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A case of necrosis of the entire extrahepatic biliary tract after cardiac catheterization is presented. The axial blood supply to these structures makes them susceptible to ischemic injury.
Once considered dangerous and potentially life threatening, cardiac catheterization of the patient with pulmonary hypertension can be performed safely and provides essential information in the diagnosis and management of pulmonary hypertension. This article summarizes the modern techniques used for right-heart catheterization, selective pulmonary angiography, and pulmonary angioscopy in the evaluation of the patient with pulmonary hypertension or suspected chronic thromboembolic disease.
This article describes the current management of patients undergoing an interventional cardiac catheterization. New catheters, monitoring equipment, and standards for skilled personnel have allowed for more aggressive and definitive treatments for improving the life of a fragile patient.
Severe acute respiratory syndrome (SARS) is a highly contagious disease that has led to large hospital and community outbreaks, necessitating stringent infection control in its management. Among 90 SARS patients in our institution in the 2003 outbreak, 2 underwent cardiac catheterization. We report the personal respiratory protection and environmental control measures implemented to minimize the risk of droplets spread during these procedures, including re-engineering of the ventilation system of the cardiac catheterization laboratory (CCL). The report highlights the importance of collaboration of CCL personnel with relevant hospital engineering and management teams to develop a contingency infection control plan to prepare for future outbreaks of SARS or other epidemics.
This study evaluated the efficacy of intraarterial papaverine infusion after pediatric cardiac catheterization in reducing the incidence of lost pulse. This study was conducted at a teaching pediatric hospital and was designed as a randomized, prospective, double-blind, placebo-controlled study. Patients were children 5 years old or less undergoing antegrade and retrograde heart catheterization. The intervention used was an intraarterial infusion of placebo or 1.5 mg/kg papaverine after catheterization. Bilateral femoral artery ultrasound study was performed pre- and postcatheterization, including two-dimensional, color, spectral, and pulsatility index analysis. Outcome measures included clinical loss of pulse, ultrasound findings, plus other clinical factors. Fifty-six patients participated in the study (28 per group). Six patients clinically lost the pulse in the catheterized arteries [four in the papaverine and two in the placebo groups (p > 0.64)]. Clinical loss of pulse correlated with diminished pulsatility index (p < 0.035). The use of papaverine did not prevent decreased pulse or pulsatility index (p > 0.79). Increased arterial time was the only clinical factor associated with lost pulse (p < 0.0004). Pulsatility index <3.34 correlated with loss of pulse in the catheterized artery. The results indicated that intraarterial papaverine infusion after femoral artery catheterization does not prevent loss of pulse in the catheterized artery, and decreased pulsatility index correlates with diminished pulse and represents a good noninvasive method of evaluating femoral artery patency and flow.
BACKGROUND: Femoral pseudoaneurysm (FPA) is one of the common complications of percutaneous catheterization procedures performed via the femoral artery. The aim of this research was to evaluate factors associated with FPA of sufficient clinical significance that they required surgical treatment after diagnostic or interventional cardiac catheterization. METHODS: We evaluated 41,322 transfemoral catheterization procedures performed in our center within 7 years. Among all procedures, 630 FPAs developed that required surgical repair. Eighty-five cases were managed by compression with duplex guidance. As a case-control group, 1260 patients were selected from the patients who had been catheterized during the same time period but did not develop FPA. Two controls were selected for each study patient, matched according to age, sex, and catheterization day. Body mass index, hypertension, diabetes mellitus, catheter diameter, coronary artery disease, atherosclerosis, and number of cases performed per day in a particular room were evaluated as risk factors by using multivariate techniques. RESULTS: Femoral pseudoaneurysm required operative repair in 1.1% (n = 398) of patients who underwent cardiac catheterization for diagnostic purposes and in 4.7% (n = 232) of patients after cardiac interventional procedures. Factors found to be independently predictive of FPA were hypertension (P = .011; odds ratio, 1.52), diabetes mellitus (P = .035; odds ratio, 1.11), coronary artery disease (P = .022; odds ratio, 1.21), larger (> or = 28 kg/m2) body mass index (P < .001; odds ratio, 2.21), larger number of cases (> or = 18) performed per day in a particular room (P < .001; odds ratio, 2.39), and larger (> or = 7F) catheter diameter (P < .001; odds ratio, 2.82). CONCLUSIONS: Due to the development of technology and experience, more and more diagnostic and interventional catheterization procedures are performed on a daily basis. In our study, a high volume of cases in a particular room and use of large catheters were important risk factors for FPA complications. When these situations are combined with other risk factors (such as obesity, diabetes mellitus, hypertension, and arteriosclerosis), giving particular attention to local compression therapy would be more crucial to decrease the FPA rate.
