Pregnancy Induced Microangiopathy, HELLP OR TTP!

Introduction: Thrombotic thrombocytopenic purpura (TTP) in pregnancy is rare and can be fatal if misdiagnosed.Typically patients present with microangiopathic hemolytic anemia, thrombocytopenia, Altered mental status, fever, and renal abnormalities Case Description: We are presenting a case of 26 year old pregnant female presented with elevated BP. She had scattered Bruises in her legs, thighs and arms along with +2 bilateral pitting leg edema. Initial and subsequent laboratory studies showed features of microangiopathic hemolytic anemia (MAHA), which brought up the suspicion of HELLP (hemolysis, elevated liver enzymes, low platelets )syndrome initially. Labor was induced after transfusion of 2 units of PRBCs and 2 units of Platelets. The patient platelets and hemoglobin showed no improvement after delivery and she continued to have hemolysis despite delivery and steroids administration. So daily therapeutic plasma exchange was initiated as the index of suspicion for TTP increased. After two sessions, there was a significant improvement in the platelet count and hemolysis profile which were normalized by the 4th session. Conclusion: Congenital TTP is a rare syndrome that clinicians should be aware of. Early initiation of plasma exchange dramatically improves survival from less than 10% to approximately 80%. This can only be achieved by having high level of suspicion and awareness to this possibility

Acute Limb Ischemia due to a Fractured Superficial Femoral Artery Stent

Peripheral Vascular Disease (PVD) is a rapidly growing and recognized disease of the peripheral circulation. Its presentation can vary between asymptomatic state, exercise limiting limb pain, limb loss and even death. Advances have been achieved in the treatment of PVD specially in the field of interventional cardiovascular medicine. Different devices and techniques are used in the treatment of peripheral atherosclerotic disease, which has lowered the need for bypass surgery. Although invasive peripheral intervention has a low rate of complications, there are still well recognized acute and chronic complications that an operator should be aware of. We present an interesting case of acute limb ischemia due to Superficial Femoral Artery (SFA) stent fracture

Retrograde Pedal Access For Revascularization Of Infrapopliteal Arterial Occlusive Disease In Critical Limb Ischemia (CLI) Patients As A Primary Approach.

Introduction: We are presenting three cases (out of similar several cases) where tibio-pedal approach was performed as an initial primary approach for limb salvage in patients with CLI secondary to Infra-popliteal (IP) disease. We consider this approach to be a necessary evolution in endovascular intervention. Discussion: Retrograde pedal access is safe, feasible with high technical success rate and a relatively low procedural complication rate, with low 30 days mortality and low rate of major adverse cardiac events. Freedom from major adverse limb events and limb salvage are both high at 1 year follow up. It allows quick therapy and short procedure time with less observation time in the hospital. A retrograde approach utilizing pedal access improves the crossing success of lesions as well as facilitates the use of some atherectomy devices to remove large plaque burden and modify the compliance of severely calcified infra-popliteal vessels. Using the retrograde approach will minimize the classic complications of the antegrade femoral approach. Conclusion: Retrograde tibio-pedal arterial access, as an initial primary approach for endovascular intervention in CLI patients confined to IP vessels, is an effective, safe, and feasible approach with a high technical success rate and a relatively low procedural complication rate

Endovascular Therapy of TASC-D Lesion in Critical Limb Ischemia

CLI (Rutherford class IV-VI) is a terminal stage of peripheral artery disease (PAD); it is defined by the presence of resting pain and/or tissue loss for at least two weeks that may require urgent revascularization to promote healing and prevent limb loss.For patients with infrarenal aortoiliac occlusive disease, the revascularization options are surgery like aortofemoral bypass and axillofemoral bypass or percutaneous intervention. Aortoiliac and aortofemoral bypass procedures are associated with 74% to 95% 5-year patency rates, respectively, which are comparable but not superior to percutaneous therapies.These operations may imply a significant morbidity and mortality on CLI patients who usually have multiple comorbid conditions and are considered high risk patients

Endovascular Therapy of TASC-D Lesion in Critical Limb Ischemia

CLI (Rutherford class IV-VI) is a terminal stage of peripheral artery disease (PAD); it is defined by the presence of resting pain and/or tissue loss for at least two weeks that may require urgent revascularization to promote healing and prevent limb loss.For patients with infrarenal aortoiliac occlusive disease, the revascularization options are surgery like aortofemoral bypass and axillofemoral bypass or percutaneous intervention. Aortoiliac and aortofemoral bypass procedures are associated with 74% to 95% 5-year patency rates, respectively, which are comparable but not superior to percutaneous therapies.These operations may imply a significant morbidity and mortality on CLI patients who usually have multiple comorbid conditions and are considered high risk patients

