Training and Learning Curve
STEMI Patients Undergoing Primary PCI in a Radial Approach Skilled Center can be Equally Treated with Either Femoral, Left, or Right Radial Access
Gabrić ID, Pintarić H, Babić Z, Trbušić M, Krčmar T, Manola Š, Nikolić-Heitzler V, Radeljić V, Zeljković I
PURPOSE: In the last few years, our center has become dedicated to the radial approach with nearby 85% of PCI performed with either left or right radial access route. In time radial approach has become first choice even in patients with STEMI. The aim of the study was to establish whether the type of access had an influence on the procedure success, procedure and fluoroscopy time, and bleeding complication counted as periprocedural blood loss in STEMI patients undergoing primary PCI.
METHODS: In this retrospective analysis, we included 767 patients with STEMI treated in our center with primary PCI from January 1, 2011 to January 5, 2013. Radial approach was used in 523 patients (68.2%) (TR group), divided according to the site of access in either “left” (413 patients; 78.9%) or “right” (110 patients; 21.1%) subgroups. Femoral route was used in 244 patients (TF group).
RESULTS: There was no significant difference in procedure success, door-to-balloon time, total procedure time, fluoroscopy time and radiation dose between TR and TF groups. In sub-analysis of TR group, we did not find that left or right side access had any significant influence on any of the analyzed parameters. Also, there were no differences in periprocedural blood loss between TR and TF procedural access route (drop of hemoglobin, TR = 10±10 vs TF = 11±11 g/L, p=0.254), as well as in either left or right TR approach (drop of hemoglobin, left = 10±10 vs right = 10±12 g/L, p=0.254).
CONCLUSION: In patients with STEMI undergoing primary PCI in a radial dedicated center, there is no difference in effectiveness, safety, and blood loss between radial and femoral approach. Also there is no significant difference in either left or the right radial access type.
The Effect of Body Mass Index on Transradial Artery Approach in Patients Undergoing Coronary Angiography
Le J, Iqbal S, Miller LH, Bangalore S, Coppola J, Shah B
PURPOSE: The aim of this study was to determine whether body mass index (BMI) has an effect on radial to femoral artery crossover in patients undergoing coronary angiography via the transradial approach (TRA).
METHOD: We retrospectively evaluated 1,343 consecutive patients who underwent a first coronary angiography procedure via TRA at a tertiary center from January 2011 to July 2013. Of this cohort, 7.5% (n=101) were excluded as they underwent planned percutaneous coronary intervention (PCI) without diagnostic coronary angiography, and an additional 1.0% (n=14) was excluded due to lack of body mass index (BMI) data. BMI was calculated from height and weight measured during the procedure visit and categorized as underweight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (>30.0 kg/m2). The primary endpoint of interest was the proportion of patients undergoing crossover from TRA to transfemoral approach (TFA) during the procedure and was compared across the 4 BMI categories using the chi-square test.
RESULT: Of the 1,228 patients undergoing coronary angiography with (31.3%) or without (68.7%) PCI, 2% (n=24) were underweight, 22.8% (n=280) were normal weight, 35.4% (n=435) were overweight, and 39.8% (n=489) were obese. The proportion of patients who underwent crossover from TRA to TFA was 12.1% (n=149), with 24.8% (n=37) due to arterial access failure, 32.2% (n=48) occurring after access but before coronary angiography was performed, 34.9% (n=52) occurring during coronary angiography, 5.4% (n=8) occurring between coronary angiography and PCI, and 2.7% (n=4) occurring after a plan for PCI via TRA was made. In addition, 15.4% (n=23) of crossover events occurred due to significant radial artery spasm. Across the BMI spectrum, there was no significant difference between the proportions of crossover events (underweight 4.2%, normal weight 14.6%, overweight 11.3%, obese 11.9%; p=0.33).
CONCLUSION: In a contemporary cohort of patients undergoing coronary angiography with or without PCI via TRA, BMI had no effect on proportion of TRA to TFA crossover.
Ulnar Artery. Is It As Safe As the Radial for Cardiac Catheterization?
Valdesuso RM, Gimeno JR, Lacunza FJ, Rodriguez RC, Rodriguez JA, Fleites HA, Toruncha A
PURPOSE: Analyze complications of ulnar artery (UA) approach (Apr) and propose “How to do” UA puncture (Ptur).
METHODS: We analyzed 1405 consecutive patients in which the UA Apr was attempted from November 2002 until January 2013 in two cath labs. All studies were performed by operators with experience in transradial Apr. Follow-up at 24 hours and 3 months after procedure was indicated. Hematomas (H) and neurological complications related to the UA Ptur recorded.
RESULTS: Of a total of 25,212 patients, 1405 (5.5%) were indented via UA. Mean age was 67±8 years, 66% were males, 35% were diabetics, and more than 55% had hypertension, hyperlipidemia, or were smokers. Study was completed by UA in 1279 patients (91%). Initially, UA Ptur was attempted at the place where pulse was felt stronger. The main cause of crossovers was the Ptur failure (40% of cases). Out of 1635 procedures performed, 768 (47%) were PCI, 81% through the right UA. 53 H >15 cm were documented; 12 (12%) of them, within the first 100 cases; and the rest 41 H, in the next 1305 patients (3.1%) (p<0.05). There was only 1 temporary neurological complication related to the nerve compression by H. The unintentional Ptur of the ulnar nerve (UN) was painful and occurred in 137 (9.7%) patients without neurological sequel. In a multi-variable analysis of first 100 patients, the higher incidence of H was related to Ptur proximal to the wrist folds that led to a difficult compression of the artery.
CONCLUSION: Ulnar Apr could be another access way for cardiac catheterization, despite a higher than radial rate of vascular complications. Ptur at the level of the wrist skin fold is strongly recommended to reduce complications. According to the relationship between UA and UN, Ptur must be performed from lateral to medial, avoiding unintentional Ptur of UN.
Temporary Pacemaker from the Forearm: Simple Algorithm of a Useful Tool
Yadav PK, Baquero GA, Gilchrist IC
PURPOSE: High-degree atrio-ventricular block requiring a temporary pacemaker can be seen in acute myocardial infarctions. In the acute setting where time is of essence, an already present forearm venous access can easily and rapidly be utilized for placement of a transvenous pacemaker.
METHOD: From our 15-year experience in right heart catheterization and central venous access via a forearm vein, we describe our algorithm used to place temporary pacing wires (4-7 Fr).
RESULTS: A forearm peripheral IV placed by the nursing staff is prepped in sterile fashion along with the access site for catheterization. The IV is exchanged over a 0.021 wire for a radial sheath and a venogram is performed with 3-5 cc contrast. The clearance of the contrast is slow and leaves a track, which the temporary pacemaker wire can follow under fluoroscopy. The relatively straight course of basilic vein (medial) allows easy advancement of the pacemaker. The cephalic vein (lateral) may give resistance at the “T junction” (where it joins the axillary vein). This can be easily overcome by a deep breath from the patient and/or half inflation of the pacemaker tip balloon. The balloon is fully inflated once in the subclavian vein; pacemaker is then advanced and placed in the right ventricle.
CONCLUSION: Temporary pacemakers can be placed via a forearm vein and may serve as an alternate to conventional techniques. This strategy can potentially avoid the bleeding risk of femoral access and pneumothorax of jugular/subclavian access and extend the benefits of transradial catheterization. This single center experience needs to be proven in a larger study before it is broadly accepted.
Hemostasis, Radial Artery Injury, and Occlusion
DRAPE Study: Same Day Dual Radial Artery Puncture Examination in Patients Requiring PCI – Incidence of Radial Artery Occlusion
Amruthlal Jain S, Gorges R, Larsen T, Miller R, Alexander P
OBJECTIVES: This study was designed to investigate the rate of radial artery occlusion (RAO) after same day dual radial artery puncture in patients transferred from a hospital where the diagnostic coronary angiogram was performed via radial approach in a facility without percutaneous coronary intervention (PCI) capabilities to a hospital with PCI capabilities to complete the intervention on the same day via the same radial artery.
BACKGROUND: The rate of RAO has been reported between 5% and 10% after single transradial catheterization in the recent literature, with almost 99.9% asymptomatic. The rate of total and subtotal RAO after same day dual puncture is unknown. Only few cases are reported on the safety.
METHODS: 25 patients who underwent dual radial artery puncture for PCI at the Providence Hospital Heart Institute from January 2012 to date were included. All diagnostic cases were performed with a 5 French (Fr) sheath and upgraded to 6 Fr if needed for PCI. Heparin, nitroglycerin, and verapamil were used as per the preference of the interventional cardiologist. They were asked to follow up (December 2012 to date) for evaluation of radial artery patency by palpation of pulse, modified Allen’s test, Barbeau’s test, and duplex ultrasound.
RESULTS: The mean age was 68 years. 8/25 (32%) were females. None experienced symptoms related to RAO. All felt extremely comfortable during the procedure. 3/25 (12%) had a weak distal radial pulse by palpation and 1/25 (4%) had no distal radial pulse. All had modified Allen’s test within 8 sec and type A or B Barbeau’s test (no/transient loss of waveform), both confirming very good collaterals to the hand. 4/25 (16%) had inverse Allen’s test with mean of 12 sec and type C Barbeau’s test (transient loss of waveform with dampened in recovery), both confirming sufficient collaterals recruited to the hand. None had type D Barbeau’s test (complete loss of waveform). These 4 patients were found to have subtotal occlusions by duplex ultrasound. None had total occlusions.
CONCLUSION: This is the first study reporting the dual radial artery puncture and incidence of radial artery occlusions in these patient populations. Dual radial artery puncture appears to be a viable and safe strategy if appropriate anticoagulation is used and the patients are transferred to a PCI capable hospital for coronary interventions.
How We Can Manage Radial Artery Late Occlusion: Recanalization of Occlusion or “High” Puncture of Radial Artery
Babunashvili AM, Kartashov DS, Dundua DP
BACKGROUND: Transradial interventions (TRI) are associated with certain risk of radial artery (RA) occlusion, limiting the possibility of re-intervention through the same access site.
METHODS: In case of late radial/ulnar artery (RA/UA) occlusion if the distal stump was palpable pulse, puncture, and cannulation of the post-occlusion segment and retrograde RA/UA recanalization and angioplasty was performed using the "Dotter-technique” or plain balloon dilatation or mixed technique. In case of patent preocclusion segment (confirmed by ultrasound) ”high” puncture and cannulation of this segment is possible.
RESULTS: Recanalization of occluded RA/UA was attempted in 61 cases, 49 in chronic total occlusions, and 12 in subacute RA/UA occlusions. Immediate success was achieved in 52 cases (85.2%): in 41 out of 49 chronic total occlusion cases (83.7%) and 11 out of 12 cases of subacute occlusion (91.7%). In 24 out of 52 cases of successful recanalization, late reocclusions occurred (46.2%). Of these, 2 patients were subjected to repeat successful recanalization of reoccluded artery. In 4 cases we have successfully performed under ultrasound guidance “high” puncture and catheterization of proximal (preocclusion) segment of RA and coronary intervention thereafter. In these cases retrograde recanalization of occluded RA was impossible due to lack of collateral pulse on the RA stump.
CONCLUSION: Retrograde recanalization of late radial/ulnar artery occlusion for repeat arterial access is technically feasible and safe. Despite the high risk of reocclusion in the long run, this new technique allows to solve the problem of access in cases where no other traditional access sites are available. In case of inability of retrograde recanalization of occluded RA (absent of collateral pulse) “high” RA puncture under ultrasound guidance is possible in certain anatomic situations.
Randomized Comparison of Low (2500 IU) versus Standard (5000 IU) Heparin Dose for Prevention of Forearm Artery Occlusion after Coronary Angiography
Hahalis G, Xanthopoulou I, Koniari I, Tsigkas Gr, Almpanis G, Christodoulou J, Grapsas N, Stayrou K, Alexopoulos D
PURPOSE: Radial artery occlusion (RAO) remains the “Achilles heel” of transradial coronary procedures. Higher over lower levels of systemic anticoagulation are believed to reduce RAO rates but this is ill supported by scientific evidence.
METHODS: This was a prospective, randomized, single-center study of parallel design. Patients were enrolled if they were older than 18-years-old, were scheduled for diagnostic coronary angiography, and the interventional cardiologist was willing to proceed with either radial or ulnar access. Patients were randomized before diagnostic catheterization in a 1:1 ratio to receive either 2,500 IU or 5,000 IU of unfractionated heparin. Patients were excluded after randomization when crossover to another arterial access site had been required, a different than 5 Fr sheath size had been inserted or ad hoc PCI had been performed. Study’s primary endpoint was arterial access site occlusion rate, as confirmed by absence of antegrade flow by Doppler examination, within 60 days after coronary angiography.
RESULTS: Between June 2010 and January 2013, 1167 patients were randomized to receive either 2,500 or 5,000 IU of heparin. In total 654 patients were excluded after randomization, leaving 603 patients (2,500 IU N=302 vs 5,000 IU N=301) to test study’s hypothesis. Patients’ baseline and angiographic characteristics (74.5% men, 31.3% diabetics, 38.3% with acute coronary syndrome) were well balanced between groups. At a median follow-up of 8 (1-60) days (Doppler available in 97.7% of patients), we observed 60 arterial occlusions among the 589 analyzed patients (10.2%). However, the occlusion frequency did not differ between the 2,500 and 5,000 IU heparin arms (12.0% vs. 8.4%, p=0.2).
CONCLUSION: Standard dose of heparin was not found superior to low dose, in reducing forearm artery occlusion rate after coronary angiography.
Is the Transradial Approach Always Safe?