Cerebral embolization has been documented as one of the complications of diagnostic heart catheterization by transcranial Doppler (TCD). This study aimed to evaluate our hypothesis that the nature of embolic signals involved in different stages of catheter manipulation may be distinct. TCD-detected cerebral emboli occurring at different phases of cardiac catheterization were registered and differentiated by comparing their acoustic signatures with the Doppler signals generated from clinically frequently encountered embolic materials in an in vitro middle cerebral artery model. We found that there was a significant difference in embolic signal intensity and duration between different phases of cardiac catheterization. Our data suggest that different types of emboli may be involved in different phases of the catheterization. Cathet Cardiovasc Intervent 2001;53:323-330.
Access site pseudoaneurysms are uncommon but well-known complications of cardiac catheterization. We report the first known case of a pseudoaneurysm mimicking the presentation of a deep venous thrombosis by causing extrinsic compression of the venous system. The patient had complete resolution of the pseudoaneurysm and his symptoms following treatment with ultrasound-guided percutaneous thrombin injection.
Despite the continuous reduction of sheath sizes in diagnostic and interventional cardiac catheterizations and the discontinuation of coumadin use after coronary stent implantation, a challenging role remains for hemostatic devices in the sealing femoral puncture sites. Since the introduction of the vascular hemostatic device (VHD) in 1991 and the hemostatic puncture closing device (HPCD) in 1992, numerous studies investigating these devices have been published. The deployment success rates reported in 2,292 patients for VHD is 97%, ranging from 88 to 100%. For HPCD, the mean deployment success rate resulting from 622 published patients leads to an identical result of 97%, ranging between 91 and 100%. For time to hemostasis, data have been analyzed according to the four different clinical situations, depending on level of anticoagulation (none or full) and the time of sheath removal (immediate or delayed). In randomized studies, when compared with the manual control groups, both devices revealed a statistically significant reduction in time to hemostasis: 12 to 16 minutes less for diagnostic catheterization and 14 to 30 minutes less for PTCA. As for minor local complications, no clinically relevant differences seem to exist. None of these devices has been proven to reduce major local complications. Prospective trials addressing early mobilization after percutaneous transluminal coronary angioplasty and the cost effectiveness of arterial closure devices in defined subgroups are warranted.
BACKGROUND: Although modern contrast agents have tolerability superior to older agents, significant differences remain between the agents currently in use. METHODS: To investigate the incidence of early (<24 hours) and late (>24 hours to 7 days) reactions to 3 contrast agents commonly used in cardiac catheterization, we performed a randomized, prospective, double-blind trial in which 2001 patients received one of the following agents: iopamidol 340, a nonionic monomer; ioxaglate 320, an ionic dimer; and iodixanol 320, a nonionic dimer. Possible reactions to contrast were recorded during the hospital admission and after discharge by means of a questionnaire, telephone follow-up, or both. RESULTS: Early reactions occurred in 22.2% of those receiving ioxaglate, 7.6% of those receiving iodixanol, and 8.8% of those receiving iopamidol (P <.0001). Late skin reactions occurred in 12.2% of those receiving iodixanol, 4.3% of those receiving ioxaglate, and 4.2% of those receiving iopamidol (P <.0001). CONCLUSIONS: The early side effect profile of certain ionic contrast agents suggests that these agents should no longer be used routinely in cardiac catheterization. The use of nonionic agents, however, is associated with late skin reactions, but there are notable differences between the monomeric and dimeric compounds. Although the skin reactions are generally benign, this is not always the case. Patients should be advised accordingly.
BACKGROUND: Remifentanil is recommended for use in procedures with painful intraoperative stimuli but minimal postoperative pain. However, bradycardia and hypotension are known side-effects. We evaluated haemodynamic effects of i.v. glycopyrrolate during remifentanil-sevoflurane anaesthesia for cardiac catheterization of children with congenital heart disease. METHODS: Forty-five children undergoing general anaesthesia with remifentanil and sevoflurane were randomly allocated to receive either saline, glycopyrrolate 6 microg kg(-1) or glycopyrrolate 12 microg kg(-1). After induction of anaesthesia with sevoflurane, i.v. placebo or glycopyrrolate was administered. An infusion of remifentanil at the rate of 0.15 microg kg(-1) min(-1) was started, sevoflurane continued at 0.6 MAC and cisatracurium 0.2 mg kg(-1) was given. Heart rate (HR) and non-invasive arterial pressures were monitored and noted every minute for the first 10 min and then every 2.5 min for subsequent maximum of 45 min. RESULTS: Baseline HR [mean (SD)] of 117 (20) beats min(-1) decreased significantly from 12.5 min onwards after starting the remifentanil infusion in the control group [106 (18) at 12.5 min and 99 (16) beats min(-1) at 45 min]. In the groups receiving glycopyrrolate, no significant decrease in HR was noticed. Glycopyrrolate at 12 microg kg(-1) induced tachycardia between 5 and 9 min after administration. Systolic and diastolic arterial pressures decreased gradually, but there were no significant differences in the pressures between groups. CONCLUSION: I.V. glycopyrrolate 6 microg kg(-1) prevents bradycardia during general anaesthesia with remifentanil and sevoflurane for cardiac catheterization in children with congenital heart disease. Administering 12 microg kg(-1) of glycopyrrolate temporarily induces tachycardia and offers no additional advantage.
