Faculty Bibliography

Previous studies have reported worse outcomes for patients with right bundle branch block (RBBB) complicating acute ST-segment elevation myocardial infarction (STEMI). There is a paucity of data examining outcomes with RBBB and STEMI in contemporary large-scale studies. This study aims to explore the outcomes of patients with anterior wall STEMI (AW-STEMI) and RBBB. Using ICD-9 codes, we queried the National Inpatient Sample of 1999 to 2014 to identify AW-STEMI admissions and stratified them for the presence of RBBB. Primary outcome was in-hospital mortality within 30 days. Secondary outcomes included acute heart failure, complete heart block, and permanent pacemaker implantation. Cox-proportional logistic regression models were used to determine the hazard ratios of the primary outcome and secondary outcomes and interventions. Among 1,075,875 weighted anterior wall STEMI (AW-STEMI) admissions, 19,153 (1.8%) had RBBB. Compared with patients without RBBB, mortality was significantly higher for patients with RBBB (9.2% vs 15.3%; p <0.0001). RBBB in the setting of AW-STEMI was associated with a 66% increased risk of 30-day in-hospital mortality (hazard ratios [HR], 1.66; 95% confidence interval [CI], 1.52 to1.81; p <0.0001) and a higher likelihood of acute heart failure (HR, 1.37; 95% CI, 1.29 to 1.45; p <0.0001), complete heart block (HR, 2.90; 95% CI, 2.64 to 3.18; p <0.0001) and utilization of a permanent pacemaker (HR, 2.51; 95% CI, 1.89 to 3.35; p <0.0001). In conclusion, the presence of RBBB in the setting of an AW-STEMI is a significant independent predictor of a poor prognosis, including a higher rate of acute heart failure, complete heart block, need for a permanent pacemaker, and a higher 30-day in-hospital mortality.

BACKGROUND:Transpedal access is increasingly utilized for the treatment of peripheral artery disease (PAD). Femoral-popliteal artery chronic total occlusions (CTOs) are some of the most difficult lesion subsets that sometimes require the use of re-entry support devices during percutaneous intervention. Limited data is available on the use of re-entry devices when treating femoral-popliteal CTOs via transpedal access. The aim of this study was to demonstrate the feasibility of using the Outback® Elite re-entry device for the treatment of femoral-popliteal CTOs via the transpedal approach in an outpatient based lab setting. METHODS:Seventeen patients presented with femoral-popliteal CTOs in which treatment required the use of the Outback® Elite re-entry device. All procedures were performed in a single outpatient based lab. Patients were followed at 1 week and 1 month post-procedure, with lower extremity arterial duplex ultrasound assessment during the 1 month follow-up. RESULTS:The average patient age was 78 years-old, with 71% being males. Most patients presented with Rutherford class IV symptoms. Procedural success was achieved in all patients with no requirement to convert to femoral artery access in any of the cases. No immediate post-procedural complications nor at any time during follow-up were observed. Ultrasonography at 1 month follow-up showed patent intervention sites and access site vessels in all patients. CONCLUSION/CONCLUSIONS:The use of the Outback® Elite re-entry device for the treatment of femoral-popliteal CTOs via transpedal access is a feasible option and may have potential benefits by avoiding risks associated with traditional femoral artery access.

OBJECTIVES:This study investigated the feasibility and safety of transulnar access (TUA) and efficacy of novel TR band modification for dual site hemostasis in patients with failed ipsilateral transradial approach. BACKGROUND:Failed transradial access requires cross over to alternative access site. There is paucity of data on feasibility and safety of ipsilateral TUA due to concern of potential risk of hand ischemia. METHODS:We retrospectively reviewed ten patients who underwent coronary angiography and intervention via ulnar artery in the setting of failed ipsilateral transradial access. Patent hemostasis for both ulnar and radial arteries was achieved with novel modification of the TR band to compress both arteries at the same level of puncture sites. RESULTS:TUA after failed ipsilateral transradial access was successful in all ten cases. All patients were followed within 7 days and there were no adverse complications such as ulnar artery occlusion, nerve injury, or hand ischemia. CONCLUSION:TUA maybe a safe and viable option when cross over is necessary from failed ipsilateral transradial access. Modification of the TR band for both radial and ulnar access site can achieve patent hemostasis effectively at the level of both puncture sites.