Hajlaoui N, Ghommidh M, Jedaida B, Ben Mansour N, Lahidheb D, Haggui A, Dahmani R, Fehri W, Haouala H
BACKGROUND: Transradial approach for coronary angiography and intervention is actually widely used. The near absence of local vascular complications is one of its advantages. In our cath lab, we perform almost 1,600 coronary angiograms and angioplasties per year, most of them by transradial approach. We have reported three cases of major vascular complications in 10 years.
- Case 1: A patient of 84 years, hypertensive, diabetic, under anti-vitamin K for flutter, is hospitalized in our service for recurrent angina. The angiography procedure was made by transradial approach. Two days after angiography, the patient developed a blowing hematoma at the puncture point level. An ultrasound Doppler objectivizes a right radial arterio-venous fistula. A multibarette scan has supported a radio-cephalic fistula and a rudimentary ulnar artery. The patient had surgical repair with a total recovery.
- Case 2: A 73-year-old smoker underwent a coronary angiogram for effort angina. The procedure was made by transradial catheterization. The patient developed some days after a hematoma at the puncture point level. An exploration through ultrasound Doppler showed a false aneurysm that was not thrombosed by manual compression. An angioscan confirmed the diagnosis and the patient received a resection of the false aneurysm with a total recovery.
- Case 3: A 76-year-old man was admitted in our cardiac care unit for inferior ST-elevation myocardial infarction. A thrombolytic therapy was indicated. 30 minutes after, the patient presented signs of shock. He underwent a rescue angioplasty by 6 French transradial approach. Angioplasty with a bare metal stent was performed with a good angiographic result. 6 hours after, the patient complained of right forearm pain and numbness. Radial artery bleeding with acute compartment syndrome was diagnosed, so he received fasciotomy. Postoperative evolution was not favorable with persistent signs of shock.
CONCLUSION: The transradial catheterization remains an invasive procedure not devoid of risks. The most serious local complications are arteriovenous fistula, aneurysms, and compartment syndrome, which can lead to surgical treatment. Risk factors for occurrence of such complications may include advanced age, longer duration of catheterization and comorbidity.
Radial Artery Acute Injury After PCI Assessed by Optical Coherence Tomography
Kanovsky J, Poloczek M, Bocek O, Miklik R, Jerabek P, Ondrus T, Novakova T, Spinar J, Kala P
PURPOSE: To study the frequency of the acute injury of the radial artery (RA) caused during the percutaneous coronary intervention (PCI) in the patients examined and treated for the acute coronary syndrome (ACS). We used frequency-domain optical coherence tomography (FD-OCT) for the assessment, as it is the intravascular imaging method with the highest available resolution.
METHOD: We performed FD-OCT of the RA in 40 patients admitted to the PCI center for non-ST elevation acute myocardial infarction (nSTEMI). We used automated pullback with the manual injection of the contrast fluid and X-ray contrasting ruler, targeting the segment of 5 cm proximally from the sheath insertion in the vessel. All the FD-OCT recordings were assessed by two analysts, evaluating acute dissection, perforation, or other injury of the RA.
RESULT: We found acute injury of RA in 2 patients (5%), both dissections (one limited on the intimal layer, one involving medial layer of the vessel). Both dissections were of minor importance, asymptomatic with no clinical significance.
CONCLUSION: Acute radial injury during PCI is very rare. Only minor injuries of no clinical importance were found in two patients. Chronic changes of the artery are the subject of further research, as all the patients are scheduled for the follow-up FD-OCT within one year from the baseline examination.
Supported by the Grant of the IGA Ministry of Health of the Czech Republic no. NT/13830.
Radial Artery Occlusion after Catheterization: Can We Effectively Prevent It?
Skvaril J, Danickova K, Broulikova K, Maly M
INTRODUCTION: Radial artery occlusion (RAO), also marked as “asymptomatic loss of pulsation,” represents a specific complication of transradial approach in catheterization. Its character is fortunately benign in most cases. Neither Allen test, nor oximetry/plethysmography are sufficient predictors of hand ischemia in RAO. To prevent occlusion, some devices (TR band) and procedures (Barbeau test, so called ''perfusion hemostasis technique'') were developed. With their application, the artery compression is possible without interruption of blood flow.
METHODS: The occurrence of RAO was estimated in 2 periods: before and after introduction of the perfusion hemostasis technique in our workplace. TR band was used invariably. RAO incidence was evaluated 1 day after procedure and after a month (30 days). Beside physical examination, duplex ultrasonography of appropriate radial artery and ipsilateral ulnar artery was performed (arterial morphology, possible hematoma or fistula, vessel diameter, flow velocity).
RESULTS: In period 1 (804 patients), the incidence of RAO decreased from 10.8% to 5.8% (p<0.001) during 30 days. Similarly, in period 2 (after the perfusion hemostais technique introduction), the decrease was from 5.5% to 2.85% in the cohort of 532 patients. The perfusion hemostasis technique led to a significant decline of RAO incidence immediately as well as after 30 days (p=0.015).
CONCLUSION: The recanalization of RAO happens in approximately one half of the cases, independently of the used method of compression. The technique of perfusion hemostasis further decreases the RAO incidence to a half. Long-term incidence of RAO in our cohort of patients remains under 3% level.
Radial Artery Size Using Vascular Ultrasound Before and After Catheterization
Yadav PK, Lingle KC, Baquero GA, Foy A, Gilchrist IC, Kozak M
PURPOSE: Transradial cardiac catheterization is becoming more and more common in the United States. This access site is much safer than the femoral approach. However, there have been reports showing that up to 38% of individuals undergoing transradial cardiac catheterizations suffer from radial artery occlusion post-procedure. The mechanism of this remains unclear.
METHODS: We obtained radial artery ultrasounds from 50 randomly selected patients immediately before and after transradial catheterization between July 2012 and April 2013. Three different physicians independently measured the diameter of the radial artery.
RESULTS: Total 50 patients, 62% male and mean age 65 years. The average diameter and area post-procedure was significantly larger than prior to the procedure (3.1 vs 2.7 mm and 8.0 vs 6.8 mm2; p<0.0001). There was no evidence of post-procedure radial artery occlusion in our patient population. Three different sheath sizes were used: 6 Fr (82%), 5 Fr (28%), and 4 Fr (8%). Eighty-two percent of the cases were diagnostic and 18% had coronary intervention performed.
CONCLUSION: Despite the literature reports of up to 38% of individuals having radial artery occlusions post-transradial cardiac catheterization, we did not have any radial artery occlusions at our institution and we found that the radial artery was in fact larger post-procedure than prior to the procedure. Although this is a small observational study, it leads us to believe that radial artery spasm is not the cause of radial artery occlusion after transradial cardiac catheterization.
Effect of Local Heat Application on the Size of Radial Artery
Alqaqaa A, Ahmed A, Yadav P, Foy A, Kozak M, Glichrist I
PURPOSE: Small artery diameter along with vasospasm induced by radial artery puncture can limit the utility of the radial artery for cardiac catheterization and is often the source of major discomfort for patients. Many studies showed increased blood flow in extremities in response to local warming. This effect is due to vasodilation at the level of the arterioles leading to decreased vascular resistance. We hypothesize that the application of local heat will lead to increased size of larger arteries including the radial artery.
METHOD: 21 adult volunteers (>18 years of age, 5 females, and 16 males) self-identified as being healthy were included in this study. Two operators measured the diameter of the radial artery, 2 centimeters proximal to the styloid process using standard ultrasound techniques before and 10 minutes after forearm heat application. A digitally controlled, moist heating pad was used to warm the forearm to a target skin temperature of 42 degrees centigrade. Paired t-test was used to compare the results.
RESULTS: The mean diameter of the radial artery at baseline was 2.60 mm ± 0.4 mm. The mean diameter post local heat application was 2.85 mm ± 0.4 mm. The mean increase in diameter was 0.25 mm (95% CI: 0.15 to 0.35 mm), p=0.0001. There was no variation in response to heat application based on gender. There were no reported complications of local heat application.
CONCLUSION: Local heat application was associated with statistically significant increase in the size of radial artery. This physiologic response may have important clinical implications on radial arterial access success rate, sheath size, patient comfort, and occlusion rates; however, this needs to be tested in larger studies.
Initial Experience with the Glidesheath Slender for Transradial Coronary Angiography and Intervention: a Feasibility Study with Prospective Radial Ultrasound Follow-up
Aminian A, Dolatabadi D, Lefebvre P, Zimmerman R, Brunner P, Michalakis G, Lalmand J
OBJECTIVE: The aim of this study was to evaluate the feasibility and safety of the Glidesheath Slender in routine transradial (TR) coronary angiography and intervention.
BACKGROUND: In recent years, the TR approach has gained in popularity because of several advantages, such as reduced vascular access site complications and immediate patient mobilization. Procedural success has been further improved through technological innovations and the development of less invasive devices. The Glidesheath Slender (Terumo) is a new dedicated radial sheath with a thinner wall and hydrophilic coating. It combines an inner diameter compatible with 6 Fr guiding catheter with an outer diameter close to current 5 Fr sheaths. Its use has the potential to decrease invasiveness and access site complications during TR procedures.
METHODS: 114 consecutive patients undergoing TR coronary angiography and/or PCI using the Glidesheath Slender were included in a single center prospective registry of effectiveness and safety.
RESULTS: The mean age was 63 +/- 11 yr and 74 patients were male (65%). 27 patients had acute coronary syndrome (24%). During the procedure, the use of at least one 6 Fr catheter was noted in 38 patients (34%). Ad-hoc or planned PCI was performed in 35 patients (31%). In case of PCI, a 6 Fr guide catheter was required for the treatment of bifurcation lesions in 16 patients with subsequent kissing balloon inflation in 13 patients, the use of a thromboaspiration catheter in 9 patients, the use of rotational atherectomy in 2 patients, and the use of an IVUS catheter in 1 patient. Procedural success was 99.1% with only one case requiring conversion to femoral access. There were 6 minor hematomas but no patient experienced major vascular complications. The rate of symptomatic radial spasm was 4.4% (5/114). No case of major sheath kinking was noted. Doppler ultrasound examination of the radial artery at 1-month follow-up was available in 113/114 patients with only one case of radial artery occlusion (0.88%).
CONCLUSIONS: Routine use of the Glidesheath Slender for TR coronary angiography and interventions is safe and feasible with a high rate of procedural success and a low rate of radial artery occlusion.
Transradial PCI via 4 French Diagnostic Catheters - Initial Experience
Bernat I, Bertrand OF, Jirous S, Rokyta R
OBJECTIVES: In case of small radial artery diameter transradial PCI requires downsizing of sheaths and guiding catheters. We evaluated the novel strategy of direct stenting via 4 French (Fr) using a stent with new integrated delivery system (IDS).
METHODS and RESULTS: After initial experience with stenting via 5 Fr diagnostic catheters we included eight consecutive patients (4 men, 4 women, age 67±8 years) suitable for transradial 4 Fr diagnostic coronary angiography with good quality imaging. All patients had history of recent acute coronary syndrome (ACS) without ST segment elevation and indication for PCI by direct stenting de novo lesions in native coronary arteries. Seven of them had ad hoc PCI of one lesion and one elective PCI with two lesions. A total of eight bare metal stents on a wire ISD (Svelte Medical Systems) were implanted to eight lesions with good angiographic results (TIMI III flow and residual stenosis <20%). Post-procedural radial artery compression time was 92±34 min. There was no conversion to conventional PCI or complication during all procedures and in 30 days clinical follow-up.
CONCLUSION: Transradial direct stenting with new IDS via 4 Fr diagnostic catheters is safe and feasible alternative to standard PCI in selected patients with reduction of material used and short radial artery compression time.
Supported by MH CZ – DRO (Faculty Hospital in Pilsen – FNPI, 00669806)
A Unique GuideLiner-Related Complication During a Transradial PCI and its Successful Management
Bhat T, Tamburrino F, Beydoun H
INTRODUCTION: We are reporting a unique GuideLiner-related complication and its successful management during a radial approach PCI that has not been reported previously.
CASE: A 69-year-old Caucasian male presented to our hospital with unstable angina and transradial coronary angiography was performed. It showed 80% diffuse, highly calcified lesion the mid LAD. A percutaneous coronary angioplasty was planned following the diagnostic procedure through a right radial artery access. The left main was engaged with a 6 Fr XB LAD 3.5 guide catheter. After multiple balloon inflations in the diseased segment we were unable to deliver stent due to calcification and tortuosity. Multiple attempts using different techniques such as buddy wires, placement of Ironman wire (Abbott Vascular), for delivery of stent were unsuccessful. Finally a 6 Fr GuideLiner catheter was used for distal delivery of stent. During the balloon angioplasty there was severe dampening and multiple attempts were made to retrieve the balloon, but seemed to be stuck, and due to severe dampening of the whole system, which includes the guiding catheter, the GuideLiner and the balloon were pulled out from the coronary artery. As we were trying to pull GuideLiner catheter out we discovered that the flexible guide extension (distal cylinder) of the GuideLiner was detached from the stainless-steel push tube and was floating into the ascending aorta and fortunately proximal edge was still inside the guiding catheter. In order to retrieve this part, a guidewire was threaded through the guiding catheter and the flexible guide part (distal cylinder) of the GuideLiner. A small balloon was then delivered past the distal tip of the GuideLiner catheter. It was inflated and, while balloon inflated flexible guide part (distal cylinder) of the GuideLiner, was pulled into the guiding catheter and with no risk of embolization into the aorta or coronaries. The whole system was then pulled out without any complications.
