bivalirudin and Constriction--Pathologic

Since the introduction of thrombolytic therapy for acute myocardial infarction, the incidence of coronary artery reocclusion has been intensively studied. Also, the prediction and diagnosis of reocclusion by angiographic and clinical variables, as well its invasive and pharmacologic prevention, have gained much attention. By angiographic definition, reocclusion requires three angiographic observations: one with an occluded artery, one with a reperfused artery and a third for the assessment of subsequent occlusion (true reocclusion). Since the introduction of early intravenous reperfusion therapy, most studies use only two angiograms: one with a patent and one with a nonpatent infarct-related artery. A search for all published reocclusion studies revealed 61 studies (6,061 patients) with at least two angiograms. The median time interval between the first angiogram after thrombolysis and the second was 16 days (range 0.1 to 365). Reocclusion was observed in 666 (11%) of 6,061 cases. Interestingly, the 28 true reocclusion studies showed an incidence of reocclusion of 16 +/- 10% (mean +/- SD), and the 33 studies with only two angiograms 10 +/- 8% (p=0.04), suggesting that proven initial occlusion of the infarct-related artery is a risk factor for reocclusion after successful thrombolysis. The other predictors for reocclusion are probably severity of residual stenosis of the infarct-related artery after thrombolysis and perhaps the flow state after lysis. Reocclusion is most frequently seen in the early weeks after thrombolysis. The clinical course in patients with reocclusion is more complicated than in those without this complication. Left ventricular contractile recovery after thrombolysis is hampered by reocclusion. Routine invasive strategies have not been proven effective against reocclusion. In the prevention of reocclusion, both antiplatelet and antithrombin strategies have been tested, including hirudin and hirulog, but the safety of these agents in thrombolysis is still questionable. Thus, reocclusion after thrombolysis is an early phenomenon and is more frequent after proven initial occlusion of the infarct-related artery. Reocclusion can be predicted by angiography after thrombolysis. Because reocclusion is detrimental, strategies to prevent it should be developed and carried out after thrombolytic therapy for acute myocardial infarction as soon as they are deemed safe.

Topics: Antithrombins; Constriction, Pathologic; Coronary Angiography; Fibrinolytic Agents; Heparin; Hirudin Therapy; Hirudins; Humans; Incidence; Myocardial Infarction; Peptide Fragments; Prognosis; Recombinant Proteins; Recurrence; Thrombolytic Therapy

Topics: Angioplasty; Anticoagulants; Constriction, Pathologic; Hemorrhage; Heparin; Hirudins; Humans; Ischemia; Peptide Fragments; Peripheral Vascular Diseases; Radiography; Recombinant Proteins; Risk Assessment; Risk Factors; Severity of Illness Index; Treatment Outcome

To present real-world data to evaluate the safety and effectiveness of bivalirudin, a direct thrombin inhibitor, in an unselected group of patients undergoing percutaneous peripheral interventions (PPI).. Data were extracted from a prospectively collected peripheral vascular registry developed for quality assurance measures at 2 centers. Of 398 consecutive patients (195 men; mean age 69.4+/-11.3 years) who underwent PPI in a 2-year period, 369 (92.7%) received bivalirudin (0.75 mg/kg bolus followed by a 1.75 mg/kg/h infusion) and 29 (7.3%) received unfractionated heparin (UFH). In the bivalirudin sample, critical limb ischemia was present in 28.0% of patients, TASC D lesion in 29.5%, and angiographic thrombus in 7.8% of vessels. Demographic, clinical, procedural, and angiographic variables and in-hospital complications were analyzed. All in-hospital adverse events were independently adjudicated.. Procedural success (<30% residual narrowing) was achieved in 359 (97.3%) patients receiving bivalirudin. Adverse events included stroke (1, 0.3%), acute renal failure (1, 0.3%), major bleeding (3, 0.8%), distal embolization (11, 3.0%), vascular access complications (2, 0.5%), and minor amputation (2, 0.5%).. Bivalirudin had an excellent safety profile in a real-life cohort of patients undergoing PPI, including high-risk patients with critical limb ischemia and TASC D lesions. In-hospital major bleeding and other adverse events were infrequent. A randomized trial of bivalirudin versus UFH is needed to verify these results and establish bivalirudin as a standard anticoagulant in PPI.

