Coronary artery fistula (CAF) is an anomalous connection between a coronary artery and a major vessel or cardiac chamber. Most of the coronary fistulas are discovered incidentally during angiographic evaluation for coronary vascular disorder. The management of CAF is complicated and recommendations are based on anecdotal cases or very small retrospective series. We present three cases of CAF, two of which were symptomatic due to hemodynamically significant coronary steal phenomenon. They underwent successful transcatheter coil embolization, leading to resolution of their symptoms. Percutaneous closure offers a safe and effective way for the management of symptomatic patients. CAFs are rare cardiac anomalies but can give rise to a variety of symptoms because of their hemodynamic consequences or complications. They should be part of cardiac differential diagnosis particularly in patients without other risk factors. Correction of CAF is indicated if the patients are symptomatic or if other secondary complications develop.

Summary. Background: Heparin-induced thrombocytopenia (HIT) is an adverse immune-mediated response to unfractionated heparin and, less commonly, low molecular weight heparin. It is associated with a high thrombotic risk and the potential for limb and lifethreatening complications. Argatroban is the only approved and currently available anticoagulant for HIT treatment in the USA. Objectives: To report safety and efficacy outcomes with bivalirudin for HIT treatment. Methods: We retrospectively examined records from our registry of patients with a suspected, confirmed or previous history of HIT and who had received bivalirudin for anticoagulation in a single tertiary-care center over a 9-year period. Results: We identified 461 patients who received bivalirudin: 220 (47.7%) were surgical patients, and 241 (52.3%) were medical patients. Of this population, 107 (23.2%) were critically ill, and 109 (23.6%) were dialysis-dependent. Suspected, confirmed and previous history of HIT were reported in 262, 124 and 75 patients, respectively. Of 386 patients with suspected or confirmed HIT, 223 patients (57.8%) had thrombosis at HIT diagnosis. New thrombosis was identified in 21 patients (4.6%) while they were on treatment with therapeutic doses of bivalirudin. No patient required HIT-related amputation. Major bleeding occurred in 35 patients (7.6%). We found a significant increase in major bleeding risk in the critically ill population (13.1%; odds ratio 2.4, 95% confidence interval 1.2-4.9, P = 0.014). The 30-day allcause mortality rate was 14.5% (67 patients), and eight of 67 (1.7%) deaths were HIT-related. Conclusion: Bivalirudin may be an effective and safe alternative option for the treatment of both suspected and confirmed HIT, and appears to reduce the rate of HITrelated amputation.

(MI). A stepwise logistic regression with adjustment using propensity scores was performed to determine if statin therapy was independently associated with the risk reduction of adverse postoperative cardiovascular outcomes. Results: We identified 752 patients. Seventy-five of them (9.97%) developed composite end points; 10 (1.33%) had in-hospital nonfatal MI, 44 (5.85%) developed AF, and 35 (4.65%) died within 30 days. The 30-day all-cause mortality was 31/478 (6.48%) among statin nonusers vs 4/274 (1.45%) for statin users (P < 0.002). As compared with nonusers, patients on statin therapy had a 5-fold reduced risk of 30-day all-cause mortality. Statin therapy was associated with decreased CEP after adjusting for baseline characteristics, with a propensity score to predict use of statins (odds ratio [OR]: 0.54, 95% confidence interval [CI]: 0.30-0.97, P = 0.039). After further adjustment for propensity score, diabetes mellitus, percutaneous coronary intervention, and prior coronary artery bypass grafting, statin therapy proved beneficial (OR: 0.51, 95% CI: 0.28-0.92, P = 0.026). Conclusions: Statin use in the perioperative period was associated with a reduction in cardiovascular adverse events and 30-day all-cause mortality in patients undergoing intermediate-risk NCNVS. IntroductionDespite advances in surgical techniques and medical management, cardiovascular complications remain the most common cause of postoperative morbidity and mortality in patients undergoing noncardiac surgery. 1 Patients with perioperative myocardial infarctions (MI) have an in-hospital mortality of 15% to 25%. 2,3 The pathophysiology of perioperative MI is complex. It can be related to myocardial

The diagnosis of heparin-induced thrombocytopenia (HIT) can be challenging. The HIT Expert Probability (HEP) Score has recently been proposed to aid in the diagnosis of HIT. We sought to externally and prospectively validate the HEP score. We prospectively assessed pre-test probability of HIT for 51 consecutive patients referred to our Consultative Service for evaluation of possible HIT between August 1, 2012 and February 1, 2013. Two Vascular Medicine fellows independently applied the 4T and HEP scores for each patient. Two independent HIT expert adjudicators rendered a diagnosis of HIT likely or unlikely. The median (interquartile range) of 4T and HEP scores were 4.5 (3.0, 6.0) and 5 (3.0, 8.5), respectively. There were no significant differences between area under receiver-operating characteristic curves of 4T and HEP scores against the gold standard, confirmed HIT [defined as positive serotonin release assay and positive anti-PF4/heparin ELISA] (0.74 vs 0.73, p = 0.97). HEP score ≥ 2 was 100 % sensitive and 16 % specific for determining the presence of confirmed HIT while a 4T score > 3 was 93 % sensitive and 35 % specific. In conclusion, the HEP and 4T scores are excellent screening pre-test probability models for HIT, however, in this prospective validation study, test characteristics for the diagnosis of HIT based on confirmatory laboratory testing and expert opinion are similar. Given the complexity of the HEP scoring model compared to that of the 4T score, further validation of the HEP score is warranted prior to widespread clinical acceptance.

The renal arteries are frequently involved in FMD, affecting ≈80% of FMD patients who undergo renal imaging studies.1 Renovascular hypertension related to FMD is common, and treatment of hypertension with balloon angioplasty may be effective in curing or better controlling blood pressure in select patients.2 Anecdotal case reports have reported stent fracture because of the compression of the renal artery by musculotendinous fibers originating from the diaphragm. Another contributing factor is significant mobility of the kidney (nephroptosis). Although this can occur in all patients, severe nephroptosis has been shown to be more common among patients with renal FMD. 4 Increased kinetic stress applied over the stent struts may lead to both reactionary intimal hyperplasia and metal fatigue resulting in-stent restenosis and fracture. Balloon angioplasty remains the mainstay of endovascular therapy for renal FMD, in contrast to severe atherosclerotic renal artery stenosis for which stenting has become the standard approach. For patients with renal FMD, stenting is generally reserved for cases in which angioplasty has failed or when required to manage renal artery dissection. If renal artery stenting is required, the potential for nephroptosis with subsequent mechanical stress on the stent should be considered in determining revascularization approach. Long areas of stenting should generally be avoided. Surgical revascularization remains a viable therapeutic option for patients with renal FMD with extensive disease not amenable to angioplasty. DisclosuresDr Gornik is a volunteer member of the medical advisory board of Fibromuscular Dysplasia Society of America, a nonprofit organization. The other authors have no conflict to report. KEy WORDS: angiography ◼ fibromuscular dysplasia ◼ renal artery stenosis ◼ stent fracture by guest on