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Original Investigation |

Bloodstream Infections After Invasive Nonsurgical Cardiologic Procedures FREE

Patricia Muñoz, MD, PhD; Jose Ramón Blanco, MD, PhD; Marta Rodríguez-Creixéms, MD, PhD; Eulogio García, MD, PhD; Juan Luis Delcan, MD, PhD; Emilio Bouza, MD, PhD
[+] Author Affiliations

From the Clinical Microbiology Laboratory (Drs Muñoz, Blanco, Rodríguez-Creixéms, and Bouza) and the Cardiology Department (Drs García and Delcan), Hospital General Universitario "Gregorio Marañón," Madrid, Spain.


Arch Intern Med. 2001;161(17):2110-2115. doi:10.1001/archinte.161.17.2110.
Text Size: A A A
Published online

Objective  To define the incidence, risk factors, and characteristics of bloodstream infections (BSIs) after invasive nonsurgical cardiologic procedures (ICPs).

Methods  Retrospective case-control study; multivariate analysis.

Results  Between January 1991 and December 1998, 22 006 ICPs were performed in our hospital and 25 BSIs were documented within 72 hours after ICP. Overall incidence of bacteremia was 0.11% (25 cases) (0.24% after percutaneous transluminal coronary angioplasty [14 cases of 5625 patients], 0.6% after diagnostic cardiac catheterization [9 cases of 14 034 patients], and 0.8% after electrophysiologic studies [2 cases of 2347 patients]). These 25 patients with bacteremia were compared with 50 controls randomly selected among patients who underwent an ICP but did not have BSIs. Patient-related risk factors for BSI were age older than 60 years (20 cases [80%] vs 28 controls [56%]), valvular disease (4 [16%] vs 1 [2%]), congestive heart failure (7 [28%] vs 1 [2%]), indwelling bladder catheter before the ICP (5 [20%] vs 1 [2%]), more than 1 puncture for the ICP (5 [20%] vs 3 [6%]), a prolonged procedure (83.7 vs 65.1 minutes); and/or more than 1 ICP performed (2 [8%] vs 0). Multivariate analysis identified the presence of congestive heart failure (odds ratio, 21; 95% confidence interval, 6.8-66.0) and age older than 60 years (odds ratio, 1.9; 95% confidence interval, 1.9-6.3) as independent risk factors for BSI after ICP. Bloodstream infection was detected a median of 1.7 days after the procedure. Gram-negative bacteremia accounted for 17 cases (68%) of the BSIs. Among the patients with BSI, the duration of hospital stay was significantly increased (21 vs 6 days). The overall mortality rate was 0.009% for patients who underwent an ICP (8.0% for the 25 patients with bacteremia documented within 72 hours after ICP).

Conclusions  Bloodstream infection should be included among the potential complications of ICP. Elderly patients with recent congestive heart failure episodes constitute a subgroup with a higher risk of postprocedure bacteremia. Therapy with antimicrobial agents against gram-positive and gram-negative bacteremia should be initiated after performing blood cultures in patients with signs suggestive of infection.

IN MODERN hospitals many invasive nonsurgical cardiologic procedures (ICPs) are performed every day. Although these techniques are safe, a wide array of systemic and local potential complications associated with these procedures have been reported. Systemic adverse effects include cerebrovascular accidents (0.07%-0.30%), myocardial infarction (0.06%-4.80%), and even death (0.10%-1.10%).18

Related infectious complications are not commonly reported, and local problems predominate.6,824 However, patients undergoing ICP may develop bloodstream infections (BSIs) that may cause death or significantly extend the hospital stay, which increases the cost.

An ICP-related BSI is an infrequent finding, and most of the available literature consists of isolated case reports that do not allow for an accurate definition of risk factors.14,16,17,1922 Herein we report what is to our knowledge the largest case-control series of early BSI after ICP from a single center. Our objective was to define the incidence, risk factors, and clinical characteristics of early BSI in patients who have undergone ICP.

Our institution is a 2000-bed teaching hospital with a very active invasive cardiology department and heart transplantation program. The records of ICPs performed in the Cardiology Department were cross referenced with the records of BSI detected in the Clinical Microbiology Laboratory. Patients with BSI detected within 72 hours after ICP were selected as "cases." This period was chosen to maximize the likelihood of only including BSIs related to the ICPs. For each case subject with ICP-related BSI, 2 "control" subjects were elicited from a random number table from patients who had undergone ICP in the same period but had not developed a subsequent BSI.