Topics: Aged; Aged, 80 and over; Angioplasty; Anticoagulants; Chi-Square Distribution; Constriction, Pathologic; Female; Hemorrhage; Heparin; Hirudins; Humans; Inpatients; Iowa; Ischemia; Logistic Models; Male; Middle Aged; Peptide Fragments; Peripheral Vascular Diseases; Radiography; Recombinant Proteins; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Severity of Illness Index; Treatment Outcome

Anticoagulant therapy is required to prevent radial artery occlusion (RAO) after transradial catheterization. There is no data comparing bivalirudin to standard heparin.. We studied 400 consecutive patients. In case of diagnostic angiography-only (n = 200), they received an intravenous bolus of heparin (70 U kg(-1)) immediately before sheath removal whereas in case of angiography followed by ad hoc percutaneous coronary intervention (n = 200), they received bivalirudin (bolus 0.75 mg kg(-1), followed by infusion at 1.75 mg/kg/h). RAO was assessed 4-8 weeks later using two-dimensional echography-doppler and reverse Allen's test with pulse oximetry.. At follow-up, 21 of the 400 (5.3%) patients were found to have RAO with no significant difference between the two groups (3.5% bivalirudin vs. 7.0% heparin, P = 0.18). Patients with RAO had a significantly lower weight compared to patients without RAO (78 ± 13 kg vs. 86 ± 18 kg, P = 0.011). By multivariate analysis, a weight <84 kg (OR: 2.78, 95% CI 1.08-8.00, P = 0.032) and a procedure duration ≤20 min (OR: 7.52, 95% CI 1.57-36.0, P = 0.011) remained strong independent predictors of RAO. All cases of radial occlusion were asymptomatic and without clinical sequelae.. Delayed administration of bivalirudin or heparin for transradial catheterization provides similar efficacy in preventing RAO. Because of its low cost, a single bolus of heparin can be preferred in case of diagnostic angiography whereas bivalirudin can be contemplated in case of ad hoc percutaneous coronary intervention. © 2010 Wiley-Liss, Inc.

Topics: Aged; Angioplasty, Balloon, Coronary; Anticoagulants; Arterial Occlusive Diseases; Cardiac Catheterization; Chi-Square Distribution; Constriction, Pathologic; Coronary Angiography; Echocardiography, Doppler; Female; Heparin; Hirudins; Humans; Infusions, Intravenous; Injections, Intravenous; Logistic Models; Male; Middle Aged; Odds Ratio; Oximetry; Patient Selection; Peptide Fragments; Radial Artery; Recombinant Proteins; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

Topics: Angioplasty, Balloon, Coronary; Anticoagulants; Arterial Occlusive Diseases; Cardiac Catheterization; Constriction, Pathologic; Coronary Angiography; Heparin; Hirudins; Humans; Infusions, Intravenous; Injections, Intravenous; Peptide Fragments; Radial Artery; Recombinant Proteins; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome

Percutaneous peripheral interventions (PPI) are often complex procedures performed on high-risk patients with a significant thrombus burden. Although there is no approved anticoagulant for use in PPI, heparin is commonly used but is associated with several limitations. The APPROVE data provide a foundation for further study of bivalirudin in the setting of PPI.

Topics: Anticoagulants; Constriction, Pathologic; Endovascular Procedures; Heparin; Hirudins; Humans; Iliac Artery; Peptide Fragments; Peripheral Arterial Disease; Recombinant Proteins; Renal Artery Obstruction