Introduction:For suitable end-stage renal failure (ESRF) patients, renal transplantation gives better long term survival and quality of life as compared to dialysis. Prior to entry into the renal transplant wait list, potential candidates are screened for the presence of cardiovascular disease. However, the waiting time on the transplant list is long, and interval screening for cardiac fitness for surgery is not well defined. We aim to study the risk factors for the development of a cardiovascular event (CVE) and the time interval from recruitment to onset of a CVE that resulted in their removal from the transplant wait list.Methods:A retrospective study of all patients registered under the cadaveric renal transplant waiting list in Singapore General Hospital (SGH) from 16th April 1987 to 31st October 2010. We identified patients who developed a CVE among this cohort. We compared the demographics and clinical characteristics of patients who experienced a CVE versus those who did not. Univariable and multivariable cox regression were performed to investigate the significant variables for the development of a CVE. The time to development of CVE was estimated using Kaplan Meier estimation and log-rank test was used to compare the time to CVE between those with diabetes mellitus and those without.Results:1265 patients were enrolled in this study. 273 patients dropped out of the wait list due to medical reasons or death, of which 38.8% were due to CVE. The mean and median time duration from recruitment into the waiting list to development of a CVE was 14.42 (95% CI 13.72 to 15.11) and 15.69 (95% CI 13.86 to 17.51) years respectively. For patients with diabetes mellitus, this was 8.22 (95% CI 6.30 to 10.14) and 8.16 (95% CI 4.95 to 11.36) years respectively. Factors associated with an increased risk of developing a CVE included male gender (adjusted HR 2.21, 95% CI 1.43 to 3.41, p<0.001), presence of diabetes mellitus (adjusted HR 5.13, 95% CI 2.85 to 9.24, p<0.001) and patients who were either not working or working part-time as compared to their full-time counterparts (adjusted HR 1.76, 95% CI 1.14 to 2.72, p=0.010). In addition, hazard ratio for CVE significantly increased with advancing age quartile (p<0.001 by log rank test for trend).Conclusion:A significant proportion of patients exited from the renal transplant wait list due to a CVE. Being male, age 37 years old or more, presence of diabetes mellitus and non-working or part-time workers as compared to full-time workers were found to increase the risk of developing a CVE during the wait period for transplantation. The presence of diabetes mellitus significantly shortened the time to development of a CVE.
The transradial approach for coronary angiography and intervention is the preferred approach because of its superior safety profile as compared to the transfemoral approach. However, like all procedures, transradial approach is not free from complications. In this case, we describe a unique case of a large symptomatic radial artery pseudoaneurysm requiring urgent surgical intervention. The pseudoaneurysm developed after treatment with a short duration of subcutaneous low molecular weight heparin for radial artery occlusion that occurred a day after transradial coronary catheterization. The pseudoaneurysm was repaired successfully and there was no recurrence during subsequent follow-up. Access-related complications post transradial approach are generally uncommon and this is the first reported case of radial artery occlusion further complicated by a large pseudoaneurysm to the best of our knowledge. Preventive measures are crucial in reducing radial artery occlusion while we recommend an individualized approach based on clinical history coupled with anatomic features of pseudoaneurysm in managing radial artery pseudoaneurysm. hLearning objective: Access-related complications post transradial approach coronary angiography, while rare, can still occur. Preventive measures as well as close monitoring post angiography are crucial in the prevention as well as early detection of access-related complications. Management of radial artery pseudoaneurysm should be individualized based on clinical context as well as anatomic characteristics of the pseudoaneurysm.i
A middle-aged patient presented to the Emergency Department with angina lasting 30 min. He did not have any risk factors for coronary artery disease. Electrocardiogram and cardiac enzymes changes were consistent with Non ST Elevation Myocardial Infarction.We proceeded with invasive coronary angiography which showed aortic regurgitation, and 90% focal stenosis of both the left main (LM) ostium (Figure 1(A); see supplementary online video A), and the right coronary artery (RCA) ostium (Figure 1(B); see supplementary online video B) with normal distal beds.Transthoracic echocardiogram showed normal left ventricular ejection fraction, and moderate aortic regurgitation. An MRI of the aorta did not reveal any aortic aneurysm or abscess. There was pan-diastolic flow reversal seen at the descending thoracic aorta.Bilateral LM and RCA ostial stenosis in the absence of cardiovascular risk factors raised our clinical suspicion of possible cardiovascular syphilis. Treponema palladium hemagglutination antibody was reactive, confirming cardiovascular syphilis. He subsequently admitted to having unprotected intercourse with commercial sex workers. Upon diagnosis, the patient was commenced on a 2-week course of intravenous penicillin to treat for tertiary syphilis.The patient underwent a coronary artery bypass graft with left internal thoracic artery grafting to the left anterior descending artery, and the right internal thoracic artery grafting to the RCA, and a bioprosthetic aortic valve replacement. Postsurgery recovery was uneventful. Figure 1(A) Coronary angiogram demonstrating focal stenosis of LM artery. Arrow demonstrating focal narrowing of the LM coronary artery.Figure 1(B) Coronary angiogram demonstrating focal stenosis of RCA. Arrow demonstrating focal stenosis of the RCA.
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