Blood cultures were ordered when the patients experienced fever, chills, or others signs suggestive of infection. Only significant bacteremic episodes were included, and all blood cultures were obtained through direct venipuncture rather than through an intravascular device. When a case of Staphylococcus epidermidis bacteremia was found, the episode was only included when at least 2 blood culture sets yielded the same microorganism and the patient showed clinical signs suggestive of infection. Blood samples were processed with an automated monitoring system (BACTEC NR; Becton, Dickinson and Company, Franklin Lakes, NJ). Isolates were identified with standard microbiological tests and automated methods (MicroScan; Dade International Inc, West Sacramento, Calif). None of the patients received prophylactic treatment, and ICPs were performed using standard sterile techniques and infection prevention measures.25 Femoral access was undertaken in all instances.

Data collected included age; sex; underlying diseases (diabetes mellitus, malignancy, central nervous system disorders, chronic renal failure, liver disease, human immunodeficiency virus, valvular heart disease, congestive heart failure in the previous 14 days, presence of intravascular prosthetic material, chronic obstructive pulmonary disease, and previous myocardial infarction); risk factors (alcoholism, current smoking, drug abuse, steroid treatment, central venous catheters, and indwelling urinary tract catheter); type of ICP (percutaneous transluminal coronary angioplasty [PTCA], diagnostic cardiac catheterization, or electrophysiologic studies); priority of the ICP (urgent or not); procedure variables (duration of the procedure, number of punctures, and number of days the sheath was left in place); complications and outcome during or after ICP (fever, chills, vascular lesion, neurologic lesion, hematoma at the site of puncture, primary BSI, catheter-related BSI, urosepsis, pneumonia, meningitis, endocarditis, shock, intensive care unit admission, and death); analytical data (white blood cell count, left deviation, platelet count); microorganism identified from blood cultures (gram-positive, gram-negative, or polymicrobial); duration of hospital stay; and empirical treatment (adequate or inadequate). Antimicrobial therapy was considered adequate if 1 or more antimicrobial agents with in vitro activity against the corresponding isolate were administered for a minimum of 5 days. Death was attributed to the infectious process if the patient died within 10 days of the bacteremic episode with a clinical course suggesting persistent infection; it was always attributed if the patient died during the phase of acute infection and death could not be clearly attributed to any other cause.

Assessment of significant risk factors for BSI was performed by univariate and multivariate analyses. Quantitative variable analysis was analyzed with the Mann-Whitney test. The study of qualitative variables was performed with the χ2 test with the Yates correction or the Fisher exact test (2-tailed) whenever possible. Adjusted risk ratios with 95% confidence intervals were assessed by stepwise logistic regression analysis (SPSS software; SPSS Inc, Chicago, Ill). Nonrelated variables identified as significant in the univariate analysis were entered into the logistic regression analysis. Statistical significance was defined as P<.05.

During the study period (January 1991 to December 1998), 68 patients had an episode of BSI among the 22 006 who underwent an ICP. Of these episodes, 25 occurred within 72 hours after the procedure, resulting in an overall incidence of 0.11%. Incidence of early BSI was significantly higher after PTCA: 14 (0.24%) of 5625 patients who underwent PTCA followed by 9 (0.06%) of 14 034 patients who underwent cardiac catheterization and 2 (0.08%) of 2347 patients who underwent electrophysiologic studies (P = .001). However, the type of cardiologic procedure was not an independent risk factor in the multivariable study.

RISK FACTORS FOR BSI

Risk factors predisposing to BSI were grouped into those present before the procedure (the first group) and those related to the procedure itself (the second group) (Table 1). Among the first group, age older than 60 years (20 cases [80%] vs 28 controls [56%]), prior valvular disease (4 [16%] vs 1 [2%]), congestive heart failure (7 [28%] vs 1 [2%]), and indwelling bladder catheterization (5 [20%] vs 1 [2%]) were more common among patients with BSI. Among the second group, more than 1 ICP performed (2 [8%] vs 0), number of punctures needed (mean of 1.2 vs 1.05), duration of the procedure (mean of 83.7 vs 65.1 minutes), and development of inguinal hematoma (4 [16%] vs 1 [2%]) were associated with a higher risk of developing BSI in the univariate analysis. Multivariate analysis identified the presence of congestive heart failure (odds ratio [OR], 21; 95% confidence interval, 6.8-66.0) and age older than 60 years (OR, 1.9; 95% confidence interval, 1.9-6.3) as independent risk factors for BSI after ICP.

