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AIMRadial2015 Abstracts: Coronary & Vascular 4th Advanced International Masterclass
Liverpool, United Kingdom, September 17-18, 2015
Learning Curve & Radial Approach
AIM 2015-1: Single Catheter Left Transradial Artery Approach to Graft Angiography
Kadhim HJ, Radomski ARL
Cardiology Dept, Craigavon Area Hospital, 68 Lurgan Road, Portadown, United Kingdom
PURPOSE: A retrospective audit of 22 single operator coronary graft angiography cases over a six-month period demonstrates the feasibility and option to use the left transradial approach (LTRA) to perform a coronary and graft study with the use of a single diagnostic catheter – the TIGER (TIG) catheter (Terumo Medical Corporation).
METHODS: All 22 patients had history of CABG, number of grafts ranged from 2 to 4. A positive Allen’s test using confirmed Barbeau scores ranging from A to C verified ulnar arch patency using pulse oximetry. Standard angiography procedure was followed in every patient. Any incidences of radial spasm or pain were documented. Screening times and doses were documented. Following radial sheath insertion and administration of 200 µg nitrate and 5000 IU heparin intra-arterially, the catheter intubated in the following order: LCA, RCA, SVG to OM, SVG to PDA and finally the LIMA graft.
RESULTS: Radiation and exposure times may be prolonged due to the catheter exchanges or spasm that may occur in standard transradial graft cases. We compared the mean doses and screening times for these cases against the same number (n = 22) of retrospectively performed transfemoral graft angiography cases. Using this single catheter approach via the L-TRA, the procedure dose and screening times were reduced by 25.4% and 21.3%, respectively. Although challenging at first (15-case learning curve), due to its manipulation, the TIG was found to intubate the LIMA when it was the last artery to review. We deduce that this may be due to the catheter having ‘softened’ during the procedure and, therefore, being more malleable to co-axially align itself to the angulation of the vessel.
CONCLUSION: When considering using the L-TRA for coronary and graft angiography, the TIG catheter can be safely used to successfully engage all grafts and native coronary arteries, thereby enhancing the patient experience, promoting less spasm, reducing radiation doses and exposure times.
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AIM 2015-2: Factors Influencing Success of Transradial Coronary Procedures: Role of Operator Experience, Procedure Type, and Patient Demographics
1Konstantinou K, 2Panoulas VF, 1Bogle RG
1Cardiac Catheterization Laboratories, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
2National Heart & Lung Institute, Imperial College London, London, United Kingdom
PURPOSE: The transradial (TR) approach has been adopted as the access route of choice for invasive coronary procedures. The aim of this study was to identify patient and operator factors influencing the conversion to, or need for, additional transfemoral (TF) access.
METHODS: In this retrospective study we included consecutive patients presenting to the Cardiac Catheterisation Laboratory at St George’s Hospital for TR approach diagnostic coronary angiography (DCA), percutaneous coronary intervention (PCI) or primary PCI (P-PCI) between April 2012 and July 2015. Operators were grouped into tertiles of low, intermediate, and high-volume based on their annual TR procedures. Variables associated with conversion from TR to TF access were identified using univariate analysis, followed by logistic regression to assess independence.
RESULTS: During the 39 months study period, 5478 patients underwent coronary procedures (75.4% DCA, 14.8% PCI and 9.7% P-PCI) via an initial TR approach. Conversion from TR to TF route, or the requirement for additional TF vascular access, occurred in 4.3% of cases. There was no significant effect of patient gender, height, weight, diabetes, hypertension, smoking status or peripheral vascular disease on TR to TF conversion. Increasing age (OR per 10 year increase 1.2; 95% CI 1.08-1.33, P<.001), low operator procedure volume (OR low vs. high volume 1.6; 95% CI 1.21-2.16, P<.001), and procedure subtype (OR PCI vs. DCA 1.88; 1.37 to 2.58, P<.001; OR P-PCI vs. DCA 2.15; 95% CI 1.55-2.99, P<.001) were independently associated with a significantly increased likelihood of TR to TF conversion. In DCA the conversion rate was 2.9% whereas in P-PCI cases conversion or need for additional TF access occurred in 10.4% of cases (P<.01). When conversion from TR to TF occurred it was associated with a significant increase in contrast volume and radiation exposure time.
CONCLUSION: Older patient age and low operator case volume were independently associated with increased rate of TR to TF conversion. Contrary to previous studies there was no effect of gender, height or weight. Almost all DCA procedures were successfully completed via the TR route with a very low TF conversion rate. In P-PCI the requirement for additional TF vascular access was more common, but still infrequent.
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AIM 2015-3: Transradial Learning Curve Paradox: Selection Bias Mitigates Transradial Learning Curve Associated Contrast and Radiation Load
Lux A, Ruzsa Z, Berta B, Jambrik Z, Toth K, Vamosi Z, Edes I, Molnar L, Becker D, Merkely B
Semmelweis Univ. Heart Centre, Városmajor u 68, Budapest, Hungary
PURPOSE: Increased radiation time and dose and longer procedures are associated with the learning curve of transradial percutaneous interventions. The aim of this dual-centre, prospective registry was to assess the influence of this phenomenon on the technical aspects and short-term outcome of primary percutaneous coronary interventions (pPCI) in acute coronary syndrome (ACS).
METHODS: Data on medical history and procedure characteristics was collected consecutively from 1333 troponin positive ACS patients and information on 30-day mortality was available in 444 of the cases. Patients were treated by either experienced operators (EO) or PCI fellows (PF) at dedicated transradial centres (>85%). Operators with over 250 PCIs/year in 5 consecutive years were classified as experienced. Endpoints were dose area product (DAP) accumulation, fluoroscopy time (FT), procedure time (PT) and 30-day mortality.
RESULTS: EOs treated significantly older patients with a higher incidence of chronic renal insufficiency and history of CABG surgery (68.0 ± 13.0 vs 64.5 ± 13.0; P=0.001; 7.8% vs 4.1% P=.03, 15.2% vs 7.25% P<.001, respectively), while PFs had more patients with diabetes (28.1% vs 16.1%; P=.008). STE and non-STE cases were equally distributed between the operator groups. EOs had to face a higher number of left main interventions and multivessel PCI-s (8.0% vs 3.6%; P=.006, 18.7% vs 11.18%; P=.001, respectively) and they delivered larger volumes of contrast and higher doses of radiation (137 mL [104-177] vs 121 mL [90-160] P<.001, 10675 cGy•cm2 [5206-19542] vs 863 cGy•cm2 [421-1873] P<.001, respectively). Naturally, linear regression verified that among others LM involvement and multivessel PCI are both independent modifiers of DAP accumulation and contrast delivery (P=.001 for both). The exclusion of these cases and patients with prior CABG surgery however did not change the significantly higher contrast and radiation use among EOs. Mortality was not influenced by the chosen operator, however STE at admission (OR 3.9, P=.005), the presence of diabetes (OR 4.3, P=.002) and femoral access (OR 6.6, P<.001) showed significant correlation with it.
CONCLUSION: A strictly controlled transradial learning curve will not increase mortality or radiation exposure during pPCI in ACS patients. Beside LM involvement and multivessel PCI other complicating factors have to be identified for the planning of a low-risk training course.
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AIM 2015-4: Svelte Coronary Stent Integrated Delivery System (IDS) Performance Examined Through
Diagnostic Catheter Delivery: The SPEED Registry
Nijjoff F, Stella P, Khattabl A, Berland J, Schofer, Meier B, Nietlispach F
University Medical Center Utrecht, Utrecht, The Netherlands
PURPOSE: The multicenter SPEED registry evaluated the procedural success and in-hospital clinical outcomes of direct stenting with the Svelte IDS through diagnostic catheters and primarily a radial approach across various patient and lesion subsets to identify the clinical indications for which this potential time and cost saving approach is ideally suited.
METHODS: Forty-eight (48) patients with 54 lesions of lengths <20 mm and RVD 2.5-3.5 mm were targeted for direct stenting through diagnostic catheters (4-6 Fr). Inclusion of ‘real-world’ clinical presentations was encouraged: patients with ACS, complex lesions and distribution across all coronary vessels.
