Real-world use of fractional flow reserve in Germany: results of the prospective ALKK coronary angiography and PCI registry

BACKGROUND

There is growing evidence for beneficial prognostic and economic effects of FFR-guided treatment of stable coronary artery disease. We sought to evaluate the real-world use of FFR measurements in patients undergoing elective coronary angiography.

METHODS AND RESULTS

We analyzed the data of the prospective ALKK coronary angiography and PCI registry including data of 38 hospitals from January 2010 to December 2013. A total of 100,977 patients undergoing coronary angiography were included. In 3240 patients (3.2 %) intracoronary pressure measurement was performed. There was a wide range of use of FFR measurement in the different analyzed ALKK hospitals from 0.1 to 8.8 % in elective patients with suspected or known coronary artery disease (median 2.7 %, quartiles 0.9 and 5.3 %), with a successive increase of use over time during the study period. Overall, it was performed in 3.2 % of coronary angiographies. Use in patients with three-vessel disease (2.5 %) and recommendation for bypass surgery (1.6 %) was less frequent. In procedures without PCI, dose area product was higher in the FFR group (2641 cGy × cm² vs. 2368 cGy × cm², p < 0.001), while it was lower in procedures with ad hoc PCI (4676 cGy × cm² vs. 5143 cGy × cm², p < 0.001). The performing center turned out to be the strongest predictor.

CONCLUSIONS

The use of FFR measurement was very heterogeneous between different hospitals and in general relatively low, in particular in patients with multivessel disease or recommendation for bypass surgery, but there was a positive trend during the study period. Technically, FFR measurement was not associated with an increased periprocedural complication rate.

Fibrinogengesteuerte Urokinaselyse einer Portal- und Mesenterialvenenthrombose bei akutem Schub einer Colitis ulcerosa

HISTORY AND ADMISSION FINDINGS

A 23-year-old woman with a 5-year history of ulcerative colitis was admitted to our hospital because of bloody diarrhea. Two years previously she had undergone a hemicolectomy for a right colonic stricture. A recurrence of inflammatory bowel disease was suspected and treatment with prednisolone begun. The symptoms improved gradually, but 7 days later she complained of lower abdominal pain. Physical examination revealed a soft abdomen, but bowel sounds were reduced.

INVESTIGATIONS

The abdominal X-ray was unremarkable, but ultrasonography revealed moderate ascites and no blood flow in the portal vein on Doppler examination. The spleen was slightly enlarged. Contrast-enhanced abdominal magnetic resonance imaging (MRI) was performed immediately, revealing thrombosis of the portal and mesenteric veins.

TREATMENT AND COURSE

As there was no suggestion of intestinal necrosis, laparatomy was not considered necessary. Intravenous thrombolytic treatment with urokinase was given continuously (bolus of 250,000 units, followed by 200,000 units per hour), in order to lower the fibrinogen level to 100 - 150 mg/dl, together with unfractionated heparin, maintaining the activated partial thromboplastin time between 60 and 85 seconds. The thrombolytic treatment had to be stopped several times because of bloody diarrhea, but no transfusion was necessary. Two days after the start of thrombolytic treatment the abdominal pain and ascites ceased. Doppler sonography now demonstrated hepatopetal flow in the previously occluded portal vein. 4 days later, MRI revealed that the thrombus in the portal vein had dissolved and the portal vein was fully patent. The mesenteric vein was partially perfused, a residual thrombus extending into the portal vein. Tests for thrombophilia were negative. The thrombolytic therapy was stopped after 112 hours and the patient was treated with oral anticoagulation for 6 months. The patient recovered completely, with no evidence of portal hypertension during the following 6 months.

CONCLUSIONS

Thrombolysis with urokinase, guided by the level of fibrinogen, may be an alternative, semi-invasive treatment option in acute thrombosis of the portal and mesenteric veins.