Table Graphic Jump LocationTable 1. Characteristics and Underlying Diseases of Cases and Controls*
CLINICAL PRESENTATION OF BSI AFTER AN ICP

Bloodstream infection was detected a median of 1.7 days after ICP (range, 0-3 days); 9 (36%) of them were detected in the first 24 hours after ICP and 21 (84%) in the first 48 hours. The main clinical signs of BSI were fever (25 [100%]) and chills (16 [64%]), which were both only present in patients with BSI. One patient developed endocarditis, which was possibly related to an episode of Staphylococcus aureus BSI after an electrophysiologic study. However, it was not included in this analysis because the BSI occurred 7 days after the procedure. None of the patients with both bacteremia and valvular heart lesions who were included in this study developed endovascular infection. No local infection was documented in this series.

Microorganisms responsible for BSI are listed in Table 2. Of the episodes, 17 (68%) were caused by gram-negative microorganisms. None of them were polymicrobial and no grouping of cases was detected. Our 4 patients with previous valvular heart lesions had a gram-negative bacteremia (Pseudomonas cepacia, Klebsiella pneumoniae, Enterobacter cloacae, and Escherichia coli), and none of them had endocarditis or endarteritis. The origins of the bacteremia in the patients with an indwelling bladder catheter were S aureus in 2; Enterococcus faecalis in 1; Serratia marcescens in 1; and E coli in 1.

Table Graphic Jump LocationTable 2. Microorganisms Isolated From the 25 Patients With Bloodstream Infection After an Invasive Nonsurgical Cardiologic Procedure

Antimicrobial therapy was considered adequate in 75% of cases. Five patients did not receive therapy (1 patient died before treatment was initiated, and the other 4 had already been released from the hospital or were asymptomatic when the results were available). All of them survived, and the origins of these bacteremias were Klebsiella oxytoca in 2; E faecalis in 1; and E coli in 1.

Three patients (12%) developed septic shock, and 2 of them died (the overall mortality was 12%, and the related mortality was 8% for the 25 patients with bacteremia that was detected within 72 hours after ICP). The median hospital stay was significantly longer for patients with bacteremia (21 vs 6 days) (Table 1).

The use of ICP has experienced a rapid expansion in recent years, and a large number of patients undergo these procedures every day. More than 300 000 PTCAs were performed in the United States in 199023 and more than 600 000 in 1999.

Although infectious complications are uncommon, the great number of procedures performed every year implies that even a low incidence of infection may have significant consequences. We are reporting what is to our knowledge the largest series of early BSIs after ICP. In our hospital, 0.11% of all patients who had undergone an ICP had a clinically significant procedure-related BSI in the following 3 days. Incidence of BSI was significantly higher among patients who underwent PTCA (0.24%), although the type of procedure was not an independent risk factor in our multivariate model. In the literature, incidence of bacteremia after PTCA ranges from 0.20 to 0.80,911,19 although the study by Samore et al11 includes bacteremias that were detected in the first 7 weeks following PTCA.

To identify patients with a higher risk of severe infectious complications who would require a closer follow-up or even prophylaxis, we performed a case-control study and literature review. Risk factors proposed in previous studies (all but 2 were derived from series with less than 6 patients with bacteremia) are summarized in Table 3.

Table Graphic Jump LocationTable 3. Summary of Studies That Identify Risk Factors for Infection After ICPs*

Congestive heart failure was the most significant risk factor in our multivariate model (OR, 21; 95% confidence interval, 6.8-66.0). This factor was also identified by Samore et al11 in the only other comparative series of patients with bacteremia after PTCA (OR, 43.3). The reason for this association is not clear. In our series, patients with bacteremia and previous congestive heart failure were younger than those without BSI (median age, 61 vs 71 years; P = .04), had a greater incidence of valvular diseases (3 cases [42%] vs 1 control [5%]; P = .02) and diabetes mellitus (4 [57%] vs 1 [5%]; P = .003), were more commonly receiving mechanical ventilation (2 [28%] vs 0; P = .01), required more central venous catheters (3 [43%] vs 1 [5%]; P = .02), and needed more than 1 puncture for the ICP (4 [57%] vs 1 [5%]; P = .03).