BACKGROUND:Improved equipment and techniques have resulted in transition from surgical bypass to endovascular intervention to treat superficial femoral artery (SFA) chronic total occlusions (CTO). A change in access site to radial (TRA) or tibiopedal (TPA) artery for the treatment of these SFA CTO has been reported. The feasibility, efficacy and safety of these two access sites for treatment of SFA CTO have not been reported. METHODS:We performed an as treated analysis of 184 SFA CTO interventions in 161 patients from 01/2014 to 09/2016 using either primary TRA or TPA (operator discretion) at two institutions. Primary end point was 30 day major adverse event (MAE) - death, amputation or target vessel revascularization, secondary endpoint was success of procedure. RESULTS:Primary TRA was used in 46 patients with 47 CTO lesions .Primary TPA was used in 115 patients with 137 CTO lesions. Primary crossing success rate was higher with TRA compared to TPA (74% vs 54%, P = 0.01). Dual TRA-TPA was required in 72 prior uncrossed lesions resulting in a crossing and procedural success of 99% and 96% respectively. The overall crossing and procedural success rate using either of these approaches was 99% and 98% respectively. The 30 day MAE was 5% in TRA arm, 0% in TPA arm and 2% in dual TRA-TPA arm, P = 0.08. All access sites were patent, confirmed by ultrasound. CONCLUSION/CONCLUSIONS:The treatment of SFA CTO is feasible and safe using both TRA or TPA approach providing high success rates and no access site complications.

Lack of health insurance is associated with adverse clinical outcomes; however, association between health insurance status and outcomes in patients presenting with ST-elevation myocardial infarction (STEMI) is unclear. Using the Nationwide Inpatient Sample data from 2003 to 2014, hospitalizations with STEMI in patients 18 years of age and older were extracted. Based on health insurance status, patients were categorized into insured and uninsured groups. The primary outcome measure was in-hospital mortality. Adjusted analysis using inverse probability weighting with multivariable regression was performed to identify independent predictors of in-hospital mortality. Of 2,710,375 patients included in the final analysis, 220,770 patients were uninsured. Unadjusted in-hospital mortality was lower in uninsured patients (5.1% vs 9.3%; p <0.001). Adjusted analysis showed that lack of health insurance was associated with the worst in-hospital mortality (odds ratio [OR] = 1.77, 95% confidence interval [CI] 1.72 to 1.82; p <0.001). Other independent predictors of in-hospital mortality were low household income (OR = 1.08, 95% CI 1.07 to 1.09; p <0.001), acute stroke (OR = 2.87, 95% CI 2.80 to 2.95; p <0.001), acute kidney injury (OR = 2.60, 95% CI 2.57 to 2.64; p <0.001), cardiac arrest (OR = 8.88, 95% CI 8.77 to 8.99; p <0.001), cardiogenic shock (OR = 5.81, 95% CI 5.74 to 5.88; p <0.001), requirement of pericardiocentesis (OR = 10.54, 95% CI 9.64 to 11.52; p <0.001), gastrointestinal bleeding (OR = 1.41, 95% CI 1.38 to 1.54; p <0.001), and pneumonia (OR = 1.43, 95% CI 1.41 to 1.45; p <0.001). The multivariate model demonstrated good statistical discrimination (c-statistic = 0.89). In conclusion, lack of health insurance is independently associated with increased in-hospital mortality in patients presenting with STEMI.