DISCUSSION: We believe that in our case the balloon may have gotten stuck at metal transition zone “collar” of the GuideLiner catheter and after multiple attempts, may have led to fracture and dislodgment of the GuideLiner parts as described. To prevent this complication, it has been suggested to lengthen the silicon-coated straight guide extension beyond its existing 20 cm to 30 cm, which would result in the interface between the stent balloon and GuideLiner ‘collar’ to be further from the distal aspect of the guide, and more likely to be coaxial within the guiding catheter. This simple modification could prevent deformation and/or damage to the balloon stent during retraction of the GuideLiner.
A New 5 Fr Guiding Catheter for Left Transradial RCA & SVG-Percutaneous Coronary Interventions: Report of Performance
PURPOSE: Success of percutaneous coronary interventions (PCI) through transradial access (TRA) relies on capable guiding catheters (GC). Most of the actual GC shapes address the problem of the back up support through optimized contact with the aortic ascending wall. Through a shape modification in the shaft of existing GC, we tried to add a pendular effect, in order to make easier and safer the re-cannulation of coronary artery (CA) ostium. We tested the modification for GC used for left and right CA via right TRA, as for right CA (RCA) and saphenous vein graft (SVG) via left TRA. The present communication reports the results of a modified GC aimed at RCA and SVG PCI via left TRA.
METHODS: The new shape was added to the actual 5 Fr Sherpa NX Active™ GC from Medtronic and the catheter was tested on consecutive patients requiring RCA PCI (n=38) or SVG PCI (n=5) through 5 Fr left TRA. The catheter’s performance was scored on a scale of 5 for ease of RCA/SVG cannulation (“friendly”), degree of support, and level of safety (well aligned in the center of the lumen’s vessel, no induced wall damage). Presence of a pendular effect, fluoroscopy time, volume of contrast used, and crossover to another GC were recorded. RCA cannulation time was also monitored for 22 cases. Level of difficulty of the PCI was evaluated as “easy,” “not easy,“ or ”hardish” using a scoring system based on patient, aorta, coronary anatomy, and lesions characteristics.
RESULTS: The RCA PCI population was scored as “difficult” for 25 (66%), mean age 75, mean 25’ of fluoroscopy time, “not easy” for 11 (29%), mean age 62, fluoroscopy time 17’, and “easy” for 2 (age 47 and 59, fluoro time 6’30). RCA PCI was successful for 34 patients: 4 cases failed due to inability to cross occlude vessels by wire (3) or balloon (1), despite crossover to another GC in 2 cases. A total of 8 GC crossovers occurred [MRESS (n= 5), RRAD (n=2), and AR1 (n=1) curves]. Ease of RCA cannulation was graded ≥ 3/5 for 24 cases. RCA cannulation was obtained in 30 sec or less for 11 of the 22 recorded cases and in less than 60 sec for 15 (68 %). For the 28 successful PCIs with the new GC shape, degree of support and safety were respectively scored at 4.5 and 5/5. A pendulum-like effect was present for a third of the cases (10/28). For the 25 PCI classified as difficult, the crossover occurred for 5, support and safety remain at 4.6 and 4.9/5. The pendulum effect was detected for 8 of the 18 (44%) difficult cases performed with the new GC. There was no complication.
All the 5 SVG-PCI were scored as “difficult,” mean age 79, fluoroscopy time 24’: 3 were successful with the new GC, and failed for 2 for which routine GCs had already failed.
CONCLUSION: A pendular effect was visible in 44% of the difficult left TRA RCA-PCI. The GC shape modification provided a good support, allowing successful PCI for 28 of the 34 successful cases and for 18 of the 25 difficult RCA cases. This GC provides a new alternative to current material.
The Effect of Acquisition Parameters on Radiation Dosage in PCI
Gladstone PSJ, Kassam S, Li C, Burstein J, Vijayaraghavan R
PURPOSE: The purpose of this study was to measure the effect of changes in acquisition parameters on radiation dosage in PCI. The installation of a new Philips Allura Clarity cath lab allowed the opportunity to determine if these changes would significantly reduce radiation dose, without affecting the procedure time or volume of contrast used.
METHODS: Rouge Valley Centenary is a busy standalone regional cardiac center performing over 1200 procedures per year. Five operators perform these procedures. One month after installation of a new Philips Allura Clarity cath lab, the acquisition parameters were changed to significantly reduce the dose required. The cine acquisition rate was reduced to 7.5 FPS and the exposure reduced by 70%. The option of higher dose and frame rates remained open to the operator at anytime through a touch screen interface. The patient dose (mGy), fluoro time, and dye used were compared retrospectively for both protocols. Two groups, before and after the equipment adjustment, were used as the comparison.
RESULTS: Two sequential groups of 40 PCI patients formed the basis of the study. The mean values for high dose (Hi) and low dose (Low) X-ray settings were compared for absorbed dose (mGy), dye volume (mL), and fluoro time (min). In both groups 55% were primary PCI for code STEMI and 85% were ad hoc procedures. Over 90% were transradial procedures. The changes in the X-ray settings resulted in a reduction in average dose from 637 mGy to 199 mGy, a reduction of 69% (p=0.001). The fluoro time remained unchanged at (Hi) 9.9 min and (Low) 7.7 min (p=ns). The dye used was also unchanged at (Hi) 120 mL (Low) 114 mL (p=ns). No patients required urgent surgery and a procedural success of 99% was achieved.
CONCLUSIONS: Radiation exposure during interventional procedure remains a significant risk to patients and particularly staff during a professional lifetime. This retrospective review indicates that new cath lab imaging protocols and lower frame rates, can reduce this exposure by over 68% without increasing the procedure time or dye consumed.
Is Magnesium Sulfate Efficacious as Classic Cocktails for the Prevention of Radial Vasospasm and Interesting in Hemodynamically Impaired Patients?
Hajlaoui N, Ben Mansour N, Jedaida B, Haggui A, Lahidheb D, Dahmani R, Fehri W, Haouala H
PURPOSE: To compare a cocktail regimen of magnesium sulfate (150 mg) + heparin (50 mg) (C1) to a cocktail of nitroglycerin (1 mg) + nicardipine (1 mg) + heparin (50 mg) (C2) for the effectiveness to prevent radial vasospasm (RV).
METHODS: Prospective randomized single blinded trial including patients undergoing transradial coronarography. Radial vasospasm was defined by visual analogic scale >5 or manipulation difficulties reported by the operators.
RESULTS: Seventy patients were included, 35 received C1 and 35 received C2. Four patients were excluded (1 for impossibility of left main cannulation, 1 for extreme arterial tortuosity, 1 for subclavian artery occlusion, and 1 for anaphylactic choc). Sixty-six patients were analyzed. Baseline demographic characteristics were similar between C1 and C2 groups. There were no significant differences between groups for procedure duration, quantity of sedative drugs received, type of sheath used, attempts of radial puncture, number of catheters used, quantity of nitroglycerin administrated during procedure, and radiation exposure. RV occurred in 23% of procedures (n=15). 10/34 patients in C1 group presented RV vs 5/32 in C2 group (p=0.13). Conversion to femoral approach occurred in 3 cases, all in C2 group. The mean systolic blood pressure (SBP) was not significantly different between the two groups before cocktail administration (160 mmHg vs 159 mmHg). After cocktail administration, the mean SBP was significantly lower in the C1 group (151 mmHg vs 129 mmHg) (p=0.01). Two patients from C2 group presented severe hypotension during the procedure necessitating administration of macromolecular solutes vs any patient in C1 group; the difference is not statistically significant.
CONCLUSION: There was no significant difference between the compared cocktails for the prevention of RV. Although the difference is not significant, magnesium sulfate seems to cause less hemodynamic impairment. Larger studies are needed to determine if magnesium sulfate is the right cocktail for patients at high risk of severe hypotension with nitroglycerine and calcium channel inhibitor cocktail.
A Review of the OCT Registry at The Prince Charles Hospital
Hlaing SH, Latona J, Sufee I, Savage M, Walters D, Raffel OC
AIM: Percutaneous coronary intervention (PCI) has long been performed at The Prince Charles Hospital (TPCH). In September 2009, optical coherence tomography (OCT) was introduced in clinical practice to assess coronary artery lesions during angiography. The aim of this study was to compile and analyze a registry of patients on whom OCT was performed.
METHODS and RESULTS: 130 patients underwent OCT during angiography between September 2009 and August 2012; however, only 111 patients' charts were accessible for analysis. Of these 111 patients, 79 were male. Access site was obtained through the right femoral artery in 90 cases, right radial artery in 20 cases and one through the brachial artery.
Indications for OCT included: 25 STEMI, 45 NSTEMI, 19 unstable angina, 11 stable angina, 6 dyspnea, and 5 elective PCI. 59 of these cases had known coronary artery disease, while 52 were newly diagnosed. Diseased vessels included: 7 left main, 69 left anterior descending, 20 circumflex, and 42 right coronary arteries. There were 3 intra-procedural complications that were directly related to OCT. This includes 2 patients with chest pain and transient ECG changes and one successfully defibrillated VF arrest. There were no direct post-procedural complications of OCT; however, one patient died from cardiogenic shock secondary to myocardial ischemia.
CONCLUSION: TPCH has introduced and continues to successfully maintain an expanding registry of patients on whom OCT is performed.
Reduction in Total Radiation Dose by Default Reduction in the Digital Fluoroscopy and Cinefluoroscopy Rates
Jeon C, Piemonte T, Resnic F, Waxman S, Pyne C
PURPOSE: An important determinate of radiation exposure during cardiac procedures using digital pulsed fluoroscopy (DPF) and cinefluorography is the x-ray pulse rate. Most catheterization laboratories have default settings for the pulse rate, which is often set at 15 frames per second (fps). Beginning in early 2012, our laboratory decreased the default fluoroscopy and cinefluorography pulse rates for catheterization procedures from 15 fps to 10 fps. There were no complaints by physicians relating to image quality and the change became permanent. We sought to examine the impact of this default change in pulse rate on patient and physician radiation exposure as expressed by the mean x-ray dose.
METHODS: An internal database was used to retrospectively review procedures done with the different default x-ray pulse rates and create 2 comparison groups. Group 1 consists of 491 patients undergoing diagnostic or interventional coronary procedures during a 3-month period in 2012 (DPF rate of 10 fps). Group 2 consists of 524 patients having the same procedures during an identical 3-month period in 2011 (DPF rate 15 fps). Non-coronary procedures were excluded from analysis. Patient history, demographics, procedure types, fluoroscopy time, and x-ray dose were compared between groups. The primary outcome is the reduction in mean x-ray dose with the reduction in the x-ray pulse rate. The x-ray dose is reported as the Air Kerma [in milligray (mGy)] obtained from the x-ray tube for each procedure. The study was approved by the local institutional review board.
RESULTS: There are no significant differences between groups 1 and 2 in patient ages, sex, height, weight, or body mass index. There are no significant differences in patient history including any history of prior CHF, MI, or CABG. There are no significant differences between groups in access site [Group 1: 61.3% radial, Group 2: 62.2% radial (p=0.7655)], mean fluoroscopy time [Group 1: 12.8 +/- 12 min, Group 2 13.2+/-12.3 min (p=0.5931)], or mean contrast dose [Group 1:155+/- 98cc, Group 2: 147+/- 86cc (p=0.1523)]. There was a significant reduction in mean x-ray dose between groups (Group 1: 1179.1+/- 1147 mGy, Group 2 1763 +/- 1388 mGy, p<0.0001). The unadjusted reduction in radiation dose for Group 1 compared to Group 2 is 39.9% (95% CI, 36.6% to 43.0%, p<0.001). When adjusted for other predictors of radiation dose, the reduction for Group 1 compared to Group 2 remained large and highly significant at 38.3% (95% CI, 36.1% to 40.5%, p<0.0001).
CONCLUSION: Reducing the default digital pulse fluoroscopy and cinefluorography rates from 15 fps to 10 fps yields large and significant reductions in total x-ray dose as measured by the Air Kerma. A blinded angiographic quality assessment study evaluating a secondary outcome of image quality is ongoing. Strong consideration should be given to reducing default pulse rate settings in all laboratories as part of an overall program to reduce patient and operator radiation exposure.
Optical Coherence Tomography: What is it?
PURPOSE: The Optical Coherence Tomography (OCT) is a new technique of invasive imaging based on the infrared light applied recently to the coronary. The main part of the histological data was based on a post-mortem study of the coronary arteries. Today the imaging of very high resolution, offers us in vivo superimpose images in the histological sections of the coronary arteries through the diffusion and reflection of an infrared spectrum.
METHODS: OCT uses an optical fiber, a case of withdrawal and a console of post-treatment. To make a good image it is important to know how to use this technique and to make a good analysis of OCT image, it is necessary to know the possible interactions between the spectrum of infrared light and the coronary wall. The analysis of the image also includes the detection of artifacts.
RESULTS: The analysis of several clinical cases allows us in the long-term to estimate the endothelialization of the stent and in-stent restenosis. OCT allows us the analysis of the atherosclerotic plaques and its constituents, for the viewing of thrombus during pain events.
CONCLUSION: OCT is a new technique of invasive imaging, which seems today, finds its place in our room of catheterization in spite of its high cost. We use this technique within the framework of the follow-up of atherosclerotic plaques and its constituents, stents and medicinal treatments, and too for viewing of thrombus during pain events.
Guiding Catheter for Coronary Intervention Through Radial Approach: Are There Any Differences?
Rezek M, Hlinomaz O, Drozdova A, Moravcova H, Sitar J, Novak M, Semenka J, Groch L
PURPOSE: The author is presenting an analysis of PCI procedures during 6 months in aspect of choice of guiding catheters and fluoroscopy time in one catheterization laboratory.