The second independent risk factor was age older than 60 years, which was also suggested in previous works.11 In our series, patients older than 60 years were more commonly heavy smokers (10 [50%] vs 0; P = .04). In the literature, cohorts of older patients who underwent PTCA include more women, more patients with unstable angina, and more patients with left ventricular dysfunction and congestive heart failure. Age older than 75 years was reported to be an independent risk factor for death, acute myocardial infarction, need for transfusion, and need for arterial repair after PTCA.3

In contrast to the results of Samore et al,11 we could not find a correlation between the risk of bacteremia and any of the factors related to the procedure itself, although some of them were significant in the univariate analysis (Table 1). Samore et al found that duration of the procedure (OR, 6.8), number of catheterizations in the same site (OR, 4.0), difficult vascular access (OR, 15.0), and length of time the sheath was left in place (OR, 6.8) increased the risk of bacteremia. The significantly lower incidence of bacteremia after PTCA in our study compared with that of Samore et al11 (14 cases [0.24%] vs 27 cases [0.64%]; P = .003) may be justified by technical factors. For example, 20 (80%) of our patients vs 12 (44%) of the patients required just 1 puncture, the duration of the procedure in our center was less than 1 hour in 36% vs 11% of the cases, and the sheath always remained in place less than 24 hours (mean time, 7.28 hours), while in the study by Samore et al11 the sheath remained in place less than 24 hours in only 7 cases (26%). In another series, duration of the procedure was also not found to be a significant risk factor.9

Retention of the sheath (40 vs 22 hours) and bleeding around the insertion site (43% vs 9% transfusion rate) were risk factors for infection in a prospective series of 500 patients who underwent angioplasty with 6 related infections (4 bacteremias).10 These factors were not found to increase the risk of bacteremia in our series, but both our transfusion rate (4%) and the length of time the sheath was left in place are significantly less than those reported in the series by McHenry et al10.

Early repuncture of the ipsilateral femoral artery or repeated procedures through a previously traumatized femoral access site have been proposed as risk factors in some short series, mainly for local complications.16,1921,24 However, these findings were not confirmed by others.6,12 Two of our 25 patients with bacteremia underwent a second cardiologic procedure, but this factor was not independently related to a higher risk of bacteremia.

Local infections are very uncommon8; there were none in our series, probably because we had focused on the early onset of bacteremia. Blood cultures may remain negative even after severe local infections,18 and femoral endarteritis may be associated with osteoarticular metastases and peripheral emboli.22,23

Fever after ICP has been correlated with the use of contrast medium2 or with the introduction of bacterial endotoxin from the surface of the catheter or from the skin.12,24 However, the change to single-use pyrogen-free catheters has virtually eliminated these problems as well as the potential for BSI due to unsterile catheters. In our study, fever 25 (100%) of the cases vs none of the controls; P<.001) and chills were the most constant symptoms of BSI after ICP. The association of fever after an ICP with real infection has also been indicated by some authors (50% of cases vs 4% of controls).10

Gram-negative microorganisms were more commonly identified in our study (17 [68%]). This finding has also been observed by other authors,15,26,27 while gram-positive bacteria (mainly Staphylococcus species) predominated in other reports.9,11,19 In a series of 7 cases of bacteremia after coronary stenting, 3 episodes were caused by S aureus, 2 by E cloacae, and 1 each by Proteus mirabilis and S marcescens.15 Gram-negative bacteria are well-known colonizers of perineal and groin skin, mainly in patients with indwelling bladder catheters. However, this was not the only reason, since 3 of our 5 cases with indwelling bladder catheter had gram-positive bacteremia.

Other potential reasons for the importance of gram-negative bacteremia in our series is that our population was severely ill and older (mean age, 66.6 years), both well-recognized risk factors for colonization by gram-negative bacteria. In some of the published series in which gram-positive bacteremia predominated, blood cultures were obtained from the femoral catheter or from the vessel from which the catheter had just been removed. Thus, some of these isolates may represent contamination by skin pathogens.12 This practice is not useful for the diagnosis of BSI unless lysis centrifugation techniques are used and another blood culture is obtained through the vein.

The overall mortality rate related to the bloodstream infection was 0.09 per 1000 ICPs (8% of the 25 patients with bacteremia that was detected within 72 hours after ICP). In other series, 1.7% of the deaths were caused by a related infection (0.16 per 1000 PTCAs).2 Patients with bacteremia had a much more prolonged hospital stay (21 vs 6 days), which also increased the cost.