RESULTS: Univariate analysis revealed a statistically significant association between strategy success and RVD (P=.05), target vessel (P=.01), lesion location (P=.01), and diagnostic catheter size (P=.05). Significantly greater device success in Type A/B1 lesions compared with Type B2 lesions (OR 15.7; 95% CI, 1.60-153) and in main branches compared with side branches (OR 24.0; 95% CI, 2.14-269) was demonstrated. Significantly higher strategy success rates were also realized in main-branch vs side-branch lesions (OR 45.0; 95% CI, 4.01-505), RCA/LAD vs LCX vessels (OR 10.5; 95% CI, 1.87-58.9), larger diameter (>2.5 mm) vs small diameter vessels (OR 8.20; 95% CI, 1.55-43.5) and smaller (<6 Fr) vs larger caliber catheters (OR 11.9; 95% CI, 1.35-106). When sub-grouping patients treated by operators ‘inexperienced’ (24 patients with 28 lesions) and ‘experienced’ (24 patients with 26 lesions) with diagnostic catheter delivery, significant improvements in crossing time (2.5 [1.0-4.9] vs 0.8 [0.3-3.0] min; P=.01) and intervention time (16.0 [9.8-36.0] vs 6.8 [4.8-10.9] min; P=.01), as well as trends toward improvement in device and strategy success and reductions in procedure time, were observed. Small decreases in radiation time and contrast were also noted.
CONCLUSION:: Direct stenting through diagnostic catheters using the Svelte coronary stent IDS is feasible and associated with good in-hospital outcomes. Significant improvement in crossing and intervention time and trends toward improvement in device and strategy success, reductions in procedure and radiation time and contrast use were observed, suggesting this approach is a viable alternative to conventional stenting in certain clinical indications and especially beneficial in facilitating use of small-caliber catheters and the radial approach.
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Hemostasis, Radial Injury or Occlusion
AIM 2015-5: Hand Grip Test After Transradial Percutaneous Coronary Procedures (HANGAR Study)
Sciahbasi A, Rigattieri S, Sarandrea A, Cera M, Di Russo C, Fedele S, Romano S, Penco M, Pugliese FR
Interventional Cardiology, Sandro Pertini Hospital - ASL RMB, Rome, Italy
PURPOSE: To measure, in patients who underwent transradial percutaneous coronary procedures, muscle force of the hand, thumb and forefinger according to a patent or occluded radial artery at follow-up.
METHODS: Elective patients with chronic stable angina undergoing percutaneous coronary procedures were evaluated the day before the procedure for radial artery patency, Allen test, hand grip, thumb and forefinger pinch test. The same measures were performed the day after the procedure and at follow-up. At follow-up patients were divided in two groups according to the radial patency (Group 1) or occlusion (Group 2). The hand grip strength and the pinch for thumb and forefinger was measured respectively with the Jamar Plus dynamometer and pinch gauge (Sammons Preston). The primary endpoint of the study was the variation in hand grip strength after the procedure (the day after and at follow-up) compared to baseline in the two groups.
RESULTS: From a total of 108 patients enrolled, 9 patients that could not complete the follow up were excluded, thus obtaining a sample size of 99 patients. Of the 99 patients included in the analysis 90 patients had a patent radial artery at follow-up (Group 1) and 9 patients (9.1%) had a persistent occluded radial artery (Group 2). Compared to Group 1, Group 2 patients were significantly shorter, more frequently had a family history of coronary artery disease and had a trend to a higher rate of smoking habitus. According to the procedural characteristics the occlusion of the radial artery was associated with a significantly longer procedure duration and fluoroscopy times. At baseline there were no significant differences in hand grip test between the two groups (42 ± 11 kg in Group 1 and 41 ± 17 kg in Group 2; P=.74). In both groups after the procedure the hand grip test was significantly reduced compared to baseline (40 ± 11 kg in Group 1 [P<.0001] and 37 ± 17 kg in Group 2 [P=.007]. Finally, at follow-up in both groups, the hand grip test returned to baseline values. Thumb and forefinger pinch tests did not show significant differences after the procedure and at follow-up compared to baseline.
CONCLUSION: In our study radial artery occlusion after percutaneous coronary procedures was not associated with a reduction in hand and finger strength.
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AIM 2015-6: Radial Artery Occlusion in Transradial Interventions: A Systematic Review
Rashid M, Kwok CS, Pancholy SB, Bernat I, Kedev S, Chugh S, Fraser D, Large A, Nolan J, Ratib K, Mamas MA
Keele Cardiovascular Research Group, University of Keele, Stoke On Trent, United Kingdom
OBJECTIVES: To investigate the incidence and factors influencing radial artery occlusion (RAO) post transradial access (TRA) for cardiac catheterization.
BACKGROUND: RAO may occur post TRA intervention and limit the radial artery as a future access site which in turn may limit its use as an arterial conduit. We investigated the incidence and factors influencing the RAO in the current literature.
METHODS: We searched MEDLINE and EMBASE for studies of RAO in TRA. Relevant studies were identified and data were extracted. Data were synthesized by meta-analysis, quantitative pooling, graphical representation or by narrative synthesis.
RESULTS: A total of 66 studies with 31,345 participants were included in the analysis. Incident RAO ranged between <1% to 33% and varied with timing of assessment of radial artery patency (incidence of RAO within 24 hours was 7.7% which decreased to 5.5% at greater than 1 week follow-up). The most efficacious measure in reducing RAO was higher dose of heparin as lower doses of heparin were associated with increased RAO (RR 0.36 [0.17-0.76]) whilst shorter compression times also reduced RAO (RR 0.28 [0.05-1.50]). Several factors were found to be associated with RAO including age, gender, sheath size, and diameter of radial artery, but these factors were not consistent across all studies.
CONCLUSION: RAO is a frequent complication after TRA intervention. Maintenance of radial patency should be an integral part of all TRA procedures. High dose heparin along with shorter compression time and patent hemostasis are recommended in reducing RAO.
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AIM 2015-7: Intra-Arterial Vasodilators in Transradial Cardiac Catheterization to Prevent Radial Artery Spasm: A Systematic Review and Pooled Analysis of Clinical Studies
Kwok CS, Rashid M, Fraser D, Nolan J, Mamas MA
Keele Cardiovascular Research Group, Institute for Science & Technology in Medicine, Keele University, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, United Kingdom
PURPOSE: Different vasodilator agents have been used to prevent radial artery spasm (RAS) in patients undergoing transradial cardiac catheterization. It is unclear which are the best agents to prevent RAS so we conducted a systematic review of the available literature to evaluate the efficacy and safety of agents used for prevention of RAS.
METHODS: We searched MEDLINE and EMBASE for studies that evaluated any intra-arterial drug administered in the setting of transradial cardiac catheterization. Data were collected on study design, participant characteristics, type of treatments administered, radial artery spasm rate, procedural time, procedural failure rate, and bleeding events. Collected results were presented in tables and analysis was performed by pooling of trials with similar treatment arms.
RESULTS: A total of 22 studies were included in the review. The pooled RAS rate was 12% for placebo (4 studies, n = 638), 12% for 2.5 mg of verapamil (3 studies, n = 768) and 4% for 5 mg of verapamil (2 studies, n = 497). Nicorandil treatment was associated with a higher rate of RAS than placebo (16%, 3 studies, n = 447). Treatments associated with low rates of RAS were nitroglycerin at both 100 µg (4%) and 200 µg (2%) doses, isosorbide mononitrate (4%), and nicardipine (3%). We found no information regarding the procedure failure rates, patent hemostasis, and radial artery occlusion in these studies.
CONCLUSION: In this review on intra-arterial vasodilators used to prevent RAS, we have found that the verapamil at a dose of 5 mg or verapamil in combination with nitroglycerine are the best combinations to reduce RAS.