METHODS and RESULTS: The procedures were performed by 6 different operators, all of whom have passed the learning curve in radial approach during the past years. The approach has changed from femoral to preferred radial in this catheterization laboratory during the past 5 years (10% radial in the year 2007, 75% radial in 2012). A total number of 436 PCI was analyzed, 300 where performed through the radial approach (68%). There were 130 primary PCIs for STEMI in this analysis and the right radial approach was dominant by 90%. Inter-individual variance among the operators by choosing the guiding catheters was noted, but there were no differences in the judged parameters by the operators if choosing radial or femoral approach.
PCIs of left coronary artery
Guiding Catheter No. of procedures Mean fluoroscopy time
IKARI IL 3.5 (radial) 87 6:22
XB 3.5 Vista (radial) 53 7:01
JL4 Vista (radial) 38 7:32
AL2 (radial) 10 8:16
JL4 Vista (femoral) 62 7:29
XB 3.5 Vista (femoral) 11 8:32
PCIs on right coronary artery
Guiding Catheter No. of procedures Mean fluoroscopy time
IKARI IR 1.5 (radial) 53 7:55
JR4 Vista (radial) 21 8:28
JR4 Vista (femoral) 33 7:20
AR2 (radial) 10 8:24
CONCLUSION: The slightly worse result by femoral approach for left coronary artery may be caused mainly by the fact that most of the operators still prefer femoral approach for more complex procedures. In radial approach, there seems to be a trend to lower fluoroscopy time by using dedicated radial guiding catheters (IKARI) and lower fluoroscopy time for procedures on left coronary artery. The comparison of guiding catheters is very difficult in retrospective analysis. There are many variables that can affect the results, but it appears that there may be some differences among the catheters.
4 Fr in 5 Fr Sheathless Techniques with Standard Catheters for Transradial Coronary Interventions
Rimac G, Abdelaal E, Plourde G, MacHaalany J, Roy L, Costerousse O, Bertrand OF
BACKGROUND: There is a relationship between radial artery injury and stretch during transradial access and the risk of radial artery occlusion (RAO). Hence, smaller sheaths and catheters have been associated with less risks of RAO.
OBJECTIVE: To demonstrate the feasibility and potential benefits of performing sheathless 5 Fr transradial percutaneous coronary interventions (PCI) using 4 Fr diagnostic catheters as dilators.
METHODS and RESULTS: From September to December 2011, we recruited 130 patients who underwent 4 Fr sheathless diagnostic angiography with super torque (Cordis Corporation) catheters followed by ad hoc PCI. To facilitate skin and vessel penetration, the Judkins right catheter (110 cm) was inserted inside the 5 Fr guiding catheter (100 cm) as dilator. The mean age of patients was 63 ± 12 years with 74% of males. The mean weight was 81 ± 15 kg for a BMI of 29 ± 5. In 27% of the cases, radial access for PCI had been used prior to the index procedures. 24% of patients were diabetic and baseline creatinine clearance was 94 ± 37 mL/min. Procedures were performed in 24% of the cases for non-STEMI and in 24% for STEMI (primary and rescue). Unfractionated heparin was used in 71%, bivalirudin in 12% and platelet glycoproteins IIb-IIIa inhibitors in 13%. Right radial artery was used in 99%. In 3 cases, no PCI was performed (FFR) and in 2 (1.5%) cases, a sheath was required after guiding catheter insertion due to local bleeding. In 6 cases (4.6%), upscale to 6 Fr sheathed approach was required for chronic total occlusion PCI (n=2), right coronary dissection after diagnostic 4 Fr sheathless with AL (n=1), thrombectomy (n=1), and insufficient backup support (n=2). No spasm occurred. Overall procedural success was achieved in 114/119 (96%) cases, including left main PCI, bifurcation PCI in 10 (8%) cases, CTO in 5 (4%), and IVUS use in 6 (5%) cases. Immediately after hemostasis completion, duplex ultrasound showed normal flow in 76%, occlusive thrombus in 13%, pseudo-aneurysmal dilatation in 11%, and local hematoma surrounding puncture site in 20%. Hemoglobin dropped from 138 ± 19 g/l to 131 ± 16 g/l 4-6 hours after PCI.
CONCLUSION: Using 4 Fr super torque diagnostic catheters as dilators, most PCI can be performed as 5 Fr sheathless techniques with standard guiding catheters. However, sub-optimal transition between diagnostic and guiding catheters creates radial artery trauma leading to frequent occlusive thrombus and hematoma surrounding the radial artery. These results do not suggest significant benefits of 4 Fr in 5 Fr sheathless techniques using current catheters. Further studies using dedicated 5 Fr sheathless guiding catheters or development of tapered dilators are required.
How to Limit Radial Artery Spasm During Percutaneous Coronary Interventions? The SPasmolytic Agents to Avoid SpasM During Transradial Percutaneous Coronary Interventions (SPASM3) Study
Rosencher J, Chaïb A, Barbou F, Arnould MA, Huber A, Salengro E, Jégou A, Allouch P, Zuily S, Mihoub F, Varenne O
PURPOSE: To compare the efficacy of three vasodilators in preventing radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary interventions (PCI).
METHODS and RESULTS: 731 patients were randomized to receive diltiazem 5 mg, verapamil 2.5 mg, or isosorbide dinitrate (ISDN) 1 mg before coronary intervention. RAS occurred in 20.1% in the whole population and was significantly reduced by verapamil and ISDN compared to diltiazem (16.2%, 17.2%, 26.6 %, respectively; p<0.006). There was also a trend to less severe pain [more than 8 on a numerical scale from 0 (no pain) to 10 (maximal pain)], and less severe RAS (complete catheter blockage or severe pain), among patients treated by verapamil compared to ISDN and diltiazem (1.3% vs 2.8% vs 2.9%, p=0.43 and 5.1% vs 6.2% vs 9.5%, respectively, p=0.13). No difference was found between the three vasodilators in terms of crossover or safety events. Female gender, failure at first attempt to access the radial artery, emergency procedures, and the use of diltiazem were independent predictors of RAS.
CONCLUSION: Verapamil and ISDN considerably reduce the incidence of RAS compared to diltiazem during transradial.
Feasibility of the Use of the Tryton™ Dedicated Bifurcation Stent via the Transradial Route: A Single Centre Experience
Shah A, Uddin M, Ossei Gerning N, Anderson RA, Kinnaird TK
PURPOSE: The use of the transradial access (TR) for the treatment of coronary bifurcation lesions (CBL) with percutaneous coronary intervention (PCI) can be limited where a two-stent strategy is required as larger sheath and guide catheters are required to facilitate stent delivery. With the development of newer dedicated bifurcation stents, there is an increasing trend of these stents to be adopted in PCI centers to treat CBL. We report our experience of the use of the Tryton™ dedicated side branch bifurcation stent at our default TR center where 90% of all PCI are carried out via the TR.
METHODS: This was a prospective study of all patients who were found suitable to undergo PCI to CBL using the Tryton™ stent between September 2009 and June 2013. Data on patient demographics and procedure characteristics was collected from the local hospital database.
RESULTS: 36 patients (male 69.4%, age 68.1 years) underwent PCI using the 19 mm long Tryton™ bifurcation stent. Most of the CBL treated were located in the LAD/branch (52.8%), followed by the circumflex/branch (27.8%), left main stem/branch (13.9%), RCA/branch (2.7%), and LIMA graft (2.7%). Tryton™ stents dimensions (side branch/main branch diameters) deployed were (2.5/2.5 mm – 11.1%; 2.5/3.0 mm – 25%; 2.5/3.5 mm – 47.2%; 3.0/3.5 mm – 8.3% and 3.5/4.0 mm – 8.3%). 91.6% of cases were carried out via 6 Fr guide catheters with the remaining cases carried out via the 7 Fr. Mean contrast volume, radiation dose, and fluoroscopy times were 306 mL, 98.8 Gy/cm2, and 28.2 min, respectively. 94.4% of all cases were successfully carried out via the TR route with remaining cases switching to the transfemoral route to successfully complete the procedure.
CONCLUSIONS: When treating CBL, a wide range of Tryton™ dedicated side branch stents can be safely and effectively deployed via the TR route using 6 Fr/7 Fr guide catheter systems. This can avoid the use of the transfemoral route and its associated potential vascular complications.
Retrograde Recanalization of Radial Artery Occlusion in Patients with Need for Repeated Wrist Procedure
Spiroski I, Kedev S
PURPOSE: To present a technique of retrograde recanalization of radial artery occlusion with and without balloon dilatation in patients with need for repeated wrist procedure.
METHODS: In our transradial registry during the period of March 2011 – June 2013, we have documented 10,487 transradial procedures. In 317 patients we have found radial artery occlusion (RAO). In 281, ipsilateral transulnar approach (TUA) was performed. We selected the other 36 consecutive patients for retrograde recanalization of RAO. The selected patients were either with present ipsilateral ulnar occlusion or contralateral wrist approach was not available. We performed retrograde recanalization of RAO in 14 patients with balloon dilatation and in 17 patients (from our early practice) without balloon dilatation. In 5 patients (14%), we didn’t manage to cross the occluded segment with the wire. Primary outcome was successfully completed procedure. Secondary outcomes were procedural complications: forearm pain, access site bleeding events, clinically evident hand ischemia. Patients with documented anatomic variations of radial artery from previous transradial procedure, such as tortuosity of the vessel and high take off, were excluded from this group. All patients had palpable pulse distal of previous puncture site. We’ve punctured the radial artery with an inner metallic needle and a plastic cannula. Using radial angiography performed with plastic cannula, we were able to go through the occluded segment with different types of guide wires. After the balloon dilatation, successful catheterization, and/or percutaneous coronary intervention were achieved.
RESULTS: The primary outcome was achieved in 26 of 31 patients (83.9%). In patients where we performed balloon dilatation, the primary outcome was achieved in 14 of 14 patients (100%). Forearm pain was present in 13 cases (41.9%). Minor access site bleeding occurred in 5 patients (16.1%) and there was no single case of clinically evident hand ischemia.
CONCLUSION: Retrograde recanalization of the radial artery occlusion is safe and feasible. Balloon dilatation of radial artery occlusion is a key factor for successful catheterization and/or percutaneous coronary intervention. Left TRA or TUA remain a viable option in selected patient.
Radial Approach for Angioplasty of Distal Unprotected Left Main in the Setting of Acute Coronary Syndrome
Hajlaoui N, Ben Mansour N, Lahidheb D, Jedaida B, Haggui A, Dahmani R, Fehri W, Haouala H
BACKGROUND: Percutaneous coronary intervention (PCI) has become the treatment of choice for patients with acute coronary syndrome (ACS). Nevertheless, patients with unprotected left main (ULM) disease still represent a challenge for the interventionalist, especially in the setting of an ACS. Radial access (RA) is currently the recommended approach for coronary intervention, but cases of ULM angioplasty performed from a RA in patients with myocardial infarction are rarely reported.
CASE REPORT: We report the case of a 38-year-old diabetic man admitted in our coronary care unit for a non ST-elevation myocardial infarction. After treatment with aspirin, loading dose of clopidogrel and enoxaparin, a coronary angiography was rapidly performed. A 6 Fr radial route was used. Angiography showed a subocclusive stenosis of mid and distal left main, with ostial occlusion of left anterior descending artery (LAD). The right coronary artery was dominant with collaterals for LAD. In this setting of ACS with hemodynamic instability (80 mmHg systolic blood pressure) we decided to perform an angioplasty of left main and LAD/circumflex (Cx) bifurcation. From the same radial access, and using an EBU 3.5 guiding catheter, a guide wire was placed into the Cx. We performed a direct stenting of left main/Cx axis with 3 x 26 mm drug eluting stent (DES). A second wire was placed into the LAD and struts of the first stent opened with a 2.5 x 20 mm balloon. A second 3 x 22 mm DES was placed into LAD using a T-stenting technique because of a 90° LAD/Cx takeoff angle. A final kissing balloon with non-compliant balloons was performed (3.5 x 15 mm into Cx and 2.5 x 20 mm into LAD). The final result was good with TIMI 3 flow on both LAD and Cx. The patient was discharged 6 days after procedure and no complication was reported on 6 months follow-up.
CONCLUSION: This case report shows that distal left main PCI in ACS via RA is feasible. The strategy for LAD/Cx bifurcation management depends of anatomy and has to be carefully chosen. The second message is that radial access to reduce hemorrhagic complications is possible for this kind of complex procedures.
PCI as a Bridge to Surgery in Type A Aortic Dissection
Horak D, Hrabos V, Nedbal P, Hlubocky J, Lindner J
CASE: A 77-year-old female had been referred to our institution for acute coronary syndrome with evolving cardiogenic shock with profound ST depressions in V leads on ECG. Due to systolic murmur on brief physical exam, there was echo study performed showing moderate mitral and aortic regurgitation and mild aortic dilatation to 40 mm. Due to ongoing hypotension, selective coronarography via right radial artery was performed finding ostial left main stenosis. Glycoprotein IIb/IIIa inhibitor was given and two stents placed in the left main. Patient condition dramatically improved immediately after stent placement. Because operator felt unsure about fluoroscopic appearance of left main lesion and even native appearance of aorta, aortography had been performed revealing aortic dissection type A. Our institution does not have on-site cardiosurgery, so cooperating cardiosurgery (approx. 100 km away) had been informed about the patient and helicopter transport was arranged. Patient was operated a couple of hours after making the diagnosis. Bentall operation was performed and due to bleeding, next day delayed suture was performed. After 10 days, the patient was back in our institution and recovering well without overt neurologic deficit with good left ventricular function.
CONCLUSION: There are multiple records in literature about aortic dissection mimicking acute coronary syndrome. In our case the late diagnosis led to PCI that stabilized hemodynamically unstable patient and allowed relatively safe transport to distant cardiosurgery for definitive treatment.
