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Gluckman TJ, Wang L, Spinelli KJ, Petersen JL, Huang P, Amin A, Messenger JC, Rao SV. Differential Use and Impact of Bleeding Avoidance Strategies on Percutaneous Coronary Intervention-Related Bleeding Stratified by Predicted Risk. Circ Cardiovasc Interv 2020; 13:e008702. [PMID: 32527190 DOI: 10.1161/circinterventions.119.008702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Procedural anticoagulation with bivalirudin (BIV), trans-radial intervention (TRI), and use of a vascular closure device (VCD) are thought to mitigate percutaneous coronary intervention (PCI)-related bleeding. We compared the impact of these bleeding avoidance strategies (BAS) for PCIs stratified by bleeding risk. METHODS We performed a retrospective cohort analysis of PCIs from 18 facilities within one health care system from 2009Q3 to 2017Q4. Bleeding risk was assessed per the National Cardiovascular Data Registry CathPCI bleeding model, with procedures stratified into 6 categories (first, second, third quartiles, 75th-90th, 90th-97.5th, and top 2.5th percentiles). Regression models were used to assess the impact of BAS on bleeding outcome. RESULTS Of 74 953 PCIs, 9.4% used no BAS, 12.0% used BIV alone, 20.8% used TRI alone, 26.8% used VCD alone, 5.4% used TRI+BIV, and 25.6% used VCD+BIV. The crude bleeding rate was 4.4% overall. Only 2 comparisons showed significant trends across all risk strata: VCD+BIV versus no BAS, odds ratio (95% CI) range: first quartile, 0.36 (0.18-0.72) to top 2.5th percentile, 0.50 (0.32-0.78); TRI versus no BAS, odds ratio (95% CI) range: first quartile, 0.15 (0.06-0.38) to top 2.5th percentile, 0.49 (0.28-0.86). TRI had lower odds of bleeding compared with BIV for all risk strata except the top 2.5th percentile. Addition of BIV to TRI did not change the odds of bleeding for any risk strata. Factors potentially limiting use of TRI (renal failure, shock, cardiac arrest, and mechanical circulatory support) were present in ≤10% of procedures below the 90th percentile. CONCLUSIONS Among individual BAS, only TRI had consistently lower odds of bleeding across all risk strata. Factors potentially limiting TRI were found infrequently in procedures below the 90th percentile of bleeding risk. For transfemoral PCI, VCD+BIV had lower odds of bleeding compared with no BAS across all risk strata.
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Affiliation(s)
- Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon (T.J.G., L.W., K.J.S.)
| | - Lian Wang
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon (T.J.G., L.W., K.J.S.)
| | - Kateri J Spinelli
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon (T.J.G., L.W., K.J.S.)
| | - John L Petersen
- Swedish Heart and Vascular Institute, Providence St. Joseph Health, Seattle, WA (J.L.P., P.H.)
| | - Paul Huang
- Swedish Heart and Vascular Institute, Providence St. Joseph Health, Seattle, WA (J.L.P., P.H.)
| | - Amit Amin
- Cardiovascular Division, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO (A.A.)
| | - John C Messenger
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora (J.C.M.)
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, NC (S.V.R.)
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252
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Sattur MG, Almallouhi E, Lena JR, Spiotta AM. Illustrated Guide to the Transradial Approach for Neuroendovascular Surgery: A Step-by-Step Description Gleaned From Over 500 Cases at an Early Adopter Single Center. Oper Neurosurg (Hagerstown) 2020; 19:181-189. [DOI: 10.1093/ons/opaa153] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/21/2020] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Traditionally, neuroangiography for diagnosis and therapy has been achieved via the transfemoral route. Femoral access, however, has been associated with catastrophic complications. Although transradial access (TRA) has been adopted late by the field of neuroendovascular surgery, several groups have recently demonstrated a dramatically safe and rapid learning curve with a radial-first approach. However, there is a need for a detailed illustrative approach on the transradial technique.
OBJECTIVE
To provide a detailed description of the operative technique with step-by-step illustrations derived from our single center series of 506 cases, as an early adopter.
METHODS
A step-by-step illustrated approach to our technique of transradial angiography is provided, based on our clinical experience of an early radial-first approach. Prospective review of patients undergoing transradial angiography and interventions from April 1 to November 30, 2019, at our institution was performed. We included all cases that received radial-first arterial access for diagnostic and interventional neuroangiography. Efficacy, complications, catheter use, and radiation metrics of TRA for the entire cohort were noted. The radial approach was described in 4 stages beginning from the wrist (Stage I) and ending with distal access to target vessel of interest (Stage IV).