Bloodstream infection complicates 0.11% of ICPs. Elderly patients with recent congestive heart failure episodes constitute a subgroup with a higher risk of postprocedure bacteremia. Antimicrobial agents against gram-positive and gram-negative bacteria should be initiated after blood cultures are performed in patients with signs suggestive of infection. The selection of a subgroup of patients with a high risk of infection who could benefit from antimicrobial prophylaxis merits further study.

Accepted for publication February 12, 2001.

The authors are grateful for the help of the staff of the Cardiac Catheterization Department and Microbiology Laboratory of the Hospital General Universitario "Gregorio Marañón."

Corresponding author and reprints: Patricia Muñoz, MD, PhD, Servicio de Microbiología, Hospital General Universitario "Gregorio Marañón," Doctor Esquerdo 47, Madrid 28006, Spain (e-mail: pmunoz@micro.hggm.es).

Grossman  W Cardiac catheterization. Braunwald  Eed.Heart Diseases A Textbook of Cardiovascular Medicine 4th ed. Philadelphia, Pa WB Saunders Co1992;
Malenka  DJO'Rourke  DMiller  M  et al. Northern New England Cardiovascular Disease Study Group, Cause of in-hospital death in 12,232 consecutive patients undergoing percutaneous transluminal coronary angioplasty. Am Heart J. 1999;137632- 638
Link to Article
Lindsay  JReddy  VMPinnow  EELittle  TPichard  AD Morbidity and mortality rates in elderly patients undergoing percutaneous coronary transluminal angioplasty. Am Heart J. 1994;128697- 702
Link to Article
Davis  KKennedy  JWKemp  HGJudkins  MPGosselin  AJKillip  T Complications of coronary arteriography from the Collaborative Study of Coronary Artery Surgery (CASS). Circulation. 1979;591105- 1111
Link to Article
Dorros  GCowley  MJSimpson  J  et al.  Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA Registry. Circulation. 1983;67723- 730
Link to Article
Hannan  ELArani  DTJohnson  LWKemp  HGLukacik  G Percutaneous transluminal coronary angioplasty in New York State: risk factors and outcomes. JAMA. 1992;2683092- 3097
Link to Article
Wennberg  DEMalenka  DJSengupta  A  et al.  Percutaneous transluminal coronary angioplasty in the elderly: epidemiology, clinical risk factors and in-hospital outcomes. Am Heart J. 1999;137639- 654
Link to Article
Bredlau  CERoubin  GSLeimgruber  PPDouglas Jr  JSKing III  SBGruentiz  AR In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty. Circulation. 1985;721044- 1052
Link to Article
Szela  JMcHenry  PGrines  CBand  J Infectious complications associated with percutaneous transluminal coronary angioplasty (PTCA) [abstract]. Program and Abstracts of the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy (Anaheim) Washington, DC American Society for Microbiology1992;248
McHenry  PSzela  JMendelson  SGrines  CBand  J Infectious complications associated with interventional cardiovascular procedures: a prospective analysis [abstract]. Program and Abstracts of the 33rd Interscience Conference on Antimicrobial Agents and Chemotherapy (New Orleans) Washington, DC American Society for Microbiology1993;415
Samore  MHWessolossky  MALewis  SMShubrooks  SJKarchmer  W Frequency, risk factors, and outcome for bacteremia after percutaneous transluminal coronary angioplasty. Am J Cardiol. 1997;79873- 877