Background: Lack of health insurance is associated with adverse clinical outcomes; however, effects of health insurance status on outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) is unclear. Methods: Using the Nationwide Inpatient Sample (NIS) data from 2003-2013, hospitalizations with STEMI in patients 18 years of age and older were extracted. Depending on their primary payer status, patients were categorized into insured and uninsured groups. The primary study outcome measure was in-hospital mortality. Adjusted analysis using inverse-probability weighting with multivariable regression was performed to evaluate the independent predictors of in-hospital mortality. Results: Of 4,812,009 patients included in the final analysis, 4,426,747 (92%) patients were insured, whereas 385,262 (8%) patients were uninsured. Unadjusted in-hospital mortality was lower in uninsured patients (5% vs 9.5%; P=0.0005). Uninsured patients presented with STEMI at a younger age and with fewer diagnosed comorbidities. Independent predictors of in-hospital mortality were lack of health insurance (O.R=1.36, 95% C.I [1.34-1.39], P=0.0005), low household income (O.R=1.12, 95% C.I [1.11-1.3], P=0.0005), acute cerebrovascular accident (O.R=2.94, 95% C.I [2.89-3.00], P=0.0005), acute kidney injury (O.R=2.67, 95% C.I [2.64-2.69], P=0.0005), cardiac arrest (O.R=8.66, 95% C.I [8.58-8.75], P=0.0005), cardiogenic shock (O.R=5.31, 95% C.I [5.26-5.37], P=0.0005) requirement of pericardiocentesis (O.R=10.86, 95% C.I [10.15-11.62], P=0.0005), gastrointestinal bleeding (O.R=1.42, 95% C.I [1.39-1.44], P=0.0005), mechanical circulatory support (O.R=1.30, 95% C.I [1.29-1.32], P=0.0005) and pneumonia (O.R=1.45, 95% C.I [1.43-1.47], P=0.0005). The multi-variate model demonstrated good statistical discrimination (c-statistic=0.89). Conclusion: Lack of health insurance is independently associated with increased in-hospital mortality in patients presenting with STEMI

Background: Transradial access (TRA) as compared to transfemoral access (TFA) for percutaneous coronary intervention (PCI) is being increasingly popular because of fewer vascular complication rate and early ambulation. TF approach is the preferred approach for CTO-PCI because it allows the use of large catheters with better passive support. TRA utilization in CTO-PCI is increasing. We aimed to evaluate the safety and procedural outcomes of the TRA versus TFA for PCI of CTO. Methods: A systematic search of database, including, Pubmed, Web of Science, Google scholar and Cochrane Database were performed by two independent reviewers to identify relevant studies. Studies comparing TRA versus TFA in patients undergoing CTO-PCI were included. The primary outcome measure was procedural success rate and secondary outcomes studied were total procedure time, fluoroscopy time, contrast volume, access-site complications and other in-hospital major procedural complications. Random-effects model was used and publication bias was calculated. Results: Eleven studies, including 5120 patients were included in the analysis. The procedural success rate was significantly higher in the TRA group as compared to TFA group in the unadjusted pooled analysis (OR, 1.37 [CI 1.11, 1.68], I²=37%), however, the adjusted analysis showed no significant difference between the two groups (OR, 1.26 [CI 0.67, 2.4], I²=61%). Access-site complication rate was lower in the TRA group as compared to TFA group (OR, 0.32 [CI 0.15, 0.69], I²=10%). Total procedure time (WMD, -0.33 minutes [CI -13.54, 12.88], I²=90%), fluoroscopy time (WMD, -2.59 minutes [CI -9.73, 4.54], I²=88%) and the contrast volume (WMD, 7.17 ml [CI -27.02, 41.36], I²=79%) were comparable between the two groups. The rate of other procedural complications was also comparable between the two groups (OR, 0.71 [CI 0.38, 1.32], I²=25%). There was no evidence of publication bias for the primary outcome measure, (Begg-Mazumdar (p=0.61) and Egger's (p=0.87) rank correlation test). Conclusion: TRA is safe and feasible in patients with PCI of CTO with similar procedural success rate and is associated with a lower vascular complication rates as compared to TF approach

BACKGROUND: Atherosclerotic disease of the superficial femoral artery (SFA) is frequently seen and can be treated with percutaneous interventions, traditionally via femoral artery access. There are limited reports of transpedal artery access for peripheral artery interventions, but none to date describing routine primary transpedal artery approach for SFA stenting. METHODS: In this preliminary study, we report 4 patients who underwent successful endovascular SFA stenting using a single transpedal artery access via a new ultra-low profile 6 Fr sheath (Glidesheath Slender; Terumo Corporation). RESULTS: All patients underwent successful SFA stenting without complication. Procedure time varied from 51 to 72 minutes. The mean contrast amount used was 56 mL; mean fluoroscopy time was 21 minutes; mean radiation dose was 91 mGy. At 1-month follow-up, duplex ultrasonography showed that all pedal arteries had remained patent. CONCLUSIONS: Transpedal artery approach as a primary approach to SFA stenting appears feasible and safe. Comparative trials with standard percutaneous femoral approach are warranted.