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AIM 2015-8: Patent Hemostasis and Comparison of Two Hemostatic Devices After Transradial Cardiac Catheterization and Intervention
Bernat I, Jirous S, Durspek J, Rokyta R
University Hospital and Faculty of Medicine, Pilsen, Czech Republic
PURPOSE: Patent hemostasis significantly reduces the risk of radial artery occlusion (RAO) after transradial catheterization and intervention. The aim of our study was to compare the use of this technique in two different hemostatic devices.
METHODS: Three hundred patients (64% men, age 63.9 ± 10 years) were divided in two groups as consecutive 150 and 150 patients in our same-day discharge program. We used two different hemostatic devices - TR band (Terumo) as group A and Seal-One (Perouse) as group B after the transradial cardiac catheterization (n = 219) and intervention (n = 81). Both groups were not significantly different in baseline characteristics including the dose of unfractionated heparin ≥5000 IU. Compression pressure was reduced in short intervals. We measured time to achieve patent hemostasis, total compression time and analyzed local complications. Size of subcutaneous hematomas in centimeters were evaluated by EASY classification and RAO by using reverse Barbeau test with 1 minute ulnar compression at discharge.
RESULTS: Patent hemostasis was achieved during the first 30 minutes of compression in 98% patients in group A, in 93% patients in group B and finally in all patients. Radial artery compression time was 91 ± 39 minutes in group A and 65 ± 27 minutes in group B (P<.001). Hematoma grade II (>5 cm) was observed in 7.3% patients in group A and in 6.7% patients in group B, grade III (>10 cm) in 0.7% in group A and in 1.3% in group B (P=NS). All these hematomas had no clinical consequences. There were no hematomas grade IV and V. There was no RAO or other local complication at discharge in both groups.
CONCLUSION: Early patent hemostasis and short total compression time were associated with absence of RAO at discharge, higher incidence of hematoma grade II and minimal incidence of hematoma grade III in both groups. There were no other local complications in both groups.
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AIM 2015-9: Heparin Dosing and Radial Artery Occlusion after Diagnostic Coronary Angiography: Systematic Review and Meta-Analysis
1Rigattieri S, 1Sciahbasi A, 2Bernat I, 3Aykan A, 4Degirmencioglu A, 1Fedele S, 5Bertrand OF
1Interventional Cardiology, Sandro Pertini Hospital, Rome, Italy, 2University Hospital, Pilsen, Czeck Republic, 3Dept of Cardiology, Ahi Evren Hospital, Trabzon, Turkey, 4Dept of Cardiology, Acibadem University School of Medicine, Istanbul, Turkey, 5Quebec Heart-Lung Institute, Quebec City, Quebec, Canada
Interventional Cardiology, Sandro Pertini Hospital, Via dei Monti Tiburtini 385, Rome, Italy
PURPOSE: Radial artery occlusion (RAO) represents a drawback of transradial approach for coronary angiography (CA) since it precludes the use of the artery for further procedures, coronary bypass surgery or arteriovenous fistula for hemodialysis. Different strategies have been proposed in order to reduce the incidence of RAO, such as use of smaller sheaths, patent hemostasis and anticoagulant drugs. Unfractionated heparin (UFH) is commonly given to prevent RAO after CA; however, clear evidence about its appropriate dosing is lacking since published studies gave conflicting results.
METHODS: We systematically reviewed studies comparing low vs high UFH dose in patients undergoing transradial CA. Published prospective randomized trials reporting outcome data on rate of RAO were included in the analysis. We also investigated the rate of bleedings and time to radial artery hemostasis. Odds ratio (OR) and 95% confidence interval (CI) were calculated for dichotomous outcomes whereas weighted mean differences and 95% CI were calculated for continuous outcomes. Summary statistics were calculated by random-effects model.
RESULTS: We included in the analysis 5 randomized trials, amounting to 1798 patients randomized to low (n = 878) or high UFH dose (n = 920). Three studies compared 2500 IU vs 5000 IU of UFH; one study compared 2000 IU vs 5000 IU of UFH; one study compared a weight-adjusted UFH dosing (50 IU/kg with an upper limit of 5000 IU) vs 5000 IU. RAO was assessed by Doppler ultrasound (4 studies) or reverse Barbeau’s test (1 study) in a time window of 1-30 days after the procedure. Time to hemostasis was reported by 3 studies, amounting to 1031 patients. The overall rate of RAO was 5.7%; a trend toward a reduced rate of RAO with high UFH dose was observed (OR, 0.62; 95% CI, 0.36-1.08; P=.09) in the absence of an increased risk of bleeding (OR, 1.55; 95% CI, 0.83-2.90; P=.17). High UFH doses were also associated to a borderline statistically-significant increase in time to hemostasis (13 minutes; 95% CI, 0.10-26.39; P=.05).
CONCLUSION: High UFH dose (5000 UI) is associated with a reduced, although statistically non-significant, risk of RAO after transradial coronary angiography and with a slight prolongation of time to radial artery hemostasis as compared to low UFH dose (2000-2500 UI), in the absence of a significant increase in bleedings.
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AIM 2015-10: Influence of the Ratio Between Radial Artery Inner Diameter and the Introducer Sheath Outer Diameter on Endothelial Function in Humans after Transradial Coronary Procedures
1Rathore S, 2Dawson E, 2Cable T, 3Wright J, 3Morris J, 2Green D
1Frimley Park Hospital NHS Foundation Trust, Camberley, United Kingdom, 2Liverpool John Moores University, Research Institute for Sport and Exercise Sciences (RISES), Liverpool, United Kingdom, 3Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
Department of Cardiology Frimley Park Hospital, Camberley, United Kingdom
PURPOSE: The aim of this study was to assess the influence of radial artery (RA) diameter to introducer sheath ratio (<1.0 vs >1.0) during transradial procedures on NO-mediated endothelial-dependent and independent vasodilator function.
METHODS: Thirty-five subjects undergoing transradial catheterization using 6 Fr sheath (outer diameter 2.6 mm) were recruited and assessed before and the day after catheterization. A subgroup was also assessed 3 to 4 months after catheterization. The subjects were compared between artery to sheath ratio of <1.0 (n = 12) and >1.0 (n = 23). Baseline RA diameter, RA flow-mediated dilatation, and endothelium- and NO-dependent arterial dilatation were assessed within the region of sheath placement. Glyceryl trinitrate endothelium-independent NO-mediated function was also assessed. The non-catheterized arm provided an internal control.
RESULTS: Flow-mediated dilatation in the catheterized arm decreased from 10.6 ± 3.6% to 4.5 ± 3.5% and 8.4 ± 2.8% to 5.5 ± 3.5% in the artery to sheath ratio of <1.0 and artery to sheath ratio of >1.0 groups, respectively (P<.01). These values returned to baseline levels 3 months later (ratio of <1.0, 8.4 ± 4.0%; ratio of >1.0, 8.9 ± 3.7%; P=NS) vs pre-procedure. Glyceryl trinitrate decreased from 20.3 ± 6.7% to 8.3 ± 5.1% in group with artery to sheath ratio of <1.0 and from 11.1 ± 3.4% to 8.5 ± 4.0% in group with artery to sheath ratio of >1.0 (P<.001). There was significantly higher magnitude of decrease in flow-mediated dilatation and glyceryl trinitrate mediated dilatation in the subjects with RA to sheath ratio of <1.0. No changes in function occurred in the noncatheterized arm. RA spasm was reported higher in subjects with artery to sheath ratio of <1.0 (33.3% vs 21.0%). Wrist circumference and height were independent predictors of smaller RA diameter.
CONCLUSION: RA to introducer sheath ratio of <1.0 results in significantly higher magnitude of decrease in vasodilatory function, higher RA spasm and injury to the RA following transradial coronary procedures. RA diameter should be taken into account before deciding the size of the introducer sheath to reduce vascular complications during transradial procedures.