Repositioning of PTCA Wire Using OCT Technique and Radial Access Site
Miklik R, Kala P, Kanovsky J, Poloczek M, Jerabek P, Bocek O
INTRODUCTION: Optical coherence tomography (OCT) technique is a wise tool to visualize anatomical relations and intracoronary stent struts position and may help optimize complex percutaneous coronary intervention (PCI) procedures. It might detect possible radial artery injuries after such intervention.
CASE REPORT: A 64-year-old female presented with acute inferolateral non-STEMI acute coronary syndrome, Killip I, left ventricular ejection fraction of 60%, with Hodgkin lymphoma and hypertension in medical history. Her diagnostic angiogram revealed 2VD – 90% culprit bifurcation lesion of LCx-OM1 (medina 1,0,0), then 80% proximal LAD and 90% D1 indicated for staged PCI procedure. Using a 6 Fr guide catheter XB 3.5 Vista introduced via right radial artery selectively into LCx, two wires were placed in LCx and OM1 and lesion predilatation with a 2.25 mm balloon was performed, followed by a 3.0/14 biolimus eluting stent implantation (on the LCx- OM1 wire) with its distal part ending just before carina, jailing the wire in LCx. Using OCT technique, we successfully repositioned the LCx wire avoiding crossing through the stent struts and then post-dilated with a non-compliant 3.25/12 balloon first from LCx into OM1 and then from LCx into LCx so no struts were touching carina and were widely spread open both into LCx and OM1. OCT check showed malapposition of proximal part (0.4 mm) of the stent resulting in another high-pressure post-dilatation with optimal OCT and angiographic result. Finally, as another staged procedure is planned via radial artery, we performed radial OCT imaging after guide catheter had been pulled off with no signs of arterial injury.
CONCLUSION: We demonstrated that OCT technique could be easily used to guide repositioning of wires during a complex bifurcation intervention. OCT visualization of radial artery after such procedure might detect acute iatrogenic injuries caused by catheter manipulation and exclude this artery from subsequent interventional procedures.
Supported by a Grant from the Ministry of Health of the Czech Republic, NT 13830-4.
Is Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery via Transradial Approach Feasible for Skilled Transfemoral Operators? Initial Experience in an Unselected Population
Tomassini F, Gagnor A, Montali N, Gambino A, Bollati M, Infantino V, Tizzani E, Varbella F
BACKGROUND: The feasibility and efficacy of percutaneous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) via transradial access (TRA) is still a matter of concern, mainly in an unselected population.
METHODS: We collected data about all PCI performed in patients with ULMCA stenosis by a TRA-dedicated operator, and analyzed clinical and procedural characteristics as well as in-hospital and long-term outcomes.
RESULTS: From January 2008 to December 2011, 49 PCI were performed, 27 (55%) via TRA and 22 (45%) via transfemoral access (TFA). Most patients in both groups underwent PCI for acute coronary syndrome (66.7% in TRA group vs 77.3% in TFA group, p=0.73). Patients in TRA group were more hypertensive (81.5% vs 40.9%, p=0.008) and had a higher left ventricular ejection fraction (54.6±10.3 vs 46.1±12.8, p=0.01). There were no significant differences in procedural success (100% in TRA group vs 90.9% in TFA group, p=0.38), as well as in procedural time, in fluoroscopic time and in contrast volume. Bleeding complications occurred in 1 patient in TFA group (4.5%) vs none in TRA group (p=0.91). In-hospital Major Adverse Cardiac Events (MACE) occurred in 1 patient (3.7%) in TRA group vs 3 (13.6%) in TFA group (p=0.48). At a follow-up of 32±13 months, MACE occurred in 4 cases (14.8%) in TRA group vs 7 cases (31.8%) in TFA group (p=0.28).
CONCLUSIONS: The PCI of ULMCA via TRA is feasible with good results, provided that a rigorous learning curve was followed and a TRA volume caseload was maintained.
Double Transcarpal Arterial Puncture for Cardiac Catheterization in Patients with Challenging Approach
Valdesuso R, Gimeno JR, Lacunza FJ, Rodriguez RC, Rodriguez JA, Fleites HA, Toruncha A
PURPOSE: To report the feasibility of simultaneous radial-ulnar arteries puncture during cardiac catheterization.
METHODS: From 2008 to 2013, 12 patients with unsuccessful transradial (TR) procedures (due to severe spasm, high origin, and diffuse calcification), after placing 5 Fr sheath in the right radial artery, underwent ipsilateral ulnar artery (UA) puncture. Saturation by pulse oximetry was measured in the index and middle fingers after 1 min compression of the UA. Main reasons for ipsilateral attempt were: morbid obesity (6 patients) and severe peripheral arterial disease (4 patients). Two patients with saturation <95% (in one of the fingers) were excluded and performed by humeral artery. Pulse oximetry was placed at middle finger during procedures. Both sheaths were removed after completion of procedures. Simultaneous manual compression of both arteries with Spongostan was ended with the usual TR bandage.
RESULTS: In 10 eligible patients (8 male; mean age 66 ± 8.5 years), radial and ulnar puncture was performed. There were 6 diagnostic + PTCA using 6 Fr, and 4 diagnostic with 5 Fr sheaths. Procedure mean time (from sheath place in UA) was 37 ± 18 min. Mean saturation during procedures was 98 ± 1.3%. Procedure success rate was 100%. No complications were reported at discharge (24 hours after procedure).
CONCLUSION: Double transcarpal puncture can be performed in well-selected patients after careful evaluation of palmar arch integrity by pulse oximetry. This method is easy, not time consuming, and can be performed without releasing the hand. Only patients (after initial radial or ulnar failure) with a difficult arterial access and/or corporal anatomy should be evaluated for this approach that must always be performed by skillful and fast operators.
Safety and Efficacy of Transradial Rotational Atherectomy
Zeb M, Iqbal J, Edwards T, Winterton S, Witherow F
PURPOSE: Rotational atherectomy is an effective method of debulking atherosclerotic lesions in coronary arteries. Traditionally this has been performed via a transfemoral (TF) approach to facilitate larger (7 Fr and 8 Fr) guiding catheters and temporary pacing via the femoral vein. Larger lumina 6 Fr, along with 7 Fr and 8 Fr sheathless guides allow rotablation to be performed transradially (TR), resulting in fewer complications and enabling safer use of glycoprotein IIB/IIA inhibition.
METHODS: Prospective data was collected for all patients treated with rotational atherectomy from 2007 to 2013 at our center.
RESULTS: During the study period, 66 patients underwent rotational atherectomy to 99 vessels and 136 lesions. The mean age was 74±8.9 (range 50-95) years; 47 (71%) were male. Temporary pacing wire was not used in any of the procedures, cases involving RCA, or dominant Cx were pretreated with 1.2 mg of atropine. TR was used in 45 cases (68%) and TF in 21 (32%). Overall procedural complication rates in both groups were extremely low with only 1 death in the TF group and no complications in the TR group. In comparison with TF, TR resulted in no significant difference in fluoro time, procedural time, glycoprotein IIB/IIA inhibition use, IABP use, and stent deployment rates despite 6 Fr guides being used in 75% of TR cases and 52% of TF cases; (all p=NS). 17 patients [TR=14 (31%), TF=3 (14%), p=0.001] were discharged on the same day. Mean follow-up duration was 38±21 (range 4.3-68) months, during which 6 patients had MI (unrelated to rotablated vessel), 1 patient had CVA, and 7 patients died, in TR group. While in TF group, 5 patients had MI (one rotablated vessel).
CONCLUSION: Rotational atherectomy via the radial approach is safe and effective, and can facilitate day case procedures. Temporary pacing during rotablation is an unnecessary and potentially harmful procedure especially when using glycoprotein IIB/IIIA inhibitors.
Bleeding and Anticoagulation
Bivalirudin or Heparin and Provisional IIb/IIIa Inhibitors in Primary Angioplasty Performed Through Transradial Approach
Sciahbasi A, Rigattieri S, Cortese B, Belloni F, Russo C, Silva P, Ferraironi A, Tespili M, Angeletti C, Ricci R, Bondanini F, Loschiavo P
PURPOSE: The beneficial effect of bivalirudin therapy in the setting of percutaneous coronary interventions (PCI) for acute ST-elevation myocardial infarction (STEMI) seems to be confined to patients treated through transfemoral approach and data on transradial approach are limited. Aim of our study was to evaluate bleeding complications and clinical outcomes of patients with acute STEMI who underwent PCI through transradial approach combined with bivalirudin therapy.
METHODS: We retrospectively evaluated primary PCI performed through transradial approach since January 2008 to June 2013. Patients were divided in two groups according to the use (Group 1) or not (Group 2) of bivalirudin therapy during the procedure. The primary endpoint of the study was the rate of major bleeding (according to TIMI criteria) and the major adverse cardiac events (MACE) defined as death, re-infarction, and new revascularization within 30 days. We also evaluated a net clinical outcome endpoint defined as the combination of the hemorrhagic and ischemic endpoint.
RESULTS: During the 5 years analyzed, 1009 patients underwent primary PCI through transradial approach and these patients were included in the registry. Among these patients, 154 patients were treated with bivalirudin (males 79%, mean age 65 ± 14 years) and 855 with heparin (males 82%, 63 ± 12 years, p=0.10). In Group 1 the use of glycoprotein IIb/IIIa inhibitors was only 4% compared to 55% (p<0.001) in Group 2. There were no significant differences between the two groups for major bleedings (0.65% in Group 1 and 1.17% in Group 2, p=0.88) nor for minor bleedings (1.3% in Group 1 and 1.5% in Group 2, p=0.83). There were also no significant differences in MACE between the two Groups (10.4% in Group 1 and 7.1% in Group 2, p=0.27). The 30-day mortality rate was 3.9% in Group 1 and 5.4% in Group 2 (p=0.56). Finally there were no significant differences in the clinical net outcomes between the two groups (7.8% in Group 1 and 11.6% in Group 2, p=0.21).
CONCLUSION: In this group of patients with acute STEMI who underwent primary PCI through transradial approach, the use of bivalirudin therapy was not associated with a significant reduction in major bleeding or MACE compared to a heparin therapy and provisional use of glycoprotein IIb/IIIa inhibitors.
Comparison of Radial and Femoral Access for Coronary Angiography within South Australian Public Cardiac Catheterization Facilities: A New World Radial Experience
Worthley MI, Tavella R, Worthley SG, Chew DP, Arstall M, Zeitz CJ, Beltrame JF
PURPOSE: Radial artery access for diagnostic coronary angiography has seen a rapid uptake within the past few years. Although this technique has been shown to have favorable outcomes, no Australian data exists to date comparing the outcomes between radial and femoral approaches.
METHODS: The Coronary Angiogram Database of South Australia (CADOSA) is a comprehensive registry of all public cardiac catheterization procedures performed within South Australia. Patients undergoing coronary angiogram +/- PCI were included in this analysis. Registry data for 2012 was utilized to assess the prevalence and angiographic procedure complications of radial and femoral access approaches.
CADOSA Population Radial, n=1953 (53%) Femoral, n=1719 p-value
Age 63 ± 13 65 ±13 <0.001
Male Gender 1330 (69%) 1092 (64%) 0.004
Angiogram for ACS 1047 (55%) 1092 (55%) 0.92
Atherosclerotic CAD 1407 (74%) 1251 (74%) 0.879
PCI Performed 734 (38%) 666 (39%) 0.475
PCI for STEMI 318 (18%) 266 (15%) 0.063
Death 22 (1%) 25 (1%) 0.231
Stroke 5 (0.3%) 10 (0.6%) 0.129
Access Site Complication 13 (0.6%) 39 (2%) <0.001
Bleeding within 72 hours 18 (1%) 71 (4%) <0.001
CONCLUSION: While routine radial access angiography remains less than ten years old in South Australia, it is now the preferred access site in the state. It is more often performed in younger, male patients and is the preferred approach for primary PCI. Radial access is also associated with less access site complications and in-hospital bleeding events.
Transradial Access for Embolization of Uterine Fibroids: Initial Clinical Results
AIM: To assess the feasibility and efficacy of transradial access for uterine fibroid embolization.
METHODS: Left radial access was used for selective catheterization of left and right uterine arteries in 20 patients with special design 5 Fr 135 cm length catheter. Selective embolization was performed using established technique.
RESULTS: Selective catheterization of both uterine arteries using a single catheter was successful in all patients. In two patients, catheter was exchanged with 4 Fr microcatheter due to inability of deep engagement of catheter tip into uterine artery because of spasm of radial artery. Median time for completion of procedure was 29.6±8.2 min, fluoro time was 14.8±4.3 min, radiation exposure dose 524±205 mGy comparing to 19.6±2.2 min, 9.8±3.2 min and 248±123 mGy, respectively, for transfemoral approach. All patients were active immediately after procedure without vascular access site complications.
CONCLUSION: Transradial access for embolization of uterine fibroids is feasible, safe, and an effective procedure using a single catheter. Early ambulation and less risk of vascular access site complication are “traditional” advantages of transradial access in these patients. Further evaluation of transradial access for uterine fibroid embolization procedure is needed.
Introduction of the Transradial Technique into a Busy Metropolitan Interventional Radiology Practice: The First 300 Cases
Fischman AM, Patel RS, Fung JW, Lamberson NB, Ort M, Kim E, Nowakowski FS, Lookstein RA
PURPOSE: There is a paucity of experience in the interventional radiology community with transradial approach (TRA) for peripheral interventions and complex embolization procedures. Benefits of this technique over transfemoral approach (TFA) include lower morbidity and mortality, including significant bleeding complications, increased patient comfort, decreased costs compared to femoral closure devices, and immediate ambulation in an outpatient setting. We describe our initial experience with TRA in a busy interventional radiology (IR) practice.