Acute Limb Ischemia due to a Fractured Superficial Femoral Artery Stent

Peripheral Vascular Disease (PVD) is a rapidly growing and recognized disease of the peripheral circulation. Its presentation can vary between asymptomatic state, exercise limiting limb pain, limb loss and even death. Advances have been achieved in the treatment of PVD specially in the field of interventional cardiovascular medicine. Different devices and techniques are used in the treatment of peripheral atherosclerotic disease, which has lowered the need for bypass surgery. Although invasive peripheral intervention has a low rate of complications, there are still well recognized acute and chronic complications that an operator should be aware of. We present an interesting case of acute limb ischemia due to Superficial Femoral Artery (SFA) stent fracture

Retrograde Pedal Access For Revascularization Of Infrapopliteal Arterial Occlusive Disease In Critical Limb Ischemia (CLI) Patients As A Primary Approach

Introduction: We are presenting three cases (out of similar several cases) where tibio-pedal approach was performed as an initial primary approach for limb salvage in patients with CLI secondary to Infra-popliteal (IP) disease. We consider this approach to be a necessary evolution in endovascular intervention. Discussion: Retrograde pedal access is safe, feasible with high technical success rate and a relatively low procedural complication rate, with low 30 days mortality and low rate of major adverse cardiac events. Freedom from major adverse limb events and limb salvage are both high at 1 year follow up. It allows quick therapy and short procedure time with less observation time in the hospital. A retrograde approach utilizing pedal access improves the crossing success of lesions as well as facilitates the use of some atherectomy devices to remove large plaque burden and modify the compliance of severely calcified infra-popliteal vessels. Using the retrograde approach will minimize the classic complications of the antegrade femoral approach. Conclusion: Retrograde tibio-pedal arterial access, as an initial primary approach for endovascular intervention in CLI patients confined to IP vessels, is an effective, safe, and feasible approach with a high technical success rate and a relatively low procedural complication rate

Retrograde Tibiopedal Access as a Bail-Out Procedure for Endovascular Intervention Complications

Introduction. Retrograde pedal access has been well described in the literature as a secondary approach for limb salvage in critical limb ischemia (CLI) patients. In this manuscript we are presenting a case where retrograde tibiopedal access has been used as a bail-out procedure for the management of superficial femoral artery (SFA) intervention complications. Procedure/Technique. After development of a perforation while trying to cross the totally occluded mid SFA using the conventional CFA access, we were able to cross the mid SFA lesion after accessing the posterior tibial artery in a retrograde fashion and delivered a self-expanding stent which created a flap that sealed the perforation without the need for covered stent. Conclusion. Retrograde tibiopedal access is a safe and effective approach for delivery of stents from the distal approach and so can be used as a bail-out technique for SFA perforation

Differential Response to Cardiac Resynchronization Therapy and Clinical Outcomes According to QRS Morphology and QRS Duration

ObjectivesThe goal of this study was to examine the relative impact of QRS morphology and duration in echocardiographic responses to cardiac resynchronization therapy (CRT) and clinical outcomes.BackgroundAt least one-third of all patients treated with CRT fail to derive benefit. Patients without left bundle branch block (LBBB) or patients with smaller QRS duration (QRSd) respond less or not at all to CRT.MethodsWe retrospectively assessed baseline characteristics, clinical and echocardiographic response, and outcomes of all patients who received CRT at our institution between December 2003 and July 2007. Patients were stratified into 4 groups according to their baseline QRS morphology and QRSd.ResultsA total of 496 patients were included in the study; 216 (43.5%) had LBBB and a QRSd ≥150 ms, 85 (17.1%) had LBBB and QRSd <150 ms, 92 (18.5%) had non-LBBB and a QRSd ≥150 ms, and 103 (20.8%) had non-LBBB and QRSd <150 ms. Echocardiographic response (change in ejection fraction) was better in patients with LBBB and QRSd ≥150 ms (12 ± 12%) than in those with LBBB and QRSd <150 ms (8 ± 10%), non-LBBB and QRSd ≥150 ms (5 ± 9%), and non-LBBB and QRSd <150 ms (3 ± 11%) (p < 0.0001). In a multivariate stepwise model with change in ejection fraction as the dependent variable, the presented classification was the most important independent variable (p = 0.0003). Long-term survival was better in LBBB patients with QRSd ≥150 ms (p = 0.02), but this difference was not significant after adjustment for other baseline characteristics (p = 0.15).ConclusionsQRS morphology is a more important baseline electrocardiographic determinant of CRT response than QRSd

Prasugrel Inappropriate Use in Patients Post-percutaneous coronary intervention (PCI). A Single Center Study

Prasugrel is a thienopyridine that was approved by the US Food and Drug Administration (FDA) in combination with aspirin for the reduction of thrombotic events as well as stent thrombosis in patients with ACS who undergo PCI. This retrospective study aims to assess the frequency of inappropriate use of prasugrel and to emphasize that prasugrel still needs more attention as inappropriate use may result in significant morbidity