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Technical Aspects
AIM 2015-11: Challenge to Reduce Crossover from Radial to Femoral Access for Coronary Procedures: “RURU” Approach, a Single-Center Single-Operator Experience
Mansour Sallam, Suhaib Al-Mashari, Osama Tariq
Sultan Qaboos University Hospital, Muscat, Oman
PURPOSE: It is a routine practice to crossover to femoral access once the radial route fails. The aim of this study was to highlight our experience in reducing crossover rate from radial to femoral access to sustain safety and patient satisfaction.
METHODS: This prospective, single-center, single-operator observational study included all comers for coronary procedures from January 2010 to December 2014. The default access for coronary procedures was the right radial artery (RRA) unless there was a specific cause to use different vascular access. Whenever RRA failed, second choice was the right ulnar artery (RUA), third choice was left radial artery (LRA), if failed fourth choice was the left ulnar access (LUA), respectively (the “RURU” approach). We studied 888 patients in whom the first access was the radial artery.
RESULTS: Majority of patients were males (70.3%), mean age was 58.2 years with predominance of hypertension and diabetes (64.8% and 54.6%, respectively). Radial access succeeded in 810 patients (91.2%) and classified as group I, and failed in 78 (8.8%) patients and constituted group II. Whenever radial access failed, we crossed over to RUA access that succeeded in 35/78 patients reducing necessity to crossover to femoral route to 4.8%. RUA failed in 43 patients, crossed-over to LRA that succeeded in 20 patients reducing the necessity to crossover to femoral route to 2.6%. LUA was successful in extra 2 patients out of the 23 patients reducing the need to crossover to femoral approach to 2.36% (P=.0001).
CONCLUSION: The RURU approach has resulted in significant crossover rate reduction from radial to femoral access maintaining safety and patient satisfaction.
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AIM 2015-12: Glide Sheath Slender: New Developments, Promises, and Shortcomings
Takashi Matsukage
Tokai University Hachioji Hospital, Tokyo, Japan
PURPOSE: Examine the proper method for using the Glide Sheath Slender.
BACKGROUND: Transradial intervention (TRI) is 20 years old. This procedure is an adequately proven technique to reduce bleeding complications and patient discomfort in PCI using small diameter catheter.
METHODS: Recently, we have provided a new-concept sheath: the “Glide Sheath Slender (GSS)” from Japan. This device is compatible with 6 Fr guiding catheter while maintaining the outer diameter of the current 5 Fr sheath. We are pleased to describe availability, tips, traps and proper usage of this product involving 4 Fr and 7 Fr sized GSS, scheduled to be available in the near future.
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Complex PCI by Radial Approach
AIM 2015-13: Safety and Efficacy of the 7 French Glidesheath Slender for Complex Transradial Coronary Interventions: A Prospective Study with Radial Ultrasound Follow-up
1Adel Aminian, 2Carlos Van Mieghem, 3Iglesias Juan-Fernando, 2Angela Ferrara, 1Georges Khalil, 3Eric Eeckhout,
2Bernard De Bruyne, 1Jacques Lalmand, 4Shigeru Saito
1Centre Hospitalier Universitaire de Charleroi, Belgium, 2OLV Aalst, Aalst, Belgium, 3Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland, 4Shonan Kamakura General Hospital, Kanagawa, Japan
Centre Hospitalier Universitaire de Charleroi, Division of Cardiology, Chaussée de Bruxelles 140, 6042 Charleroi, Belgium
OBJECTIVE: The aim of this study is to evaluate the feasibility and safety of using the 7 Fr Glidesheath Slender for complex percutaneous coronary interventions (PCI) through the transradial (TR) approach.
BACKGROUND: The TR approach is increasingly used worldwide for coronary and peripheral vascular interventions. However, the smaller size of the radial artery may potentially restrict the use of large-sized sheaths and guide catheter that are sometimes necessary for the treatment of complex coronay lesions. The 7 Fr Glidesheath slender (Terumo) is a new dedicated radial sheath with a thinner wall and hydrophilic coating. It combines an inner diameter compatible with a 7 Fr guiding catheter with an outer diameter one French smaller than current 7 Fr sheath.
METHODS: Prospective dual-center registry of complex TR-PCI cases using the 7 Fr Glidesheath Slender to determine the procedural success, rates of vascular complications, radial spasm, and radial artery occlusion (RAO).
RESULTS: A total 27 patients were included. Mean age was 67 ± 12 years and 22 patients were males (81%). Procedural success was 100% with no case requiring conversion to femoral access. Use of a 7 Fr guide catheter was indicated for the treatment of highly complex coronary lesions including unprotected distal left main (LM) disease (n = 11), complex non-LM bifurcation lesions (n = 7), CTO (n = 2), and rotational atherectomy (n = 6). There were 3 minor hematomas but none of the patients experienced major vascular complications. The occurrence of radial spasm was reported in 2 patients. No case of major sheath kinking was noted. Doppler ultrasound examination of the radial artery at 1 month follow-up was available in 23/27 patients with no case of RAO.
CONCLUSION: Routine use of the 7 Fr Glidesheath Slender for complex coronary interventions is safe and feasible with a high rate of procedural success and a low rate of vascular complications. This new dedicated radial sheath has the potential to allow the treatment of highly complex coronary lesions through the TR approach.
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AIM 2015-14: Excimer Laser in Percutaneous Coronary Intervention: Indications, Procedural Characteristics,
Complications and Outcomes
Schwarz K, Zaphiriou A, Calvert PA, Ludman PF, Doshi SN, Townend JN, Khan SQ
University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Medical Centre, Birmingham, United Kingdom
PURPOSE: Excimer laser coronary atherectomy (ELCA) offers several unique advantages to complement the management of complex coronary disease. Previous studies have documented high complication rates (30%) however most studies predate the introduction of the smaller 0.9 mm catheter and expansion of radial access route. We sought to establish the indications, procedural characteristics, complications and outcomes of ELCA in a contemporary coronary interventional practice.
METHODS AND RESULTS: In this single-centre retrospective study 32 patients treated with ELCA at University Hospitals Birmingham between January 2013 and May 2015 were analysed. Mean age of patients was 69 ± 12 with male predominance (69%). ELCA was performed in fourteen (44%) elective angina patients, twelve (38%) urgent patients and six (19%) emergency procedures for primary STEMI. Three (9%) patients presented with cardiogenic shock prior to the procedure. The indications included failure to deliver smallest available balloon/microcatheter 21 (66%), high thrombus burden 6 (19%), in-stent restenosis 2 (6%), graft angioplasty 1 (3%) or failure to adequately pre/post dilate 2 (6%). Twenty-one (66%) of the procedures were performed via radial access, 7 (22%) via femoral and 4 (13%) via combined access in cases of chronic total occlusions. In the majority of cases 25 (78%) the 0.9 mm X-80 catheter was used delivering 10594 ± 4113 pulses. Additional rotational atherectomy, aspiration catheters and distal protection were used in 8 (25%), 6 (19%) and 4 (13%) cases respectively. GP IIb/IIIa inhibitor was initiated in 8 (25%). Laser intervention was successful in 30 (94%) cases and in all these instances drug eluting stents were deployed. There were two angiographically visible (6%) dissections of the treated vessels directly related to laser use but no perforations. There was one (3%) death in a shocked patient, one (3%) stroke and one (3%) stent thrombosis 11 days after the procedure. None of these major complications could be directly attributed to the use of ELCA.
CONCLUSION: In this contemporary series we have shown that ELCA can be performed safely via the radial approach with a 0.9 mm catheter with a high success rate and low procedure related complication rate.
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Bleeding & Anticoagulation
AIM 2015-15: PCI via the Femoral Artery in a Default Radial Centre Identifies Complex Patients with High Bleeding Risk and Adverse Outcomes
Kinnaird T, Uddin M, Choudhury A, Mitra R, Ossei-Gerning N, Anderson R
Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, UK
PURPOSE: The transradial route (TRR) is preferred over the transfemoral route (TFR) for PCI. However even in high-volume default TRR centers a cohort of patients undergo TFR-PCI. We examined the demographics, procedural characteristics, and outcomes of patients undergoing PCI via the TFR.