METHODS: Over a 17-month period, 300 procedures were performed in 230 patients (180 male, 50 female; mean age 65) using a TRA. Procedures included: hepatic chemoembolization (TACE) (n=143), hepatic radioembolization (Y90) (n=117), uterine fibroid embolization (n=13), visceral and renal angioplasty/stenting (n=12), splenic embolization (n=3), internal iliac artery embolization (n=2), other peripheral embolization (n=6), iliofemoral angioplasty/stenting (n=2), subclavian angioplasty/stenting (n=1), AAA endoleak embolization (n=1). Various embolization materials were used including: n-BCA, Onyx liquid embolic system, calibrated microspheres, drug-eluting microspheres, Yttrium-90 loaded microspheres, gelfoam, microcoils, and Amplatzer plugs.
A Barbeau test was performed using a pulse oximeter prior to all procedures. A Glidesheath was placed in the radial artery (RA) using US guidance in every case (left: n=299, right: n=1). Sheath sizes included 4 Fr (n=25), 5 Fr (n=259), and 6 Fr (n=16). A solution of 3000 U heparin, 2.5 mg verapamil, and 200 mcg nitroglycerin was administered interarterially following sheath placement. At completion, a TR-band was placed for radial compression. Technical success, 30-day major and minor adverse events, and equipment costs per case were evaluated.
RESULTS: Technical success was obtained in 97% of procedures (291/300). Radial loops were encountered in 9 cases (3%). 1/9 loops were unable to be successfully navigated (11%). There were no major adverse events at 30 days. Mild pain and weakness in the left hand was observed in 3 cases (1%), which resolved with NSAIDs. Asymptomatic RA thrombosis was observed in 6 cases (2%). Minor grade I hematomas were observed in 20 procedures (6.7%), which resolved spontaneously. RA pseudoaneurysm was seen in 1 case (0.3%), which was successfully treated with thrombin injection. Equipment costs per case were less expensive by an average of 97 dollars/case as compared to TFA standard controls.
CONCLUSIONS: TRA is feasible, safe, effective and less costly for peripheral interventions and various embolization procedures in IR.
Transradial Access for Iliac Artery Interventions Using Sheathless Guiding: Pilot Study
Ruzsa Z, Nemes B, Tóth K, Berta B, Kovács N, Vámosi Z, Merkely B
PURPOSE: The purpose of this pilot study was to evaluate the acute success and complication rate of the transradial access for iliac artery stenting using sheathless guiding.
METHODS: The clinical and angiographic data of 19 consecutive patients with symptomatic iliac artery stenosis treated via transradial access using 8.5 Fr sheathless guiding between 2012 and 2013 were evaluated in a pilot study. There were no exclusion criteria. All patients underwent duplex ultrasound before and after the intervention. Primary endpoint: major adverse events (MAE), rate of major and minor access site complications. Secondary endpoints: angiographic outcome of the iliac artery intervention, consumption of the angioplasty equipment, fluoroscopy time and x-ray dose, procedural time, cross over rate to another puncture site, and hospitalization in days. Transradial cases were performed by two operators skilled in transradial technique.
RESULTS: Procedural success was achieved in 19 patients (100%) and the crossover rate was 0%. Major access site complication was not detected. Minor access site complication was encountered in 2 patients (10.5%) (1 asymptomatic radial artery occlusion and one puncture site hematoma). The incidence of MAE was 0%. Mean procedure time was 20 ± 6.5 min, mean fluoroscopy time was 373±254 min, and DAP was 742±695 Gycm2. Mean contrast volume was 82 ± 42 mL. Hospitalization day was 1 day in the investigated population.
CONCLUSION: Iliac artery stenting can be safely and effectively performed using radial access and sheathless guiding with acceptable morbidity and high technical success.
Transradial Renal Artery Stenting
Ruzsa Z, Tóth K, Kovács N, Bánsághi Z, Szolics A, Jambrik Z, Varga I, Merkely B
INTRODUCTION: Percutaneous interventional procedures in the renal arteries are usually performed using a femoral or brachial vascular access. The transradial approach is becoming more popular for peripheral interventions, but limited data exists for renal artery angioplasty and stenting.
METHODS: We have analyzed retrospectively the clinical, angiographic, and technical results of renal artery stenting performed from radial artery access between 2010 and 2012 in two catheterization laboratories. In 24 patients with hemodynamically relevant unilateral renal artery stenosis (mean diameter stenosis, 81% ± 12%; right, n=8; left, n=16), interventional treatment with PTA and stenting was performed using a left (n=4) or right (n=20) radial artery access. The access site was an operator decision.
RESULTS: The radial artery anatomy was identified with aortography using 100 cm pigtail catheter. After engagement of the renal artery ostium with a 6 Fr Multipurpose (length, 125 cm; Cordis) or 6 Fr JR5 guiding catheter (length 100 cm, Boston and Medtronic) the stenosis was passed with a 0.014″ guidewire followed by stent implantation (Express SD, Boston Scientific; Herculink, Abbott). Direct stenting was successfully performed in 23 cases. Predilatations were required in two cases. A primary technical success (residual stenosis <30%) could be achieved in all cases. There were no major periprocedural complications. In one patient asymptomatic radial artery occlusion was detected (4.1%).
CONCLUSION: Transradial renal artery angioplasty and stenting is technically feasible and safe.
Randomized Comparison of Transradial and Transfemoral Approach for Carotid Artery Stenting: RADCAR study
Ruzsa Z, Nemes B, Pintér L, Berta B, Tóth K, Teleki B, Nardai S, Jambrik Z, Kolvenbach R, Hüttl K, Merkely B
BACKGROUND and PURPOSE: Carotid artery stenting (CAS) is emerging as an attractive alternative to surgical endarterectomy for the treatment of carotid artery disease. Transradial angiography and intervention results in fewer vascular complications, earlier ambulation, and improved patient comfort. Limited data exist on radial access in carotid artery stenting. This multicenter prospective randomized study was performed to compare the outcome and complication rate of transradial (TR) and transfemoral (TF) CAS.
MATERIALS and METHODS: The clinical and angiographic data of 260 consecutive patients at high risk for carotid endarterectomy (CEA) treated by CAS with cerebral protection between 2010 and 2012 were evaluated in a prospective randomized multicenter study. 158 symptomatic patients with >70% carotid stenosis and 102 asymptomatic patients with >80% stenosis were enrolled. Patients were randomized to TR (n=130) or TF (n=130) groups and several parameters were evaluated to assess the advantages and drawbacks of the different accesses: Primary endpoint: MACCE, rate of major and minor access site complications. Secondary endpoints: angiographic outcome of the CAS, consumption of the angioplasty equipment, fluoroscopy time and x-ray dose, procedural time, crossover rate to another puncture site, and hospitalization in days. Transradial cases were performed by three operators skilled in transradial technique. All femoral access sites were closed with femoral closure device.
RESULTS: Procedural success was achieved in 260 patients (100%); the crossover rate was 10% in the TR (2 failed puncture, 1 radial artery spasm, 1 radial artery loop, and 7 cannulation problems) and 1.5% in the TF (2 iliac artery stenosis) group (p<0.05). Major access site complication was encountered in 1 patient (0.9%) (1 symptomatic radial artery occlusion) in the TR and in 1 patient (0.8%) in the TF group (p=ns). The incidence of MACCE was 0.9% in the TR and 0.8% in the TF group (p=ns). Procedure time (1744±742 vs 1665±744 sec, p=ns) and fluoroscopy time (613±289 vs 579±285 sec, p=ns) was not significantly different, but the radiation dose was significantly higher in the TR group (223±138 vs 182±106 Gycm2, p<0.05). The consumption of diagnostic catheters and buddy wires was significantly higher in the TF group. Hospitalization days were significantly lower in the TR group (1.17±0.40 vs 1.25±0.45, p<0.05).
CONCLUSIONS: The transradial approach for carotid artery stenting has the same efficacy and safety as transfemoral, however the crossover rate is higher with transradial access. There are no differences in total procedure duration, fluoroscopy time between the two approaches, but the radiation dose is significantly higher in the radial group. In both groups, vascular complications occurred rarely.
Nurse and MD Session
Usefulness of Quality Control Techniques to Reduce Vascular Complications after Coronary Angiography and Interventions
Garcimartín P, González P, Maull E, Encinas S, Pueyo MJ, Sánchez D, Simó M, Bartolomé Y
PURPOSE: 1. Evaluate the efficacy of different procedures in order to reduce the incidence of vascular complications in patients undergoing coronary angiography and angioplasty. 2. Evaluate the effectiveness of training sessions given to hospitalization unit nurses to fulfill the recommendations (hemostasis device retrieval and first mobilization after procedure).
METHODS: Observational and prospective study that included 3250 patients in three periods: 1070 patients (March 2006 to January 2008), 967 patients (February 2008 to December 2010), and 1213 patients (January 2011 to June 2013). The sample included all patients except those who were discharged before the second nurse visit 12-24 hours after the procedure. The collected data were: gender, hospitalization unit, type of procedure, vascular approach, hemostasis method, vascular complications, timing of hemostasis, mobilization after the procedure, and recommendations fulfillment. Vascular complications were divided into immediate (0 to 3 hour post-procedure) and late (from 3 to 24 hours post-procedure). Statistical analysis was performed with Chi-squared and Kappa correlation and the statistical significance was set at 5% (p<0.05). Data was analyzed with SPSS software version 21.0.
RESULTS: Men underwent more frequently coronary angiography and interventions during the three periods (69.9%, 69.7%, and 70.2%). The number of angioplasty cases progressively increased from 45.5% in the first period, 44.6% in the second, and 50% in the third. Radial approach was the main choice in the three periods: 54.2%, 70%, and 92% (p<0.05). Immediate vascular complications rate was reduced within the three periods: 4.7%, 5.7%, and 2.3% (p<0.05). Late vascular complications rate progressively decreased: 15.5%, 5.5%, and 3.5% (p<0.05). The retrieval of hemostasis device recommendations fulfillment rate show an improvement (Kappa index 0.799, 0.828, 0.922) as well as those concerning patient mobilization after procedure (Kappa index 0.583, 0.782, 0.953).
CONCLUSIONS: The procedures designed to reduce the incidence of complications have been effective, but the determining factor is the use of radial approach. Conventional compression methods are more effective in reducing the incidence of complications than using mechanical devices, which use has decreased. The training sessions given to hospitalization unit nurses have improved the recommendations fulfillment (hemostasis device retrieval and first mobilization post-procedure).
Radial Access: Not Just For Cardiology Anymore: a Nursing Perspective
PURPOSE: Improving the patient’s procedural experience by utilizing radial access for transarterial chemoembolization, as well as employing improved efficiency of financial and human resources.
METHODS: Monitoring the number of post-procedural complications associated with radial access. Surveying the nurses who are direct caregivers pre-, intra-, and post-procedurally as to their observation of patient responses to radial access versus femoral access. Monitoring the number of nursing hours required to recover a patient post-procedurally.
RESULTS: 201 radial cases done: 167 male, 34 female ranging in age from 39 to 89 years.
Complications: 4 patients developed radial artery thrombosis. 12 patients developed grade 1 hematomas. 1 patient developed a pseudoaneurysm. No patient required surgical intervention secondary to a complication.
Twelve interventional nurses were surveyed as to the patient’s individual experiences; 100% agreed the patient’s experience was improved both intra- and post- procedurally. Patient had significantly less pain at the insertion site as compared to femoral access as well as fewer complaints as sequelae of lying supine for 3 to 6 hours. Additionally, the unit was able to conserve from 1 to 3 nursing hours per patient in the recovery period. The procedure itself required no additional resources. Financially radial access resulted in an approximate cost savings of $100.00 per case.
CONCLUSIONS: Patient safety and comfort are always paramount; hence the most significant reason for transradial access. Radial access significantly reduces the odds of major bleeding by 70% as compared to femoral access. Patients are able to ambulate and sit up post-procedurally improving overall comfort and decreasing possibilities of back pain and urinary retention. Patients overall perceptions of their procedural experience are improved. Although, nursing neurovascular checks are done as frequently, they are less invasive and allow for increased patient privacy. Also, because stasis is generally safely achieved more expeditiously, there is significant cost saving in nursing recovery hours.
Radial Approach and Controversies
A Randomized Trial Comparing 7.5 and 15 Frames per Second for Fluoroscopy During Transradial Coronary Angiography and Interventions
Abdelaal E, Plourde G, MacHaalany J, Arsenault J, Rimac G, Ribeiro H, Allende R, Déry JP, Barbeau G, De Larochellière R, Nguyen CM, Costerousse O, Bertrand OF
BACKGROUND: TRA for cardiac catheterization is potentially associated with increased radiation exposure for operator and patient. Low rate fluoroscopy has potential to reduce radiation exposure.
OBJECTIVES: This study sought to determine the efficacy of low rate fluoroscopy at 7.5 frames per second (FPS) in comparison with conventional 15 FPS for reduction of operator and patient radiation dose during cardiac catheterization and percutaneous coronary intervention (PCI) via the transradial approach (TRA).
METHODS: Three hundred sixty-three patients undergoing TRA cardiac catheterization with or without PCI were randomized prior to procedure to low rate fluoroscopy at 7.5 FPS (n=182) vs conventional 15 FPS (n=181). Both 7.5 and 15 FPS fluoroscopy protocols were configured with a dose per pulse of 40 nGy. Cine acquisitions were performed at 15 FPS in both groups. Primary endpoints were fluoroscopy time, operator radiation dose (measured with a dosimeter attached to the left side of thyroid shield), and patient radiation dose, expressed as dose-area product (DAP) in μGy.m2.
