Distal embolization of atherothrombotic material often occurs during percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI), and its angiographic evidence ifigures associated with worse long-term outcomes.¹ Angiographic features of a high thrombus burden also are predictive of no-reflow and higher mortality,² thus suggesting that interventional techniques able to reduce thrombus burden may improve myocardial reperfusion. A series of thrombectomy and distal protection devices with different mechanisms of action has been, or is going to be, tested in clinical practice to reduce distal embolization during PCI. Although routine use of these devices is not recommended, the risk of noreflow by standard PCI might be unacceptably high in the subgroup of patients with a high thrombus burden.

Throughout revascularization of coronary arteries and saphenous vein grafts in acute myocardial infarction (AMI) and acute coronary syndromes, the burden of a thrombus can be “felt” by interventionalists. You know that ominous “feeling” when angiography demonstrates a large size thrombus — a notorious marker of procedural complications. And, extensive literature clearly supports your concern,^1–5 because visible thrombus poses imminent risk of flow impairment, distal embolization, “no reflow” phenomenon with micro-circular obstruction and infarct expansion. If treated inadequately, thrombus turns into an active, “angry” component causing further flow cessation and at times accounting for development of cardiogenic shock and even death. Can interventionalists discern the presence, quantify the size of a thrombus and proceed accordingly with a dedicated treatment strategy?

Coronary and peripheral interventions can result in distal embolization. Although guidelines mandate the use of embolic protection devices (EPDs) in PCI of vein grafts¹ and carotid arteries,^2,3 these devices are at most 50% effective4 and suffer from considerable shortcomings.⁵ Approximately 40%⁶–66%⁷ of patients undergoing carotid stenting with EPDs develop new MRI diffusion-weighted imaging defects. In certain emboli-prone vascular beds and settings (myocardial infarction), clinical trials employing EPDs could not demonstrate benefit.

Chronic renal disease (CRD) is a common health concern in wealthy countries, with approximately 20 million American adults currently affected.¹ While the association between renal insufficiency and increased risk of adverse non-fatal and fatal cardiovascular events has been firmly established,^2–5 the relationship between renal function and risk of restenosis after coronary artery stenting is less certain.^6,7

Chronic kidney disease (CKD) is endemic in our population, as is cardiovascular disease. Both carry large risks of major morbidity and mortality. The interaction of these two conditions is complex and the addition of CKD to cardiovascular disease worsens the long term prognosis in the latter.¹

The intra-aortic balloon pump (IABP) is the most commonly used temporary cardiac assist device. It has immediate beneficial hemodynamic effects, augmenting coronary perfusion, increasing myocardial oxygen supply and decreasing myocardial oxygen demand. In the setting of acute myocardial infarction, left ventricular unloading by an IABP could prevent early infarct expansion, ventricular remodeling, or both.¹

The intra-aortic balloon pump (IABP) is a mechanical unloading device that is used to decrease myocardial oxygen demand while at the same time increasing cardiac output.^1–3 In patients with acute MI who present with cardiogenic shock intra-aortic balloon counterpulsation (IABC) has been shown to improve survival.^3–9 Mechanical unloading of the ventricle prior to intervention has shown in animal models to reduce infarct size and decrease reperfusion injury.¹⁰ In patients with large acute infarcts, IABC has been shown to improve clinical outcomes.¹¹ Observational data have also suggested that aortic counterpulsation may reduce the rate of re-occlusion of the infarct-related artery after balloon angioplasty.^12,13 However, the use of counterpulsation in patients undergoing emergency cardiac catheterization during acute myocardial infarction (MI) has been associated with both an increase in hemorrhagic complications

The radial artery approach to diagnostic cardiac catheterization has emerged as an attractive alternative to the femoral artery approach in recent years, especially in Canada and Europe, due to more familiarity and training.^1,2 In experienced hands, the radial approach has been shown to minimize patient discomfort, achieve early ambulation and discharge,^3,4 with a reduced incidence of bleeding and other vascular complications compared with the femoral approach.^5–8

The current study of Oleg Roussanov et al describes the cost-effectiveness of the radial approach to diagnostic catheterization compared with the femoral approach, with and without use of closure devices.¹ Despite the fact that this is a non-randomized study, this paper gives accurate insight into the elements determining total procedural costs in the 3 study groups. Access costs were higher for the radial group because of the use of expensive puncture and cannulation sets. Surprisingly, more catheters were used in the femoral group. This might be due to a greater use of multipurpose catheters in the radial group.