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The most consistent procedural predictor of vascular access site complications thus far has been the intensity and duration of anticoagulant therapy during and after percutaneous coronary interventions (PCI). Several devices have been developed to aid in the closure of the femoral arteriotomy. This report describes the clinical outcome of unsuccessful deployment of femoral closure devices in a cohort of 285 consecutive patients who underwent PCI and were treated with platelet glycoprotein (GP) IIb/IIIa inhibitors. Manual femoral artery compression was used in 123 patients, Perclose in 123 patients, and AngioSeal in 39 patients. Successful homeostasis was achieved in 98.4% of patients who received manual compression, in 91.9% of the Perclose-sealed arteriotomy, and in 84.6% of patients who received the AngioSeal closure device (P = 0.004). The incidence of vascular complications after successful deployment was 9%. Patients not achieving hemostasis with closure device or 1 degrees manual compression developed complications in the majority of cases (> 80%; P < 0.05). By multivariate analysis (with adjustment for baseline differences), the use of AngioSeal closure device was found to be an independent risk factors leading to primary deployment failure and all access site complications (OR 2.97; 95% CI 1.5-6.0; P = 0.006). In summary, failed hemostasis by artery closure devices in patients undergoing PCI who are treated with GP IIb/IIIa inhibitors is associated with significant vascular complications. AngioSeal may be associated with a higher failure rate, while manual compression and Perclose seem to be more effective with a lower complication rate.

Elderly patients are increasingly referred to percutaneous coronary interventions (PCIs). Recent reports suggest complications rates are declining in the elderly. We sought to determine whether procedural and in-hospital outcomes are different in patients aged > or = 75 years undergoing nonemergent PCI as compared to patients age < 75 years. The outcome of 266 consecutive patients age > or = 75 years undergoing nonemergent PCI was compared to that of 1,681 consecutive patients age < 75 years. Compared with younger patients, greater proportions of elderly patients were women and had a history of hypertension, peripheral vascular disease, and cerebral vascular events. Elderly patients had more extensive coronary involvement. Procedural success was similar in both groups (94%). The in-hospital cardiac death rate was significantly higher in the elderly patients (2.3% vs. 0.7%; P = 0.03). Aged patients also had a significantly higher incidence of vascular and bleeding complications. Blood transfusion was required more often in the elderly group (4.5% vs. 2.6%; P = 0.07). The hospitalization length was significantly higher in the elderly group (4.1 +/- 6.0 vs. 2.5 +/- 4.3 day; P = 0.0004). By multivariate logistic regression (adjusted for baseline clinical and angiographic variables), age > or = 75 years was found to be an independent predictor of in-hospital cardiac death (odds ratio = 3.9; 95% CI = 1.3-11.5; P = 0.015). Although PCI is technically successful in patients aged > or = 75 years; it is associated with more acute cardiac and vascular complications and higher in-hospital cardiac mortality.

Catheter-induced left main coronary artery dissection is quite rare. We describe two cases of iatrogenic left main coronary artery dissection. In the first case, the aortic root was involved in the dissection process, and stenting of the entry point did not halt the progression of dissection. In the second case, the dissection did not involve the aortic root.

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