Link to Article
Shea  KWSchwartz  RKGambino  ATMarzo  KPCunha  BA Bacteriemia associated with percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn. 1995;365- 9
Link to Article
Sande  MLevinson  MELukas  DSKaye  D Bacteremia associated with cardiac catheterization. N Engl J Med. 1969;2811104- 1106
Link to Article
Deshpande  SSBremmer  SSra  JS  et al.  Ablation of left free-wall accessory pathways using radiofrequency energy at the atrial insertion site: transseptal versus transaortic approach. J Cardiovasc Electrophysiol. 1994;3219- 231
Link to Article
James  EBroadhurst  PSimpson  ADas  S Bacteraemia complicating coronary artery stenting. J Hosp Infect. 1998;38154- 155
Link to Article
Evans  BHGoldstein  EJC Increased risk of infection after repeat percutaneous transluminal coronary angioplasty. Am J Infect Control. 1987;15125- 126
Link to Article
Guerin  JMLeibinger  FMofredj  A Invasive staphylococcal infection complicating coronary angiography without angioplasty. Clin Infect Dis. 1996;22886- 887
Link to Article
Cleveland  KOGelfand  MS Invasive staphylococcal infections complicating percutaneous transluminal coronary angioplasty: three cases and review. Clin Infect Dis. 1995;2193- 96
Link to Article
Malanoski  GJSamore  MHPefanis  AKarchmer  AW Staphylococcus aureus catheter-associated bacteremia: minimal effective therapy and unusual infectious complications associated with arterial sheath catheters. Arch Intern Med. 1995;1551161- 1166
Link to Article
Wiener  RSOng  LS Local infection after percutaneous transluminal coronary angioplasty: relation to early repuncture of ipsilateral femoral artery. Cathet Cardiovasc Diagn. 1989;16180- 181
Link to Article
Frazee  BWFlaherty  JP Septic endarteritis of the femoral artery following angioplasty. Rev Infect Dis. 1991;13620- 623
Link to Article
Brummitt  CFKravitz  GRGranrud  GAHerzog  CA Femoral endarteritis due to Staphylococcus aureus complicating percutaneous transluminal coronary angioplasty. Am J Med. 1989;86822- 824
Link to Article
Topol  EJEllis  SGCosgrove  DM  et al.  Analysis of coronary angioplasty practice in the United States with an insurance-claims data base. Circulation. 1993;871489- 1497
Link to Article
McCready  RASiderys  HPittman  JN  et al.  Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty. J Vasc Surg. 1991;14170- 174
Link to Article
Heupler Jr  FHeisler  MKeys  TFSerkey  JSociety for Cardiac Angiography and Interventions Laboratory Performance Standards Committee, Infection prevention guidelines for cardiac catheterization laboratories. Cathet Cardiovasc Diagn. 1992;25260- 263
Link to Article
Leroy  OMartin  EPrat  A  et al.  Fatal infection of coronary stent implantation. Cathet Cardiovasc Diagn. 1996;39168- 170
Link to Article
Timsit  JFWolff  MABédos  JPLucet  JCDécre  D Cardiac abscess following percutaneous transluminal coronary angioplasty. Chest. 1993;103639- 641
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Characteristics and Underlying Diseases of Cases and Controls*
Table Graphic Jump LocationTable 2. Microorganisms Isolated From the 25 Patients With Bloodstream Infection After an Invasive Nonsurgical Cardiologic Procedure
Table Graphic Jump LocationTable 3. Summary of Studies That Identify Risk Factors for Infection After ICPs*