RESULTS: Mean age of study population was 65 ± 11 years, and body mass index was 29 ± 6. A total of 174 patients underwent diagnostic coronary angiography (CA) [85 (47%) in 7.5 FPS group, and 89 (49%) in the 15 FPS group] and 179 underwent PCI [93 (51%) in 7.5 FPS and 86 (48%) in 15 FPS group]. Ten patients (3%) had graft revision. Baseline and procedural characteristic were uniformly distributed between the 2 groups. Fluoroscopy time was similar with 7.5 FPS and 15 FPS for diagnostic CA (3.2 ± 1.9 vs 3.2 ± 2.0 min, p=0.83) and PCI (12 ± 8 vs 13 ± 10 min, p=0.30), respectively. For diagnostic CA, 7.5 FPS was associated with 40% absolute reduction in operator dose compared to 15 FPS (20 ± 14 μSv vs 32 ± 25 μSv, p=0.0008); and 20% reduction in patient DAP (2413 ± 1345 μGy.m2 vs 3020 ± 1638 μGy.m2, p=0.0081). For PCI, 7.5 FPS was associated with 28% absolute reduction in operator dose (45 ± 34 μSv vs 63 ± 40 μSv, p=0.0089) compared to 15 FPS; and 20% reduction in patient DAP (6102 ± 3092 μGy.m2 vs 7545 ± 4763 μGy.m2, p=0.0184).
CONCLUSIONS: Low rate fluoroscopy at 7.5 FPS is associated with significant reduction in radiation exposure to operator and patient during transradial coronary angiography and PCI compared to conventional 15 FPS. This simple measure should routinely be adopted to minimize radiation exposure.
Radial vs Femoral Approach for PCI and In-Hospital Outcomes in Normal-Weight, Obese, and Morbidly Obese Patients
Baquero GA, Yadav PK, Rhodes D, Gilchrist IC
PURPOSE: Obesity is a rapidly increasing epidemic associated with increased risk for cardiac disease and more likelihood of requiring invasive cardiac procedures. Available literature evaluating outcomes of percutaneous coronary interventions (PCIs) in this patient population is limited. The aim of this study was to analyze and compare our experience of transradial vs transfemoral approach in normal weight, obese, and extremely obese patients undergoing PCIs.
METHODS: We retrospectively reviewed all patients who underwent PCIs in our institution between 2001 and 2012. Patients were classified according to their weight and access site as follows: normal weight (NW=BMI ≤24 kg/m2), obese (O=BMI ≥24 ≤40kg/m2), and morbidly obese (MO=BMI ≥40kg/m2), and radial vs femoral. In-hospital complications including major adverse cardiac events (MACE), vascular and bleeding complications, cerebrovascular events (CVAs), as well as immediate (<24h) and 30 days all-cause mortality were evaluated.
RESULTS: A total of 5899 PCIs took place within the studied period, out of which 440 (7.4%) patients were MO, 4713 (80%) were O, and 746 (12.6%) were NW. Transradial access was performed in 2541 (43%) patients (MO=222/9%; O=2.049/81% and NW=270/10%) whereas femoral access was obtained in 3358 (57%) (MO=218/7%; O=2,664/79%, and NW=476/14%). Radial access was associated with 2 complications (1 MACE and 1 immediate death) within the MO group, 17 documented complications (2 MACE, 4 bleeding, and 11 <30 days deaths) among the O group and 7 complications (1 vascular, 4 bleeding, and 2 <30 days deaths) in the NW group when compared to 6 (1 MACE, 1 vascular, 3 bleeding, and 1 immediate death; p=0.146), 143 (12 MACE, 26 vascular, 66 bleeding, 4 CVEs, 17 immediate deaths, and 18 <30 days deaths; p=0.001), and 29 (1 MACE, 4 vascular, 20 bleeding, 1 immediate deaths, and 3 <30 days deaths; p=0.032) femoral access complications in these groups respectively. Comparison of radial access complications between the MO and O groups vs the NW patients also revealed statistical significance (p=0.009). No significant difference was noted when analyzing this data in patients that underwent femoral access (p=0.405).
CONCLUSION: In comparison to traditional femoral approach, transradial access for PCI appears to be associated with fewer vascular and bleeding complications as well as mortality rates in obese patients. Obese and morbidly obese patients are more prone on developing radial access complications when compared to normal weight patients.
Transradial vs Femoral Approach for Diagnostic Angiography and PCI in the Very Elderly
Baquero GA, Yadav PK, Gilchrist IC
PURPOSE: As the population progressively ages, the number of elderly suffering from ACS requiring intervention will continue to increase. Transradial approach is associated with fewer vascular and bleeding complications with some studies showing prolonged intervention times compared with the transfemoral approach. There is limited data available comparing the safety of transradial approach in the elderly population. The aim of this study was to compare our experience of transradial vs transfemoral approach in patients >80 years of age undergoing angiography and percutaneous coronary interventions (PCIs).
METHODS: We retrospectively reviewed all patients older than 80 years of age who underwent angiography and PCIs in our institution between 2001 and 2012. Patients were classified according to access site (radial vs femoral). In-hospital complications including major adverse cardiac events (MACE), vascular and bleeding complications, cerebrovascular events (CVAs), acute renal failure, as well as immediate and 30 days all-cause mortality were evaluated.
RESULTS: Between 2001 and 2012, 1874 patients (age 84±4; range 80-108) had diagnostic and PCI procedures (1283 angiograms; 591 PCIs) performed in our institution. Transradial approach accounted for 777 (41%) procedures (diagnostic 552/71%; PCIs 225/29%, Table 1). Within the PCI group, a total of 23 (10%) patients (5:2 to ipsilateral brachial and 3 to contralateral radial arteries; 18 to ipsi/contralateral femoral arteries) required a change of access site due to requirement of intra-aortic balloon pump in 2, severe radial spasms in 5, radial occlusions in 13, and 3 for unknown/unreported causes. Within this group, only 14 (4%) required to be converted from femoral to a different approach (p=0.001). Overall bleeding and vascular complications, as well as immediate mortality were higher within the transfemoral group (Table 2).
CONCLUSIONS: The transradial approach is clinically feasible in the elderly over 80 years of age undergoing diagnostic angiography and PCIs. Due to a relatively low adverse event rates, statistical differences between radial and femoral groups could not be defined. Nevertheless, as seen in younger patient cohorts, conversion to an alternative access site is more common with transradial, while it is reassuring to see trends such as less vascular site complication and lower rates of adverse events in this elderly cohort. Further work with properly powered trials are needed.
The Incidence of Acute Kidney Injury After Cardiac Catheterization or PCI: A Comparison of Radial vs Femoral Approach
Damluji A, Cohen MG, Smairat R, Steckbeck R, Moscucci M, Gilchrist IC
PURPOSE: Contrast induced acute kidney injury (CI-AKI) is a well-documented complication of catheterization procedures with iodinated contrast agents. Compared to the transfemoral approach, transradial access has been associated with lower incidence of chronic kidney disease. We sought to assess the incidence of CI-AKI after cardiac catheterization or percutaneous coronary interventions (PCI) according to arterial access site.
METHODS: A total of 1637 consecutive adult patients underwent cardiac catheterization or PCI at a single teaching hospital between April 1, 2009 and September 30, 2012. AKI was defined as a rise in serum creatinine >0.5 (mg/dL) or 50% from the baseline value. The independent effect of arterial access site on CI-AKI was evaluated using multivariable logistic regression analysis.
RESULTS: Transfemoral and transradial access were used in 641 (39%) and 996 (61%) patients, respectively. In the transfemoral and transradial groups, median age was 60 and 62 years (p=0.01); male gender was present in 72% and 79% (p=0.01); and median BMI was 29.7 and 29.9 kg/cm2 (p=0.35), respectively. The total contrast volume was 165 mL in transfemoral and 180 mL in transradial procedures (p<0.001). The GFR was >60 mL/min/1.73 m2 in 72% and 84% (p<0.001) of transfemoral and transradial patients, respectively. The overall incidence of CI-AKI was 3.7%. Transradial patients were less likely to develop CI-AKI compared with transfemoral patients (2.5% vs 4.5%, p<0.001). After adjustment for multiple confounders, transfemoral was no longer associated with an increased CI-AKI risk [OR=1.53, 95% CI 0.83 to 2.84, p=0.169], but a trend remained.
CONCLUSIONS: Our pilot results suggest that despite increased contrast volume use, transradial access was not associated with an increased risk of CI-AKI in a large cohort of patients undergoing cardiac catheterization and intervention procedures. The effect of transradial access on the incidence of AKI should be further prospectively studied.
Assessment of Femoral vs Radial Access in Patients in a High Volume Center
Goldsmit A, Sánchez J, Zaidel E, Sztejfman M, Trucchi D, Sztejfman C, Bettinotti M
OBJECTIVE: Radial access has shown clear benefits regarding days of hospitalization, bleeding, mortality, patient comfort, etc. However, relatively few patient cases have been reported, leading to a sound decision favoring radial versus femoral PTCA and angiography. The purpose of this work is to get a better understanding regarding these cath lab decisions.
METHODS: This is a prospective study that includes patients as treated in the Sanatorio Guemens cath lab between December 2012 and February 2013. Basal features, fluoroscopy time, incidence, and radial to femoral conversion were studied.
RESULTS: 131 endovascular procedures were recorded, 98 (74.8 %) through radial access (Table 1) and the remainder through femoral. Average age of the patients was 63 years, most of them being males (70%). 33 patients were carried out through a different access than radial (25.3%). This decision was due to: radial pulse absence in 1 patient; requiring an IABP in 1 patient; hematoma in radial site puncture in 1 patient, and 1 patient showing weak radial pulse. In all other cases, reasons backing no radial access were not sufficiently supported or reflect a personal bias of the operator (Table 2).
The exposure time radiation and contrast material was similar both in radial and femoral procedures. Radial spasm moderate to severe was observed in 5 patients, 4 coronary and 1 neck vessel angiography, and conversion to femoral access was done in only 2 subjects, due to severe spasm of the radial artery.
CONCLUSION: In spite of the low incidence of radial spasm, the conversion to femoral was negligible and in all cases due to severe radial spasm. Radial access strategies prove to be effective and no additional radiation exposure was required. The numbers of angioplasties where radial access was used was similar to the cases treated through femoral access. Also, that number proved to be inferior to the one obtained for MMII angiography, reasons backing other access different than radial were not sufficiently supported or reflect a personal bias of the operator, in spite of all arguments and new guidelines supporting that technique.
Is Transradial Approach Safe in the Elderly? A Tunisian registry
Hajlaoui N, Sherian LS, Ghommidh M, Ben Mansour N, Lahidheb D, Jedaida B, Haggui A, Dahmani R, Fehri W, Haouala H
BACKGROUND: The population of elderly patients has a greater incidence of cervical atheroma with a greater theoretical risk of mobilization of cervical atheroma during transradial procedures. We examined the safety of transradial procedures in such population in our daily practice.
METHODS: We consulted the registry of the military hospital of Tunis, and we studied 100 random patients aged more than 75 years who underwent percutaneous coronary angiogram or coronary intervention.
RESULTS: One hundred patients (55 men and 45 women) were studied. The mean age was 79 years ranging 75 to 87 years. 64% of patients were hypertensive, 37% diabetics, 30% smokers, 29% had dyslipidemia, 4% in end stage renal disease, and 3 patients (3%) on anticoagulant therapy for atrial fibrillation. Coronary angiography was indicated for acute coronary syndrome in 49 patients, stable angina in 45 patients, and for preoperative assessment of valvular heart disease in 6 patients. The radial access was performed in 35 patients, 3 of whom underwent angioplasty with implantation of stent. There were no local complications or stroke in this group. In the transfemoral approach group (65%), 4 patients (6.2%) had small hematoma in the site of puncture and no other complication was noted.
CONCLUSIONS: In this registry, we haven’t observed more incidence of mobilization of cervical atheroma in the elderly when we used the transradial approach. The transradial approach can be performed in elderly patients with less local complications, earlier ambulation, and shorter hospital stay compared to the standard transfemoral approach. The risk of embolic stroke due to mobilization of cervical atheroma is theoretical and not verified in our daily practice at least.
Transradial Coronary Intervention in Patients with Cardiac Arrest due to Acute Myocardial Infarction
Mizuguchi Y, Takahashi A, Yamada T, Taniguchi N, Nakajima S, Hata T
BACKGROUND: The latest ACCF/AHA/SCAI guideline recommended transradial percutaneous coronary intervention (TRI) for the patients with acute myocardial infarction (AMI) for the reduction in vascular complication. However, even for skilled operators, the feasibility of TRI for those who complicated with cardiac arrest during radial puncture is uncertain because of technical difficulty and possible adverse effect on the procedure time when compared with transfemoral coronary intervention (TFI).
METHODS: We retrospectively analyzed 20 consecutive patients with AMI who required extra corporeal membrane oxygenator because of cardiopulmonary arrest resistant to conventional cardiopulmonary resuscitation in the emergency room between March 2005 and February 2012. All patients undergoing TRI were performed with a skilled operator who performs TRI over 400 cases per year. The radial arteries were not palpable in all the patients before puncture. The percutaneous access sites, the time to cardiopulmonary resuscitation, the door to balloon time, and 30 days survival were investigated.
RESULTS: TRI was performed in 13 patients and 7 other patients underwent TFI. There were no significant differences in the time-to-admission time (26.8 +/- 14.6 vs 17.0 +/- 13.3 min), time-to-ECMO (41.8 +/- 18.8 vs 39.0 +/- 16.6 min), door-to-needle time (42.3 +/- 13.9 vs 49.3 +/- 16.5 min), and door-to-balloon time (61.4 +/- 19.1 vs 79.3 +/- 21.0 min) between TRI and TFI groups. 30-day survival rate was 7 of 20 (38%) in all patients, 4 of 13 (31%) in TRI group, and 3 of 7 (43%) in TFI group.