METHODS: The patient demographics, procedural data, and outcomes of 5379 consecutive patients undergoing PCI at a default radial centre between 2009 and 2012 were examined. Bleeding risk was assessed using the Mehran score. Major bleeding (MB) was classified by ACUITY definition.
RESULTS: 559 (10.4%) patients underwent PCI via the TFR and 4820 patients via the TRR (89.6%). Mehran bleed risk score was significantly higher in the TFR cohort (16.6 ± 8.4 vs 13.6 ± 6.9, P=.0008). Baseline variables independently predictive of TFR access were cardiogenic shock (OR 5.77, 3.74-8.90, P<.0001), previous CABG (OR 2.88, 2.11-3.93, P<.0001), chronic total occlusion intervention (OR 2.77, 2.20-3.48, P<.0001), rotablation/laser use (OR 2.25, 1.61-3.14, P<.0001), female gender (OR 2.05, 1.67-2.51, P<.0001), and chronic renal failure (OR 1.94, 1.28-2.96, P=.002). ACUITY bleeding was significantly higher in the TFR than the TRR cohort (11.6 vs 3.2%, P<.0001) with an excess in access (4.8 vs 0.4%, P<.0001) and non-access site MB (2.0 vs. 0.7%, P=.016). Transfusion rates were also high in the TFR cohort (6.1 vs.1.2%, P<.0001) as was vascular imaging (4.7 vs. 1.6%, P<.0001). The variables independently predictive of MB in the TFR cohort were chronic renal failure (OR 4.27, 2.67-6.16, P<.0001), acute coronary presentation (OR 3.56 1.98-4.57, P<.0001), shock (OR 1.93, 1.01-2.37, P=.04), and age (OR 1.02 per year 1.01-1.05, P<.0001). In the TFR patients with MB, mortality was high at 30 days (17.2% vs 2.6% for no MB, P<.0001) and at 1 year (37.6% vs 5.0%, P<.0001). Shock (OR 23.52, 9.11-60.66, P<.0001) and MB (OR 9.75, 4.45-21.35, P<.0001) were highly predictive of 30-day and 12-month mortality.
CONCLUSION: In a default radial PCI center, ~10% of patients undergo PCI via the femoral artery. These patients have high baseline bleeding risk and undergo complex interventions. As a result the frequencies of major bleeding, transfusion and death are high. Alternative strategies are required to optimise outcomes in this select group.
AIM 2015-16: The Prognostic Impact of Baseline Anaemia in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis
Kwok CS, Tiong D, Pradhan A, Andreou A, Nolan J, Bertrand OF, Curzen N, Zaman A, Loke YK, Mamas MA
Keele Cardiovascular Research Group, Institute for Science & Technology in Medicine, Keele University, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, United Kingdom
PURPOSE: To examine the relationship between baseline anaemia and mortality, major adverse cardiovascular events (MACE) and major bleeding in patients undergoing percutaneous coronary intervention.
METHODS: We searched MEDLINE and EMBASE for studies that evaluated mortality and adverse outcomes in anaemic and non-anaemic patients who underwent percutaneous coronary intervention. In addition, we included studies, which evaluated adverse outcomes with incremental decrease in haemoglobin. Data were collected on study design, participant characteristics, definition of anaemia, follow-up, and adverse outcomes. Collected results were presented in tables and Review Manager was used to perform random effects meta-analysis using the inverse variance method with pooled risk ratios.
RESULTS: A total of 44 studies were included in the review with 230,795 participants. The prevalence of anaemia was 26,514/170,914 (16%). The risk of mortality and MACE with anaemia compared to no anaemia was RR 2.44 (2.06-2.89) (33 studies, 134,192 participants) and RR 1.51 (1.34-1.71) (20 studies, 47,552 participants), respectively. The risk of re-infarction and bleeding with anemia compared to no anemia was RR 1.33 (1.07-1.65) (13 studies, 36,316 participants) and RR 1.97 (1.03-3.77) (11 studies, 34,388 participants), respectively. The risk of mortality for incremental decrease in hemoglobin (g/dL) was RR 1.19 (1.09-1.30) (7 studies, 82,208 participants) and the risk of mortality, MACE and re-infarction for incremental decrease in hematocrit (%) was RR 1.07 (1.05-1.10) (3 studies, 14,519 participants), RR 1.09 (1.08-1.10) (1 study, 6,025 participants) and RR 1.06 (1.03-1.10) (1 study, 6,025 participants), respectively.
CONCLUSION: The prevalence of anaemia in contemporary cohorts of patients undergoing PCI is significant. The presence of anaemia in the setting of PCI is associated with significant increase in post procedural mortality, MACE, re-infarction and bleeding. The optimal strategy for the management of anaemia in such patients remains uncertain.
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Non-Coronary Intervention
AIM 2015-17: Angioplasty of the Hand Arteries in Critical Hand Ischemia
Zoltán Ruzsa, Imre Ungi, Balázs Nemes, Júlia Tóth, András Katona, Kálmán Hüttl, Béla Merkely
Semmelweis University, Cardiac and Vascular Center, Városmajor str 68, Budapest, Hungary
PURPOSE: A prospective registry to assess the feasibility, safety and outcomes of percutaneous transluminal angioplasty in the treatment of critical hand ischemia.
METHODS: 72 patients (age 61 ± 16 years) were treated with angioplasty in critical hand ischemia between 2011 and 2015-04. We examined the procedural and clinical success and the rate of major adverse events, TLR, and vascular complications.
RESULTS: Seventeen patients (23.6%) were treated with acute hand ischemia (AHI) and 55 patients (76.4%) with chronic hand ischemia (CHI). Clinical symptoms were: rest pain in 64 (88.9%), ulcer in 1 (1.4%), digital gangrene in 7 (9.7%) patients. The cause of AHI was embolism in 9 (52.9%), thrombosis in 7 (40%), 1 radial artery trauma (5.9%). The cause of CHI was 39 (70.1%) advanced forearm atherosclerosis, 1 vasculitis (1.8%), and 15 (27.3%) post interventional. Technical success rate of the intervention was 97.2% (70/72). Angioplasty was performed in subclavian (n = 20, 27%), axillary (n = 9, 12.5%), brachial (n = 22, 30.6%), radial (n = 21, 29.2%), ulnar (n = 19, 26.4%), interosseal (n = 2, 2.8%), palmar arch (n = 7, 9.7%) and in 1 case in digital arteries (n = 1, 1.4%). Multilevel (n = 25, 34.7%), unleveled (n = 5, 6.9%) and singular (n = 42, 58.3%) dilatations were performed. Stent implantation was done in 31 cases (43%). Thrombolysis was done in 9 patients (12.5%) and in 11 patients (16.7%) mechanical aspiration was necessary. Clinical success was achieved in 64 patients (88.9%). The rate of access site complication was 2.8%, and major adverse events occurred in 7 patients (9.7%) at two-month follow-up. Target lesion revascularization at two-month was 8.3%. In 2 patients thoracic sympatectomy was necessary and 2 patients underwent minor finger amputation (2.8%).
CONCLUSION: Angioplasty of the hand vessels for critical hand ischemia is a feasible and safe procedure with acceptable rates of technical success and hand healing. Major adverse events are frequent due to high rate of severe comorbidities.
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AIM 2015-18: Transradial Access for Subclavian and Anonym Artery Intervention
Zoltán Ruzsa, Balázs Nemes, Júlia Tóth, Kálmán Hüttl, Béla Merkely
Semmelweis University, Cardiac and Vascular Center, Városmajor str 68, Budapest, Hungary
PURPOSE: The purpose of this prospective register was to evaluate the acute success and complication rate of transradial access for subclavian and anonym artery intervention.
METHODS: The clinical and angiographic data of 41 consecutive patients with symptomatic subclavian and anonym artery stenosis treated via transradial access using 6 Fr hydrophilic sheath between 2010 and 2014 were evaluated in a pilot registry. As a matched control we have compared the procedural data with the femoral group. The exclusion criteria were the conventional contraindications of the radial artery access and the acute proximal subclavian artery thrombosis. Primary endpoint: major adverse events (MAE), target lesion revascularization (TLR), rate of major and minor access site complications. Secondary endpoints: angiographic outcome of the subclavian and anonym artery intervention, consumption of the angioplasty equipment, cross over rate to another puncture site and hospitalization in days. Two interventionists skilled in transradial technique and supraaortic interventions performed transradial cases.
