference in the primary efficacy outcome, but was associated with an elevated in-hospital major bleeding rate in patients who received LMWH compared to UFH. One of the limitations of the SYNERGY trial was that monitoring was performed for the UFH group, but not for the LMWH group.

Percutaneous femoral access is utilized for 7.5 million patients per year worldwide and vascular closure devices are used in approximately 2 million patients annually. All current vascular closure devices (VCDs) have been associated with adverse events, but VCDs appear to have a similar or somewhat reduced rate of overall complications compared to manual compression.1–4 The risks associated with the use of VCDs in high-risk patient subsets, such as those with non-ideal femoral anatomy, is unclear, as these patients have been excluded from the pivotal studies leading to FDA approval of these devices.

The prevalence of diabetes has reached epidemic proportion in many sectors of the world.1 Atherosclerotic cardiovascular disease has been correlated with the presence, duration and severity of diabetes.2,3 In addition, both clinical and angiographic outcomes following percutaneous coronary intervention (PCI) are worse in patients with diabetes when compared with their nondiabetic counterparts.4,5 Although coronary stent implantation improved the outcomes of diabetic patients compared with balloon angioplasty due to a reduction in periprocedural and late (restenosis) complications,6–8 restenosis following bare-metal stent (BMS) deployment remained a significant limitation to PCI in this patient population.9,10 Stent-based elution of either paclitaxel or sirolimus from biostable polymers has been demonstrated to reduce angiographic and clinical restenosis compared with BMS deployment in patients both with or without diabetes

Vascular closure devices (VCDs) provide simple, painless and reliable hemostasis following endovascular procedures performed via femoral arterial access. Their use has enhanced patient comfort and satisfaction, shortened the time to ambulation and preserved valuable catheterization laboratory resources.^1–3 Despite these desirable results, however, VCDs are used in 20–25% of all catheter-based procedures performed worldwide.^4–5 The reason for this gap has historically been attributed to two major issues: cost considerations and the lack of level-I data proving a clinically relevant reduction in access-site major vascular complications (MVCs) compared to the gold-standard practice of manual compression. Another important, yet relatively underrated, factor that may explain this discrepancy is that the original VCD studies had remarkably long lists of exclusions, which in turn limited the pool of potential recipients.

The prevalence of diabetes has reached epidemic proportion in many sectors of the world.1 Atherosclerotic cardiovascular disease has been correlated with the presence, duration and severity of diabetes.2,3 In addition, both clinical and angiographic outcomes following percutaneous coronary intervention (PCI) are worse in patients with diabetes when compared with their nondiabetic counterparts.4,5 Although coronary stent implantation improved the outcomes of diabetic patients compared with balloon angioplasty due to a reduction in periprocedural and late (restenosis) complications,6–8 restenosis following bare-metal stent (BMS) deployment remained a significant limitation to PCI in this patient population.9,10 Stent-based elution of either paclitaxel or sirolimus from biostable polymers has been demonstrated to reduce angiographic and clinical restenosis compared with BMS deployment in patients both with or without diabetes

First-generation balloon-expandable stents such as the Palmaz-Schatz stent were often deployed at low pressure using compliant delivery balloons. Overhang of the deployment balloon outside the stent increased the risk of edge dissection when high-pressure inflation was used. Intravascular ultrasound (IVUS) studies showed that stents deployed in this fashion were often underexpanded and postdilatation with higher pressures or larger balloons was required to optimize stent expansion.1 Postdilatation following stent implantation was shown to increase the mean stent minimal lumen diameter (MLD) by 16%, and the mean stent minimal cross-sectional area (CSA) by 35%.2,3 Improvements in stent design and delivery systems have enabled modern stents to be deployed at high pressure.

First-generation balloon-expandable stents such as the Palmaz-Schatz stent were often deployed at low pressure using compliant delivery balloons. Overhang of the deployment balloon outside the stent increased the risk of edge dissection when high-pressure inflation was used. Intravascular ultrasound (IVUS) studies showed that stents deployed in this fashion were often underexpanded and postdilatation with higher pressures or larger balloons was required to optimize stent expansion.¹ Postdilatation following stent implantation was shown to increase the mean stent minimal lumen diameter (MLD) by 16%, and the mean stent minimal cross-sectional area (CSA) by 35%.^2,3

Postdilatation is the least-studied aspect of current stenting technique, the neglected child in the large family of interventional wunderkinds. In contrast to the high-stakes sirolimus-versus-paclitaxel controversy, which has produced an endless series of trials, there is not much money to be made from postdilatation. If there were, we would be inundated with postdilatation studies as well.

Contrast media plays an important role in defining coronary anatomy in diagnostic and interventional cardiac catheterization procedures as well as in radiology. Iodine-containing compounds have been shown to have radio-opaque properties that attenuate X-rays during radiographic examinations. The first organic contrast compound, lipiodol, was discovered in 1901, but was not used until years later in radiological studies.1 With the introduction of water-soluble compounds in later years, Dr. Seldinger was the first person who used contrast media in cardiac catheterization.2 At that time, sodium diatrizoate was the prototype of the tri-iodinated benzene ring compounds used in imaging.

Ductal origin of the distal pulmonary artery1 is characterized by a patent ductus arteriosus in continuity with the proximal end of a pulmonary artery (either left or right, or both) with no continuity to the main pulmonary artery (PA). Progressive closure of the ductus arteriosus results in the loss of blood flow to the dependent PA. This malformation has been recognized in a variety of congenital heart diseases including ventricular septal defect (VSD), tetralogy of Fallot, and heterotaxy syndrome tetralogy of Fallot variants.2-6
Surgical reconstruction of the disconnected pulmonary branches has been described.2-4,7,8 In recent years, percutaneous techniques have been tremendously improved and they are increasingly selected as valuable alternatives to surgery. Here we report on a series of 5 infants weighing < 3 kg with ductal origin of the PA associated with other congenital heart disease, in which a percutaneous approach was used.