RESULTS
A total of 506 patients underwent TRA over the 7-mo period. Procedural success was achieved in 92.3% of patients (93.7% for diagnostic and 88.5% for interventional). Crossover to the femoral route occurred in 33 (6.5%) cases (25 diagnostic and 8 interventional). The majority occurred in Stage I. No major complications were noted.
CONCLUSION
Our preferred technique for the transradial approach provides excellent safety and efficacy in performing diagnostic and interventional neuroangiography. The illustrated technical steps are expected to provide guidance for early adopters of TRA.
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Affiliation(s)
- Mithun G Sattur
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Jonathan R Lena
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
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253
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Rao SV, Wegermann ZK. Validation of the Academic Research Consortium Definition of High Bleeding Risk: Not Academic Anymore. J Am Coll Cardiol 2020; 75:2723-2725. [PMID: 32466888 DOI: 10.1016/j.jacc.2020.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Sunil V Rao
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Zachary K Wegermann
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
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254
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Satti SR, Vance AZ. Radial Access for Neurovascular Procedures. Semin Intervent Radiol 2020; 37:182-191. [PMID: 32419731 PMCID: PMC7224967 DOI: 10.1055/s-0040-1709173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Radial access is increasingly being considered in neurovascular procedures after becoming the standard access route in percutaneous cardiovascular interventions. Current barriers include a lack of dedicated equipment for radial to neurovascular target vessels, lack of training for physicians and fellows, and physician bias toward femoral access secondary to greater experience and familiarity. Radial access has been proven to be safer and the preferred access route by most patients. These two factors make radial access inevitability when the aforementioned barriers are overcome. The purpose of this brief article is to highlight some important considerations of radial access specific to the neurovasculature.
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Affiliation(s)
- Sudhakar R. Satti
- Neurointerventional Surgery, Christiana Care Health System, Newark, Delaware
| | - Ansar Z. Vance
- Division of Interventional Radiology, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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255
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Savas G, Poyraz E, Arslan Y, Terzi S. Successful stenting of a brachial artery occlusion following surgical retrieval of a twisted diagnostic catheter during transradial coronary angiography. J Card Surg 2020; 35:1660-1663. [PMID: 32369866 DOI: 10.1111/jocs.14606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Coronary angiography and percutaneous coronary intervention via radial access has been progressively performed over the last three decades and has become standard of care. Even though the radial approach, compared with femoral access, is safe and is also associated with less bleeding in patients with myocardial infarction, it may be problematic in some cases. Here, we describe an 80-year-old woman with brachial artery dissection due to a twisted diagnostic catheter during transradial coronary angiography, who subsequently underwent surgical retrieval of the catheter.
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Affiliation(s)
- Goktug Savas
- Department of Cardiology, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Esra Poyraz
- Department of Cardiology, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Yucesin Arslan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sait Terzi
- Department of Cardiology, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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256
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Nazir S, Nesheiwat Z, Syed MA, Gupta R. Severe radial artery spasm causing entrapment of the Terumo radial to peripheral destination slender sheath: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-4. [PMID: 32352072 PMCID: PMC7180690 DOI: 10.1093/ehjcr/ytaa038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/11/2019] [Accepted: 01/28/2020] [Indexed: 11/12/2022]
Abstract
Background Radial access for lower-extremity peripheral vascular interventions (PVIs) has been limited due to inadequate equipment lengths. The Terumo R2P Destination Slender sheath is a relatively new sheath designed for these interventions. However, complications related to this sheath or access strategy for lower-extremity PVI have not been reported. Case summary A 69-year-old woman presented with purple discolouration of her 1st and 5th toes of the left foot for approximately 1 month. Lower-extremity arterial duplex ultrasound showed mid left superficial femoral artery (SFA) greater than 90% stenosis. Peripheral angiogram was performed via the left radial artery and this confirmed the presence of severe left SFA stenosis. Intra-arterial vasodilators including verapamil and nitroglycerine were administered to prevent radial artery spasm. Next, we attempted to deliver the Terumo 6-Fr R2P Destination Slender 119 cm sheath for the interventional procedure. However, the sheath became stuck at the level of mid axillary artery due to severe radial artery spasm. Despite use of intra-arterial vasodilators, deep sedation with propofol, and gentle retraction, the sheath could not be removed and eventually broke requiring surgical removal. Discussion This case demonstrates severe radial artery spasm causing sheath entrapment that required emergency surgery for sheath removal. Unfortunately, the sheath could not be removed despite typical manoeuvres for severe spasm including intra-arterial vasodilators and deep sedation with propofol. Physicians performing PVIs via radial access need to be aware of this potentially serious complication.