Lobar emphysema is an uncommon cause of respiratory distress in infancy. Congenital heart disease is seen in about 20% of the patients with infantile (congenital) lobar emphysema. We described six infants with lobar emphysema. In three of them a congenital heart disease was demonstrated by cardiac catheterization and cineangiography; two had a tetralogy of Fallot with right aortic arch and the third infant a ventricular septal defect. The pulmonary angiography showed stretching of the arteries with very poor filling of the peripheral arteries and a characteristic smaller pulmonary vein in the affected lobe. In all the six patients the pulmonary artery pressure was normal. All the patients underwent lobectomy with good results. We feel that a preoperative cardiac catheterization and cineangiography is of value in this very sick group of infants.
It has been suggested that the myocardium is able to recruit endogenous protective mechanisms in response to repeated ischemia and reperfusion. We set out to study whether this is manifested in patients with coronary artery disease in the form of fewer signs of myocardial ischemia during the second of two successive exercise tests and whether any relations exist between ischemia adaptation and findings at cardiac catheterization. Twenty-one patients with typical angina pectoris symptoms underwent two repeated bicycle exercise tests with identical protocols, followed by cardiac catheterization and coronary angiography the next day. The first exercise test was discontinued whenever a 2 mm ST depression in the electrocardiogram (ECG) was achieved or further exercise was limited by symptoms. The second exercise test was performed after disappearance of the symptoms or ST depression or both. Kaplan-Meier survival analysis for the appearance of a 1 mm ST depression demonstrated improved ischemia tolerance during the second test, when the required time for its appearance was significantly longer (6.5 +/- 0.8 min vs 4.5 +/- 0.5 min; p = 0.005). The maximal intensity of anginal pain was lower during the second exercise (2.2 +/- 1.0 min vs 0.7 +/- 0.3 min in Borg's scale; p < 0.001), and the time required for disappearance of the ST depression was shorter after this exercise (3.0 +/- 0.8 min vs 6.2 +/- 0.9 min; p = 0.003), with a similar tendency in the disappearance of angina. The rate-pressure product on the appearance of a 1 mm ST depression was significantly higher during the second test (17,990 +/- 1210 mm Hg x min-1 vs 15,960 +/- 869 mm Hg x min-1; p = 0.009). Eighteen of the patients had three-vessel disease, as evidenced by coronary angiography, and the change in the time required for the appearance of a 1 mm ST depression in the repeated exercise tests was inversely correlated with the severity of the left anterior descending (LAD) coronary artery obstruction (r = -0.61; p = 0.006) and left ventricular end-diastolic pressure (r = -0.50; p = 0.03). No significant correlation with the degree of collateral vessels was found. We conclude that most patients with extensive coronary artery disease are able to increase their tolerance of ischemia during repeated dynamic exercise and that increased vasodilation and oxygen delivery are the major mechanisms for this warm-up phenomenon. On the other hand, collaterals visible in routine resting anglography do not predict the degree of adaptation to ischemia during repeated dynamic exercise.
Peduncular hallucinosis (PH) is a rare form of visual hallucination characterized by vivid, nonstereotypical visual images of people, animals, and plants of brief duration that are nonthreatening to the patient. The clinical syndrome of PH consists of formed visual hallucinations, localizing signs of the offending lesion, and sleep disturbances. In the absence of localizing focal neurologic deficits, it is easily confused with a delirium or psychosis. It is seen with lesions involving the upper brainstem and diencephalon. The authors report a case of PH due to ischemic infarction of the midbrain after cardiac catheterization. Although PH has been reported after vertebral angiography, it has never been reported as a complication of cardiac catheterization.
Arteriovenous (AV) fistulae are well known to cause high output cardiac failure. AV fistulae from cardiac catheterization are as rare as 0.01% in the transfemoral approach. We describe here what we believe is the first reported case of high output cardiac failure from an AV fistula due to percutaneous transluminal coronary angioplasty (PTCA). The patient had reversal of the congestive heart failure with surgical correction of the fistula.