RESULTS: The puncture and the procedure were successful in all cases, and the cross over rate to femoral access was 2.5%. Balloon angioplasty was performed in 6 cases (14.6%), and stenting was done in 35 cases (85.4%). In 19 patients CTO recanalization was performed with 94.7% success rate (dual access in 10 patients [24.3%]). Contrast consumption was 148.2 ± 86.8 mL in the radial and 116.2 ± 76.55 mL in the femoral group (P<.05) respectively. Major access site complication was not detected. Minor access site complication was encountered in 3 patients (7.3%) (2 asymptomatic radial artery occlusion and one puncture site hematoma). Long term MAEs were observed in 3 patients (7.3%) and the TLR rate was (4.8%).
CONCLUSION: Subclavian artery intervention can be safely and effectively performed using radial access with acceptable morbidity and high technical success.
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AIM 2015-19: Transradial Access for Non-Coronary Interventions in Patients with Marked Hepatic Dysfunction
Biederman DM, Posham R, Bishay V, Titano JJ, Patel RS, Kim E, Sivananthan G, Tabori NE, Nowakowski FS, Lookstein RA, Fischman AM
Icahn School of Medicine at Mount Sinai, 1184 Fifth Avenue, New York (NY), USA
PURPOSE: Transradial access (TRA) has been shown to lower bleeding complications, morbidity, and mortality compared to transfemoral access in percutaneous coronary interventions. Liver dysfunction alters hemostasis at multiple levels to impart a greater risk of bleeding complications. The Model of End Stage Liver Disease (MELD) score is a university adopted means of quantifying the severity of chronic liver disease. This study evaluates the safety and feasibility of TRA for visceral interventions in patients with a MELD score of greater than or equal to twenty.
METHODS: From 1/2012 to 8/2015, a total of 1512 procedures were performed in 936 patients via the radial artery. Procedural details, technical success, and 30-day major and minor access site bleeding and neurological adverse events were prospectively recorded. Preprocedure laboratory values were retrospectively collected. MELD score was calculated according to the United Network for Organ Sharing guidelines [9.57 • ln (creatinine) + 3.78 • ln (bilirubin) + 1.12 • ln (INR) + 6.43]. Patients with preprocedure MELD score ≥20 were included in the study.
RESULTS: Thirty-eight procedures performed in 34 patients (age: 57.7 ± 16.3 years, male: 73.5%) met the above inclusion criteria. The median pre-procedural MELD score was 22.5. Nine cases (23.7%) were performed in patients with a MELD ≥25 (maximum: 35). The median (IQR) creatinine (mg/dL), bilirubin (mg/dL) and INR were 3.5 (1.5-5.2), 1.4 (0.4-4.7), and 1.5 (1.1-2.1), respectively. Interventions included renal/visceral (n=16, 42%), chemoembolization (n = 10, 26.3%), radiomemoblization mapping and treatment (n = 7, 18.4%), other (n = 5, 13.1%). The technical success was 100%. There was one minor complication (superficial bruising) at 30 days. There were no major complications.
CONCLUSION: The extremely low procedure related morbidity in this cohort with intrinsic bleeding risk suggests TRA to be a viable option for non-coronary interventions in patients with significant liver dysfunction.
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AIM 2015-20: Carotid Artery Stenting with Proximal Embolic Protection through Transradial/Brachial Approach in Patients with Complex Anatomy: Pushing the Boundaries of the Technique while Keeping Safety and Efficacy
Montorsi P, Galli S, Ravagnani PM, Teruzzi G, Trabattoni D, Fabbiocchi F, Lualdi A, Caputi L, Tresoldi S, Bartorelli AL
Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCC, Milan, Italy
PURPOSE: Transradial (TR) and transbrachial (TB) carotid artery stenting (CAS) has been shown to be a valid alternative to transfemoral CAS in specific subsets of patients and vascular anatomies. The major limitations to this technique is the small size of the radial artery that may limit the use of a full CAS equipment, including proximal embolic protection. Thus, patients with complex anatomy and high-risk plaques who might benefit most from this combined strategy have been frequently excluded from previous studies.
METHODS: 214 consecutive patients were treated by TR/TB CAS at our academic center. Pre-CAS CT-angiography was performed in all cases. Proximal protection (8Fr Mo.Ma system) was attempted in 61 (28%) patients with right (n = 32) and left (n = 28) internal carotid artery stenosis through TR (n = 30) and TB (n = 31) approach. An 8 Fr sheath was used in all patients. The stent, brain protection, and CAS technique were left at operator’s discretion. Heparin and dedicated closure device or bivalirudin and manual compression was used in TR and TB groups, respectively. Patients were on standard double-antiplatelet treatment. Acute and long-term radial artery patency was assessed by clinical and Doppler ultrasound parameters.
RESULTS: The mean age was 73 ± 7 years (40% >75 years). 72% were at high surgical risk and 94% were asymptomatic. One patient was shifted to femoral approach due to unfavorable anatomy and in 1 pt the Mo.Ma system was too short to enter the external carotid artery from the TR approach (crossover rate: 3.4%). Four patients developed acute intolerance to occlusion and were shifted to filter. CAS was successfully completed in the remaining 55 patients. In 15/55 (27%) patients the Mo.Ma system could not be initially positioned due to complex anatomy. We therefore modified the implantation technique by removing the system mandrel (to reduce device stiffness) and by adding a second wire (to increase wire support) loaded into the main channel obtaining a success in all cases. Predilation was performed in 26% of patients and single closed cell or hybrid stent were implanted in 87% of cases. No in-hospital and 30-day MACCE occurred. Major vascular complications occurred in 2 patients (3.2%): one brachial artery pseudoaneurism and 1 acute radial occlusion that were successfully treated by surgical repair and transient ulnar compression, respectively. Chronic radial artery occlusion was detected by Doppler ultrasound in two additional patients (6.6%) at a 244 ± 224 days follow-up.
CONCLUSION: CAS with proximal protection through TR/TB approach is a safe and effective technique with low vascular complication rate.
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Nursing Aspects
AIM 2015-21: SACRED – Systematic Assessment of the Cook© Radial Sheath Device: an Observational Study to Examine the Efficacy and Safety of a Radial Introducer Sheath used in Cardiac Catheterization which was Previously Associated with Delayed Inflammatory Skin Reactions
Mars C, Livesey C, Kemp I, Stables RH
Institute of Cardiovascular Medicine and Science, Liverpool Heart and Chest Hospital Cath Labs, Thomas Drive, Liverpool, United Kingdom
PURPOSE: To investigate the incidence of allergic skin reactions following use of a widely available hydrophilic radial sheath.
METHODS: SACRED was a prospective single-centre registry study. A total of 431 patients were recruited over 54 working days. The primary outcome measure was the incidence of delayed cutaneous reaction at 28 days. Secondary outcome measures were: procedural success rate with the study sheath, rate of use of intra-arterial vasodilator agents and the incidence of access site related adverse events. Patients were tracked through the index hospital admission to discharge for access-site related complications.
RESULTS: Follow-up was complete in 429/433 (99.1%) of radial sites. A single incidence of delayed inflammatory reaction was observed 1/429 (0.23% [95% CI, 0-0.68%]). Failure to access the radial artery occurred in 19/446 attempts (4.3%). Overall, intra-arterial vasodilator was low 83/433 (19.2%) however routine, prophylactic use accounted for 70/83 (84.3%) of this. The majority of operators were non-routine users and gave vasodilators in response to radial artery spasm in 13/363 (3.6%) of cases. Access site related complications were minor and occurred in 33/446 (7.4%) of radial sites attempted. Of these 20/33 (60.6%) were managed by nurses without medical review or input. Prior to discharge from the index procedure, radial artery occlusion was observed in 15/412 (3.6%).