References

Grossman  W Cardiac catheterization. Braunwald  Eed.Heart Diseases A Textbook of Cardiovascular Medicine 4th ed. Philadelphia, Pa WB Saunders Co1992;
Malenka  DJO'Rourke  DMiller  M  et al. Northern New England Cardiovascular Disease Study Group, Cause of in-hospital death in 12,232 consecutive patients undergoing percutaneous transluminal coronary angioplasty. Am Heart J. 1999;137632- 638
Link to Article
Lindsay  JReddy  VMPinnow  EELittle  TPichard  AD Morbidity and mortality rates in elderly patients undergoing percutaneous coronary transluminal angioplasty. Am Heart J. 1994;128697- 702
Link to Article
Davis  KKennedy  JWKemp  HGJudkins  MPGosselin  AJKillip  T Complications of coronary arteriography from the Collaborative Study of Coronary Artery Surgery (CASS). Circulation. 1979;591105- 1111
Link to Article
Dorros  GCowley  MJSimpson  J  et al.  Percutaneous transluminal coronary angioplasty: report of complications from the National Heart, Lung, and Blood Institute PTCA Registry. Circulation. 1983;67723- 730
Link to Article
Hannan  ELArani  DTJohnson  LWKemp  HGLukacik  G Percutaneous transluminal coronary angioplasty in New York State: risk factors and outcomes. JAMA. 1992;2683092- 3097
Link to Article
Wennberg  DEMalenka  DJSengupta  A  et al.  Percutaneous transluminal coronary angioplasty in the elderly: epidemiology, clinical risk factors and in-hospital outcomes. Am Heart J. 1999;137639- 654
Link to Article
Bredlau  CERoubin  GSLeimgruber  PPDouglas Jr  JSKing III  SBGruentiz  AR In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty. Circulation. 1985;721044- 1052
Link to Article
Szela  JMcHenry  PGrines  CBand  J Infectious complications associated with percutaneous transluminal coronary angioplasty (PTCA) [abstract]. Program and Abstracts of the 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy (Anaheim) Washington, DC American Society for Microbiology1992;248
McHenry  PSzela  JMendelson  SGrines  CBand  J Infectious complications associated with interventional cardiovascular procedures: a prospective analysis [abstract]. Program and Abstracts of the 33rd Interscience Conference on Antimicrobial Agents and Chemotherapy (New Orleans) Washington, DC American Society for Microbiology1993;415
Samore  MHWessolossky  MALewis  SMShubrooks  SJKarchmer  W Frequency, risk factors, and outcome for bacteremia after percutaneous transluminal coronary angioplasty. Am J Cardiol. 1997;79873- 877
Link to Article
Shea  KWSchwartz  RKGambino  ATMarzo  KPCunha  BA Bacteriemia associated with percutaneous transluminal coronary angioplasty. Cathet Cardiovasc Diagn. 1995;365- 9
Link to Article
Sande  MLevinson  MELukas  DSKaye  D Bacteremia associated with cardiac catheterization. N Engl J Med. 1969;2811104- 1106
Link to Article
Deshpande  SSBremmer  SSra  JS  et al.  Ablation of left free-wall accessory pathways using radiofrequency energy at the atrial insertion site: transseptal versus transaortic approach. J Cardiovasc Electrophysiol. 1994;3219- 231
Link to Article
James  EBroadhurst  PSimpson  ADas  S Bacteraemia complicating coronary artery stenting. J Hosp Infect. 1998;38154- 155
Link to Article
Evans  BHGoldstein  EJC Increased risk of infection after repeat percutaneous transluminal coronary angioplasty. Am J Infect Control. 1987;15125- 126
Link to Article
Guerin  JMLeibinger  FMofredj  A Invasive staphylococcal infection complicating coronary angiography without angioplasty. Clin Infect Dis. 1996;22886- 887
Link to Article
Cleveland  KOGelfand  MS Invasive staphylococcal infections complicating percutaneous transluminal coronary angioplasty: three cases and review. Clin Infect Dis. 1995;2193- 96
Link to Article
Malanoski  GJSamore  MHPefanis  AKarchmer  AW Staphylococcus aureus catheter-associated bacteremia: minimal effective therapy and unusual infectious complications associated with arterial sheath catheters. Arch Intern Med. 1995;1551161- 1166
Link to Article
Wiener  RSOng  LS Local infection after percutaneous transluminal coronary angioplasty: relation to early repuncture of ipsilateral femoral artery. Cathet Cardiovasc Diagn. 1989;16180- 181
Link to Article
Frazee  BWFlaherty  JP Septic endarteritis of the femoral artery following angioplasty. Rev Infect Dis. 1991;13620- 623
Link to Article
Brummitt  CFKravitz  GRGranrud  GAHerzog  CA Femoral endarteritis due to Staphylococcus aureus complicating percutaneous transluminal coronary angioplasty. Am J Med. 1989;86822- 824
Link to Article
Topol  EJEllis  SGCosgrove  DM  et al.  Analysis of coronary angioplasty practice in the United States with an insurance-claims data base. Circulation. 1993;871489- 1497
Link to Article
McCready  RASiderys  HPittman  JN  et al.  Septic complications after cardiac catheterization and percutaneous transluminal coronary angioplasty. J Vasc Surg. 1991;14170- 174
Link to Article
Heupler Jr  FHeisler  MKeys  TFSerkey  JSociety for Cardiac Angiography and Interventions Laboratory Performance Standards Committee, Infection prevention guidelines for cardiac catheterization laboratories. Cathet Cardiovasc Diagn. 1992;25260- 263
Link to Article
Leroy  OMartin  EPrat  A  et al.  Fatal infection of coronary stent implantation. Cathet Cardiovasc Diagn. 1996;39168- 170
Link to Article
Timsit  JFWolff  MABédos  JPLucet  JCDécre  D Cardiac abscess following percutaneous transluminal coronary angioplasty. Chest. 1993;103639- 641
Link to Article

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