Because earlier ambulation and discharge after cardiac catheterization may result in the increased utilization of outpatient facilities, a prospective five center clinical pilot trial assessing the safety and outcome of early ambulation after routine left heart catheterization was performed in 287 patients. Catheterization routines at each clinical center were unchanged throughout the study. After the diagnostic catheterization using 5 French (F), preformed, large lumen catheters and arterial puncture compression (mean 15 min, range 5 to 52), 260 patients were ambulated by a physician at a mean time of 2.6 h (range 1.8 to 3.1) after catheterization. Follow-up examination or a phone call 24 to 72 h later was performed to assess late results. The mean age of the patients was 58 years (range 25 to 91); 166 (58%) were men. Left ventricular ejection fraction was 54 +/- 15%. One hundred twenty-seven patients (44%) received intravenous heparin (1,500 to 5,000 U as an intravenous bolus) and 136 (47%) received aspirin. Major complications included transient ischemic attack (one patient) and ventricular tachycardia requiring cardioversion during ventriculography (two patients). A small hematoma (less than 5.0 cm) after ambulation occurred early (from compression to standing) in 14 patients (5%; 9 received heparin, 8 were taking aspirin) and later (after standing to 72 h) in 9 patients (3%; 2 receiving heparin, 2 taking aspirin). Five patients with a hematoma had studies with a 6F sheath. No patient required surgical intervention for early or late hematoma. Only three patients (1%) needed a 7F or 8F catheter because of suboptimal 5F coronary angiography.(ABSTRACT TRUNCATED AT 250 WORDS)
After diagnostic cardiac catheterization in 8,715 patients, a pseudoaneurysm was diagnosed in 86 (1%) patients. Primary conservative management by repeated compression bandages (CB) or ultrasound guided compression (UGC) was attempted in all patients. Occlusion of the pseudoaneurysm was achieved significantly more often by UGC (41/47; 87%) than by CB (22/39; 56%; P = 0.016). Of 86 patients, 23 (27%) required surgical treatment. Major clinical acute complications occurred after surgery in 8/23 cases (35%) versus 4/63 (6%; P = 0.0004) following successful CB or UGC. However, intention-to-treat analysis showed no difference in the rate of acute complications in the CB or UGC group (15.4% versus 12.8%, P = 0.7272), because of a trend towards a higher complication rate following secondary surgery in the UGC (4/6 = 66.7%), as compared to the CB group (4/17 = 23.5%, P = 0.1589). During follow up, 22/64 (34%) patients reported persistent inguinal complaints, 9/15 (60%) after surgery and 13/49 (27%) after successful CB or UGC (P = 0.0169). However, according to the intention-to-treat analysis, there was no significant difference between the initial groups (CB: 26.1% versus UGC: 39.0%, P = 0.2958). Despite a higher effectiveness of UGC to achieve occlusion of a pseudoaneurysm compared to CB (87% vs. 56%), UGC is not superior to CB because of a higher rate of acute complications as well as long-term complaints in those patients requiring secondary surgery in the UCG group as compared to the CB group.
BACKGROUND: In Japan, prophylactic hemodialysis has been considered useful for preventing contrast-induced nephropathy (CIN). METHOD AND RESULTS: To assess whether hemodialysis prevented CIN, 391 patients (age: 69 +/- 8 years, 63 females) with chronic renal insufficiency (CRI, serum creatinine level (Scr) > or = 1.3 mg/dl) who underwent cardiac catheterization, were retrospectively analyzed. Patients were divided into 3 categories based on Scr: L (1.3 > or = Scr < 2.0 mg/dl, n = 332); M (2.0 > or = Scr < 3.0 mg/dl, n = 49); and H (Scr > or = 3.0 mg/dl, n = 10). To prevent CIN, 35 category M patients and all category L patients received hydration alone, whereas 14 category M patients and all category H patients received hemodialysis. CIN developed in 48 patients. The incidence of CIN in category H was significantly higher than that in category L or M (H, 40% vs L, 11% or M, 16% (p < 0.05)). In category M patients treated with hemodialysis, Scr increased from 2.4 +/- 0.3 to 3.0 +/- 0.5 mg/dl (p < 0.05) within 7 days, and 29% of patients developed CIN. However, in category M patients who did not receive hemodialysis, the Scr did not change (pre, 2.3 +/- 0.2 mg/dl to post, 2.2 +/- 0.4 mg/dl), and the incidence of CIN was 11%. CONCLUSION: Prophylactic hemodialysis for CRI patients undergoing cardiac catheterization does not prevent CIN.