CONCLUSION: A single self-limiting lesion was observed suggestive of granuloma but without histological confirmation. Access success rates were comparable with other studies but against a backdrop of non-routine use of intra-arterial vasodilators. Access-site complications were predominantly minor and easily managed.
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Radial Approach & Controversies
AIM 2015-22: Low Bleeding Complications and Low Mortality Rate in Transradial Intervention for Octogenarians
Khalid Tammam, Yuji Ikari, Fuminobu Yoshimachi, Fumie Saito, Walid Hassan
International Medical Center, PO Box 2172, 21451 Jeddah, Saudi Arabia
PURPOSE: Percutaneous coronary intervention (PCI) in the elderly is still a major hospital burden as this group of patients have high mortality rates and many comorbidities. The aim of this study was to analyze clinical outcomes of transradial intervention (TRI) compared to transfemoral intervention (TFI) in octogenarians.
METHODS AND RESULTS: We retrospectively analyzed a consecutive cohort of 291 octogenarian patients who underwent PCI at a tertiary care center where the default vascular access is via the radial artery. We analyzed the 30-day mortality rate and bleeding complications. TRI was performed in 218 patients (75%) and TFI in 73 (25%). The overall 30-day mortality rate was 10%; it was 1.9% after elective PCI, 14% after emergency PCI without shock, and 53% after emergency PCI with cardiogenic shock (P<.001). Bleeding complications were significantly lower in TRI than TFI (7% vs 16%, P=.01). The 30-day mortality rate was also lower in TRI (8% vs 18%, P=.02).
CONCLUSION: Low bleeding complications and low 30-day mortality rates were observed in TRI. Octogenarians are prone to bleeding complications. Thus, TRI may be advantageous in this specific group of patients because of less bleeding complications.
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AIM 2015-23: Transradial Approach vs Transfemoral Approach Use in Greece
Ziakas A, Katranas S, Bobotis G, Mavrogianni AD, Graidis C, Mezilis N, Arampatzis A, Nikas D, Economou F, Athanasiadis I, Stakos D, Dimopoulos V, Pappa E, Kouparanis A, Petroglou D, Karvounis H
First Cardiology Dept, AHEPA University General Hospital, Thessaloniki, Greece
PURPOSE: Transradial approach (TRA) gained ground during the last decade. Reliable data regarding the use of TRA are not existent in Greece as well as in many other countries. We examined TRA use in coronary angiographies (CAs) and in percutaneous coronary interventions (PCIs) in certain regions of Greece, its distribution in public and private catheterization laboratories (CLs) and its preference by operators.
METHODS: The study was performed in Northern and Central Greece, which constitutes 35.3% of the national population. The study focused on years 2004, 2009, and 2013.
RESULTS: There are 12 catheterization laboratories (CLs). CAs performed using TRA were 0.43% in 2004, 12.28% in 2009 and 39.81% in 2013, whereas PCIs performed using TRA were 0.38%, 9.20% and 39.48%, respectively. Operators familiar with TRA, but performing via TRA electively were 13.33% in 2004, 60.38% in 2009 and 42.37% in 2013. However, operators performing routinely via TRA were 2.2%, 5.66%, and 49.15%, respectively. The use of transfemoral approach (TFA) in public CLs during CAs was universal in 2004 (99.8%) and 2009 (99.2%), while in 2013 there was a slight decrease (84.4%); similar trends were noticed during PCIs as well (99.9% in 2004, 99.5% in 2009 and 76.8% in 2013). The use of TFA in private CLs was 99.4% in 2004, 78.2% in 2009 and 23.8% in 2013; TFA in PCIs was 99.97%, 83.2% and 32%, respectively.
CONCLUSION: This is the first time to reveal volumes and trends in interventions performed via TRA and TFA in Greece. TRA gains reputation among operators both in public and private CLs. TFA is still the primary approach used in public CLs, but not anymore in private CLs.
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AIM 2015-24: Transradial Access for Femoral Artery Intervention
Róbert Bellavics, Balázs Nemes, Ferenc Kuti, Kálmán Hüttl, Béla Merkely, Zoltán Ruzsa
Bács-Kiskun County Hospital, Invasive Cardiology, 6000 Kecskemét, Nyíri út 38, Kecskemét, Hungary
PURPOSE: A prospective register to evaluate the acute success and complication rate of the transradial access for femoral artery intervention.
METHODS: The clinical and angiographic data of 31 consecutive patients with symptomatic femoral artery stenosis treated via transradial access using 6Fr sheathless guiding between 2014 and 2015 were evaluated in a pilot registry. Stent implantation was done only in flow-limiting dissections and significant recoil. Secondary access was the popliteal or pedal artery. Inclusion criteria were significant isolated femoral artery stenosis without below-the-knee lesion and intermittent claudication (Fontaine IIa-b); or critical limb ischemia (Fontaine III-IV) with viable limb. The exclusion criteria were the conventional contraindications of the radial artery access, TASC D femoral artery lesions, lack of distal access site for stenting (occlusion of both below the knee arteries or diseased popliteal artery), acute limb ischemia. Primary endpoint: major adverse events (MAE), target lesion revascularisation (TLR), rate of major and minor access site complications. Secondary endpoints: angiographic outcome of the femoral artery intervention, consumption of the angioplasty equipment, cross over rate to femoral access site and hospitalisation in days. Transradial cases were performed by two interventionalists skilled in transradial technique and lower limb interventions.
RESULTS: Radial artery puncture and sheath deployment to the iliac artery was successfull in all cases. The procedure was finished with good angiographic result in 28 cases. In 8 patients CTO recanalisation was performed with 75% success rate. Secondary popliteal access was obtained in 6.45% and there was no cross over. Balloon angioplasty was performed in all cases, but additional stent implantation was done in 4 patiens (12.9%). Procedural time was 25.8 ± 12.9 min, fluoroscopy time 258.7 ± 127.2 msec, x-ray dose 326.7 ± 326.9 Gy•cm2 and contrast consumption 90 ± 56.2 mL. Major and minor access-site complications were not detected. MAE and TLR at 2 months was 0%.
CONCLUSION: Femoral artery intervention can be safely and effectively performed using radial access with acceptable morbidity and high technical success rate.
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AIM 2015-25: Feasibility and Efficacy of Transradial Coronary Intervention in Elderly Patients with ST-Segment Elevation Acute Myocardial Infarction
Yukio Mizuguchi, Sho Hashimoto, Takeshi Yamada, Norimasa Taniguchi, Shunsuke Nakajima, Tetsuya Hata, Akihiko Takahashi
8-1-3-1003 Oota, Suma-ku, Kobe, Japan
PURPOSE: The current European Society of Cardiology guidelines for the management of patients with ST-segment elevation acute myocardial infarction (STEMI) recommend transradial coronary intervention (TRI) by an experienced operator. However, TRI for elderly patients with STEMI is technically demanding because of difficulties in radial puncture and catheter advancement and poor backup support from the tortuosity of the subclavian and common carotid artery. These may lead to approach site conversion, prolonged door-to-balloon time, and device limitations even when performed by experienced TRI operators. This study aimed to evaluate whether the feasibility and efficacy of TRI is similarly observed in patients with STEMI who are older than 75 yrs.
METHODS: Between January 2008 and December 2012, a total of 399 patients with STEMI underwent percutaneous coronary intervention in our institute. For patients other than those undergoing hemodialysis for chronic renal failure and poor radial pulsation owing to a previous TRI procedure or cardiopulmonary arrest, we chose the right radial artery as the primary approach site. The intent-to-treat population with the transradial approach comprised was 292 patients. We retrospectively evaluated the clinical outcomes of the patients in terms of clinical indexes, including door-to-balloon time, access site conversion rate, procedural success rate, major adverse cardiovascular events, including 30-day mortality rate and access site complication. We compared these indices between the patients aged ≥75 yrs and those aged <74 yrs.