CONCLUSIONS: This cohort study demonstrates equivalent efficacy of TRI to TFI for the patients complicated with cardiac arrest due to AMI when performed by a skilled operator.
Radiation Exposure During Transradial Diagnostic Coronary Angiography With Multi- or Single-Catheter Use
Plourde G, Abdelaal E, MacHaalany J, Rimac G, Roy L, De Larochellière R, Larose E, Nguyen C, Barbeau G, Gleeton O, Proulx G, Rinfret S, Déry JP, Boudreault JR, Rouleau J, Rodés-Cabau J, Noël B, Costerousse O, Bertrand OF
BACKGROUND: With transradial approach, diagnostic coronary angiography (DCA) is routinely performed with routines using single- or multi-catheters. However, it remains unknown whether these strategies are associated with different radiation exposure.
OBJECTIVE: To compare fluoroscopy times and dose-area-product (DAP) during transradial DCA using 4 different routines (Judkins, Amplatz, Barbeau, Multipurpose).
METHODS and RESULTS: From November 2012 to July 2013, we recruited 1384 patients who underwent transradial DCA followed by a left ventriculography or aortography. The analysis was performed on an intent-to-treat basis, and based on the initial catheter used. The first routine consisted of Judkins left and right catheters, whereas the 3 others included Amplatz, Barbeau, or Multipurpose as single catheters (Cordis Corporation). A majority of patients (n=1,209) underwent their “intended” routine, whilst 13% (n=175) had a crossover to another routine during the procedure. See Table 1 for baseline and procedural characteristics.
CONCLUSION: Overall, fluoroscopy time was lowest with multipurpose single-catheter routine. However, radiation exposure to patients was most reduced with standard routine using Judkins left and right catheters. Further randomized studies are required to assess patient and operator exposure using universal and standard diagnostic catheters.
Vascular Access Route (Radial vs Femoral) and Radiation Exposure in Percutaneous Coronary Interventions and Diagnostic Angiography
Rigattieri S, Sciahbasi A, Mussino E, Drefahl S, Pugliese FR
PURPOSE: Radial access (RA) is being increasingly used in interventional cardiology, since it is associated with less vascular complications and bleedings compared to femoral access (FA). Nevertheless RA has some limitations, such as a steep learning curve and, possibly, an increased radiation exposure, which has been reported in the literature, although there are conflicting data.
METHODS: We designed a single-center, retrospective study aimed to compare radiation exposure during percutaneous coronary interventions (PCI) and diagnostic coronary angiography (CA) according to the vascular access route (RA vs FA). We included all patients undergoing PCI or CA in our laboratory from May 2009 to May 2013 for whom radiation exposure data were available. Radiation exposure data, expressed as dose area product (DAP, cGy.cm2) were obtained by the x-ray system. Stepwise multiple linear regression analysis was performed in order to compare radiation exposure between RA and FA adjusting for clinical and procedural confounders.
RESULTS: DAP values were available for 1396 out of 4110 procedures. RA was used in 1153 procedures (82.6%) and was right-sided in 82.3% of cases. The overall rate of RA in the cath lab was 68%, 69%, 75%, and 87% for each of the 4 years considered, respectively. Clinical and procedural characteristics were different between RA patients and FA patients, indicating a selection bias towards the use of FA in sicker patients. Indeed, RA patients were younger, less frequently female, and had higher BMI as compared to FA patients. The rates of PCI, ad hoc PCI, bypass angiography, thrombus aspiration, primary/rescue angioplasty, as well as the number of stents implanted, fluoroscopy time, and contrast dose were significantly higher in FA. Median DAP value was 7635 cGy.cm2 (IQR 4393 – 12976) in RA vs 9670 cGy.cm2 (5555-14310) in FA (p<0.001). The linear regression model showed that vascular access route was not an independent predictor of increased DAP (Beta 0.054, 95% C.I. -0.024 - 0.133; p=0.175). Age, BMI, primary PCI, ad hoc PCI, number of stents, bypass angiography, and the use of IVUS/pressure wire were associated with higher radiation exposure, whereas being female was associated with a lower DAP.
CONCLUSION: After adjusting for clinical and procedural confounders, RA was not found to be associated with increased radiation exposure as compared to FA in an experienced radial center.
Vascular Access Site and Door-to-Balloon Time in Primary PCI
Rigattieri S, Sciahbasi A, Pugliese FR, Loschiavo P
PURPOSE: Radial approach (RA) in primary angioplasty (pPCI) is associated with lower rates of mortality and bleeding as compared to femoral approach (FA). However, RA is technically more demanding, and one could expect an increase in the door-to-balloon interval (DTB) with a RA strategy. In the literature there are conflicting reports about this issue. We aimed to assess the impact of RA on DTB as compared to FA.
METHODS: We retrospectively considered all pPCI procedures performed at our hospital in a 4-year window (May 2009 to June 2013) according to the following inclusion criteria: 1) procedures performed by skilled RA operators (overall RA rate >60% in the previous 5 years); 2) availability of DTB.
RESULTS: We identified 208 procedures (204 pPCI and 4 rescue PCI) performed by 2 operators: SR (179 procedures from May 2009 to June 2013) and AS (29 procedures from June 2012 to June 2013). We identified 138 procedures performed by RA (66.3%), 70 by FA. RA patients were younger (63.6 ± 13.4 vs 68.7 ± 13.1; p=0.009) and had a greater body mass index (28.0 ± 5.2 vs 25.6 ± 4.2; p=0.004) as compared to FA patients; female gender was more prevalent in FA patients (37.1% vs 16.7%; p=0.001).
On the contrary, there were no statistically significant differences regarding the following parameters: rate of manual thrombus aspiration, rate of intra-aortic balloon, number of diseased vessels, rate of anterior myocardial infarction, prevalence of cardiovascular risk factors and diseases (hypertension, diabetes, dyslipidemia, smoking, peripheral arteriopathy, previous myocardial infarction), dye dose, radiation dose (as assessed by Dose Area Product), procedural and fluoroscopy time, number of diagnostic and guiding catheters, number of stents implanted. Procedural success was 96.4% with RA and 90.0% with FA (p=0.064). DTB was comparable in RA and FA (median and inter-quartile range were, respectively, 95 min [80-154] and 93 min [69-126], p=0.326).
As far as in-hospital outcomes are concerned, overall mortality was 5.3% and it was significantly higher in FA patients as compared to RA patients (10.0% vs 2.9%; p=0.047), whereas the length of stay was comparable (6 days [5-9] in RA and 6 days [5-12] in FA; p=0.770).
CONCLUSION: In a center with expert radial operators, RA for pPCI is not associated with a prolongation in the DTB interval as compared to FA.
Percutaneous Coronary Intervention Using Rotational Atherectomy: A Multicenter Comparison of Radial vs Femoral Approach
Scott P, Hanratty C, Ossei-Gerning N, Byrne J, Anderson RA.
PURPOSE: Rotational atherectomy (RA) is a well-established adjuvant device for use during percutaneous coronary intervention (PCI). The femoral artery has historically been the arterial access of choice for RA, facilitating the use of large-bore guide catheters. Transradial access has become a default for many European centers, but the use of RA has previously been limited. We present a large, contemporary, multicenter comparison of radial and femoral RA PCI.
METHODS: Patients from three regional cardiology centers from the United Kingdom undergoing RA PCI from 2008 to 2012 were included in the study. Patients were separated into access site used, and procedural and clinical outcomes were compared. MACE was reported at 30 days.
RESULTS: 685 patients underwent RA PCI (radial n = 398 and femoral n=287) during the study period. There was a predominance of male patients in the radial group (75.4% vs 63.4%, p<0.001) and more likely to have left ventricular impairment (32.8% vs 15.4%, p<0.001). No other difference in baseline demographics was seen between the two groups. Procedural success was identical in both cohorts (98.5 vs 97.5, p=0.62) but radial cohort received more drug-eluting stents (91.2% vs 85.3%, p=0.03). Guide catheter size in the radial cohort was smaller (6.55 vs 6.95, p<0.001), average burr size was similar. The femoral group underwent more left main-stem PCI (14.2% vs 21.8%, p=0.01) and additional imaging (23.2% vs 32.9%, p=0.03). The procedural time (76.3 min vs 92.6 min, p<0.001) and time to first balloon inflation (39 min vs 54 min, p<0.001) were significantly lower in the radial cohort, as was mean length of stay (1.4 days vs 2.9 days, p=0.008). Bleeding and vascular access complications were similar between the two groups as was 30-day MACE (radial 6.45% vs femoral 4.08%, p=0.15).
CONCLUSIONS: This is the largest comparison to date of radial versus femoral rotablation. Our data demonstrate that radial RA PCI can be performed safely, with smaller guide catheters and a similar procedural success. Procedural time and time to first balloon inflation was significantly less in the radial cohort, whereas 30-day MACE rates and access-associated complications were similar between both groups. Our results show that radial access is a safe, effective, and perhaps more efficient method for performing RA.
What Happens When Transradialists Use Transbrachial Approach
Trbušić M, Gabrić ID, Planinc D, Krčmar T, Pintarić H
PURPOSE: Radial arterial approach has become the default option for coronary procedures in our cath lab (>90%). However, there are situations when radial arterial approach is not possible (e.g. congenital anomalies, tortuous configurations, radioulnar loop, weak or absent radial pulse secondary to previous puncture or catheterization). In such situations, a common second-line approach is used (femoral or ulnar). Many clinicians considered transbrachial (TB) angiography as a high-risk and obsolete procedure. In literature, the complications rate was unacceptably high (up to 36%). The aim of this retrospective investigation was to evaluate the safety and efficiency of TB approach as alternative to radial approach, especially after unsuccessful radial artery puncture.
METHOD: Between April 2011 and 2013 TB coronary angiography in the antecubital region was performed in 22 patients with stable and unstable angina or valvular heart disease. In 11 patients, diagnostic procedure was followed by coronary intervention. Reasons for TB approach were weak radial pulse (10 cases) or unsuccessful radial artery puncture (12 cases). Procedures were performed by three experienced transradial invasive cardiologists (transradial success more than 95%). The catheter size was 6 Fr in all patients. Anticoagulation protocol was used following guidelines (aspirin, clopidogrel, unfractionated heparin) but without glycoprotein IIb/IIIa receptor inhibitors. Major complications were defined as vascular complications requiring blood transfusion or surgery or permanent neurological deficit in the lower limb. Minor complications were defined as vascular complications not requiring blood transfusion or surgery and transient neurological deficit in the lower limb. Standard post-procedural protocol was removal of artery sheath 6 hours after puncture and manual puncture site compression for 10 minutes.
RESULTS: Overall success rate was 95.5% (21/22). There were no major complications and we noticed only two minor complications (9%), both hematomas.
CONCLUSION: TB approach, when used by dedicated transradialists, seems to be easily feasible, safe, and effective. Local vascular complications could be avoided by cautious and sensitive puncture technique. Other important factors are use of 6 Fr catheters, defensive anticoagulation, and careful observation by the nursing team after sheath withdrawal. TB approach has all advantages of the arm approach over the femoral (early ambulation, patient preference, suitable for patients with severe occlusive aortoiliac disease and for patients with difficulty lying down).
Patients Having PCI via Femoral Approach in Centers that are Default Radial Centers: Results and Insights From a Single-Center Experience
Uddin M, Shah A, Ossei Gerning N, Kinnaird TD, Anderson RA
PURPOSE: Increasingly the transradial route (TR) is preferred over the transfemoral route (TF) for PCI. However even in high volume default TR centers a small cohort of patients are required to undergo TF PCI. Our study examined the clinical, procedural characteristics, and outcomes of patients undergoing PCI via the TF in a single high volume UK center.
METHODS: This was a prospective study examining the PCI procedure and outcomes of all patients undergoing PCI between January 2009 and December 2012. Patient demographics, procedure details, and outcomes were all collected from internal and national databases.
RESULTS: 5379 patients were examined, 10.4% (n=561) of patients undergoing PCI via the TF and 89.6% via the TR. The TF group included more often females (35.8 vs 24.6% when compared to TR cohort, p<0.0001), older (64.9 vs 63.0 year, p<0.0002), and lighter (80.7 vs 83.7 kg, p<0.0001). There was a greater proportion of patients with a history of previous revascularization by PCI (27.5% vs 18.1%, p<0.0001) or CABG (14.6 vs 4.8%, p<0.0001) in the TF group. Cardiogenic shock and use of intra-aortic balloon pump was also greater in the TF group (7 vs 1% and 6.5 vs 0.5%, respectively, p<0.0001). Complex procedures including use of rotational atherectomy (4.1 vs 0.7%), saphenous vein graft PCI (9.1 vs 3.0%), and chronic occlusion PCI (21.1 vs 6.8%) were also performed more frequently in the TF group (p<0.0001 for all). In-hospital mortality (2.0 vs 0.46%, p<0.0001), vascular complications (3.2 vs 0.6%, p<0.0001), and bleeding (1.0 vs 0.02%, p<0.0001) were all more common in the TF group. PCI success was less common (88.2 vs 94.6%) in the TF group despite similar number of lesions attempted (1.54 vs 1.57, p=ns) and vessels treated (1.27 vs 1.27, p=ns).
CONCLUSION: In a high volume default TR PCI center, the small cohort of patients that continue to have PCI via the TF route are more likely to undergo complex coronary intervention and have higher subsequent vascular complications and mortality. Best practice for such patients in future will require optimization of pharmacotherapy strategies, procedural techniques, and utilization of emerging interventional equipment.