RESULTS: Of the patients treated during the study period, 93 (31.8%) were aged ≥75 yrs and 199 (68.2%) were aged <74 yrs. The procedural success rate was similar between the 2 groups (98.9% and 99.5%, respectively). One patient in each group was converted from the radial to femoral artery because of the tortuosity of the subclavian and common carotid arteries (1.1% vs 0.5%; P=.58). The door-to-balloon time was similar between the 2 groups (47.0 vs 43.7 minutes; P=.17). The peak creatinine kinase levels were lower in the patients aged ≥75 yrs than in those aged <74 yrs (2057 vs 2574 IU/L; P<.05). The in-hospital and 30-day mortality rates were significantly higher in the patients aged ≥75 yrs than in those aged <74 yrs (12.9% vs 1.0%, P<.001; 9.7% vs.1.0%, P<.001, respectively), which might be attributed to the fact that the patients aged ≥75 yrs more frequently had multiple coronary artery stenosis (60.2% vs. 49.5%; P=.09), more likely had a cardiogenic shock (18.3% vs 11.1%; P=.09), and more often required intra-aortic balloon pumping (23.9% vs 13.9%; P<.05), an extracorporeal membrane oxygenator (5.4% vs. 2.5%; P=.18). The occurrence of the access-site complication was similar between the 2 groups.
CONCLUSION: TRI is equally feasible and effective for patients with STEMI aged ≥75 yrs and for younger patients. The prognosis of elderly patients with STEMI remains poor despite successful reperfusion with TRI, probably because of the complexity of coronary lesions.
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AIM 2015-26: Patient Radiation Exposure in Transradial and Transfemoral Coronary Angiography and Angioplasty
Mohammad Alian Amir Hossien, Farajollahi Alireza, Tarighatnia Ali, Ghojzadeh Morteza
Interventional Cardiology Unit, Aalinasab Hospital, Tabriz, Iran
BACKGROUND: Many factors affect on patient and operator radiation dose in cardiovascular procedures. One of them is access site. Transradial approach (TRA) has clinical superiority as compared to transfemoral approach (TFA), but radiation dose in TRA is challenging.
PURPOSE: We compared the patient dose in coronary angiography and angioplasty by both accesses.
METHODS: Mean total DAP, skin dose (SD), and FT were calculated and analysed with SPSS17 by confidence interval 95% in all procedures. In CA procedures, patient radiation dose measured at different projections was evaluated in both accesses.
RESULTS: We randomized 327 patients. Angiography and PCI were 144 in TRA and 183 in TFA. There were no statistically significant differences in demographic characteristics, clinical status and angiographic parameters in both groups. Mean DAP in TRA and TFA procedures were 3907.96 µGym2 and 4643.58 µGym2, respectivly (P<.05). No significant differences were observed in FT and SD.
CONCLUSION: TFA in comparison with TRA exhibits higher radiation dose fluoroscopy. TRA could be a suitable way instead of TFA for CA and PTCA procedures.
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Radial Lounge & Same-Day Discharge
AIM 2015-27: Virtual 3 French Transradial Coronary Stenting with the 5 French Meito Masamune® Sheathless Guiding Catheter: Feasibility and Safety in an Outpatient Setting
Amoroso G, van Dullemen A, Westgeest P, van Duinen M
Onze Lieve Vrouwe Gasthuis Amsterdam, Oosterpark 9, Amsterdam, The Netherlands
PURPOSE: To assess the safety and feasibility of “virtual 3 Fr” transradial percutaneous coronary intervention (TRA-PCI) in an outpatient setting.
METHODS: A retrospective analysis of a single-operator log-book, for the first two months after its CE-mark approval, identified 11/52 (21%) patients (6/11 males, mean age 64 ± 10) who had undergone: (1) an elective TRA-PCI, (2) in an outpatient setting, and (3) with the “sheathless” 5 Fr Meito-Masamune guiding catheter (Medikit Co Ltd).
RESULTS: Procedural success was 96% (25/26 lesions), mean procedural time and contrast usage were 26 ± 15 min and 94 ± 69 mL, respectively. Patent hemostasis was successful in 10/11 patients, all patients were discharged home within 6 hrs, and no acute radial artery occlusion occurred.
CONCLUSION: “Virtual 3 Fr” TRA-PCI in highly-selected patients seems feasible and safe also when performed in an outpatient setting.
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AIM 2015-28: Efficiency, Safety and Patient Satisfaction with a Radial Lounge for Rapid Discharge after
Invasive Coronary Procedures
Nkala T, Konstantinou K, Bogle RG
Cardiac Catheterization Laboratories, St George’s University Foundation Hospitals NHS Trust, Blackshaw Road, London, United Kingdom
PURPOSE: The frequency of transradial coronary procedures has increased in recent years due to emerging evidence about their potential advantages over transfemoral procedures. As the adoption of transradial procedures increases, it is important to understand factors that can lead to increased procedural efficiency and safety. We investigated the impact of a dedicated Radial Lounge on the potential of transradial procedures to facilitate (1) same-day hospital discharge, (2) resource utilisation, and (3) improved patient experience.
METHODS: Nurse Practitioners kept a systematic log of consecutive patients admitted to the Radial Lounge for angiography and angioplasty procedures over a five-month period. Procedural success and complications were recorded. Patient satisfaction was assessed using standardized questionnaires. A successful outcome was defined as “angiography/angioplasty completed successfully via the radial artery with the patient fit for discharge at three hours post procedure.”
RESULTS: During the study period 138 patients were admitted to the Radial Lounge (89 male, 49 female). 95% underwent diagnostic coronary angiography with the remaining having ad-hoc percutaneous coronary intervention (PCI). Discharge at three hours occurred in 94% of patients. Of those patients not fit for discharge, 3 (2.1%) had undergone complex PCI and required a further period of monitoring, 2 (1.4%) had unsuccessful radial access and required a femoral approach, 1 (0.7%) underwent transfemoral angiography due to operator preference, 1 (0.7%) developed a moderate-sized radial haematoma and 1 (0.7%) patient had coronary spasm requiring intravenous opiates during the angiography procedure resulting in a prolonged period of monitoring. The patient experience survey reported that 100% of patients felt comfortable having the angiogram in their own clothing. 97% reported being comfortable in a recliner chair pre- and post procedure although 12% stated that they would have preferred to be in bed. Overall, 76% described their experience in the Radial Lounge as excellent, 23% as good, and 1% as adequate.
CONCLUSION: Discharge at three hours following transradial coronary angiography is feasible, associated with a low rate of complications and a high level of patient satisfaction. With 94% of patients fit for discharge at three hours, a 4-chair Radial Lounge allowing 45 minutes for each angiography procedure can accommodate at least 7 patients each day making this facility an excellent use of resources with high throughput.
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Ongoing Clinical Trials
AIM 2015-29: Our Experience in PCI through Transradial Vascular Access Site
Mohammad Alian Amir Hossien, Farajollahi Alireza, Tarighatnia Ali, Ghojzadeh Morteza
Interventional Cardiology Unit, Aalinasab Hospital, Tabriz, Iran
PURPOSE: Transradial approach (TRA) has clinical benefits and safety compared to transfemoral approach (TFA) in PCI procedures in some studies. Because of the difference in speed, technique and skill of the operator and working conditions, results of clinical trials might be in two different ways. The aim of this study, was to compare the clinical and radiation factors in TRA and TFA in PCI.
METHODS: In this study, 216 patients with coronary artery disease were randomly divided into two groups: TRA (n = 70) and TFA (n = 146). Success rate, amount of contrast used, fluoroscopic and procedure time and complications in TRA and TFA were evaluated.
RESULTS: Success rate in both was comparable. Mean fluoroscopic and mean procedure time in TRA and TFA were 7.66 and 32.32 min and 7.1 and 31.79 min (P=.54 and P=.36, respectively). Although in TRA the amount of contrast media used and access site complications was less than TFA, statistical analysis was not significant (P>.05).
CONCLUSION: There is no difference between TRA and TFA PCI in term of success rate, complication access site, fluoroscopy time and contrast used. But considering pronounced safety and efficacy advantages of TRA, it could be a choice technique for PTCA