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Affiliation(s)
- Salik Nazir
- Department of Cardiology, University of Toledo Medical Center, 3000 Arlington Avenue, MS# 1118, Toledo, OH 43614, USA
| | - Zeid Nesheiwat
- Department of Cardiology, University of Toledo Medical Center, 3000 Arlington Avenue, MS# 1118, Toledo, OH 43614, USA
| | - Mubbasher Ameer Syed
- Department of Cardiology, University of Toledo Medical Center, 3000 Arlington Avenue, MS# 1118, Toledo, OH 43614, USA
| | - Rajesh Gupta
- Department of Cardiology, University of Toledo Medical Center, 3000 Arlington Avenue, MS# 1118, Toledo, OH 43614, USA
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257
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Majmundar N, Patel P, Dodson V, Bach I, Liu JK, Tomycz L, Khandelwal P. First case series of the transradial approach for neurointerventional procedures in pediatric patients. J Neurosurg Pediatr 2020; 25:492-496. [PMID: 32005020 DOI: 10.3171/2019.12.peds19448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/02/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The transradial approach (TRA) has been widely adopted by interventional cardiologists but is only now being accepted by neurointerventionalists. The benefits of the TRA over the traditional transfemoral approach (TFA) include reduced risk of adverse clinical events and faster recovery. The authors assessed the safety and feasibility of the TRA for neurointerventional cases in the pediatric population. METHODS Pediatric patients undergoing cerebrovascular interventions since implementation of the TRA at the authors' institution were retrospectively reviewed. Pertinent patient information, procedure indications, vessels catheterized, fluoroscopy time, and complications were reviewed. RESULTS There were 4 patients in this case series, and their ages ranged from 13 to 15 years. Each patient tolerated the procedure performed using the TRA without any postprocedural issues, and only 1 patient experienced radial artery spasm, which resolved with the administration of intraarterial verapamil. None of the patients required conversion to the TFA. CONCLUSIONS The TRA can be considered a safe alternative to the TFA for neurointerventional procedures in the pediatric population and provides potential advantages. However, as pediatric patients require special consideration due to their smaller-caliber arteries, routine use of ultrasound guidance is advised when attempting the TRA.
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Affiliation(s)
| | | | | | - Ivo Bach
- 2Neurology, Rutgers New Jersey Medical School, Newark, New Jersey
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258
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Yamamoto K, Natsuaki M, Morimoto T, Shiomi H, Watanabe H, Yamaji K, Watanabe H, Kato T, Saito N, Ando K, Kadota K, Furukawa Y, Kimura T. Transradial vs. Transfemoral Percutaneous Coronary Intervention in Patients With or Without High Bleeding Risk Criteria. Circ J 2020; 84:723-732. [PMID: 32188831 DOI: 10.1253/circj.cj-19-1117] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The transradial approach is reportedly associated with reduced bleeding complications and mortality after percutaneous coronary intervention (PCI). It is unknown whether the clinical benefits of transradial vs. transfemoral PCI differ between high bleeding risk (HBR) and non-HBR patients.Methods and Results:After excluding patients with acute myocardial infarction, dialysis, and a transbrachial approach from the 13,087 patients undergoing first PCI in the CREDO-Kyoto Registry Cohort-2, 6,828 patients were eligible for this study. Patients were divided into 2 groups according to bleeding risk based on Academic Research Consortium HBR criteria, and then divided into a further 2 groups according to access site, radial or femoral: HBR-radial, n=1,054 (38.3%); HBR-femoral, n=1,699 (61.7%); non-HBR-radial, n=1,682 (41.3%); and non-HBR-femoral, n=2,393 (58.7%). In the HBR group, the 30-day incidence and adjusted risk for major bleeding (1.9% vs. 4.7% [P<0.001]; adjusted hazard ratio [aHR] 0.44, 95% confidence interval [CI] 0.26-0.71 [P<0.001]) and all-cause death (0.3% vs. 0.9% [P=0.04]; aHR 0.30, 95% CI 0.07-0.93 [P=0.04]) were significantly lower in the radial than femoral group. There were no significant differences in the 30-day incidence and adjusted risk for major bleeding (0.5% vs. 1.0% [P=0.09]; aHR 0.68, 95% CI 0.30-1.45 [P=0.33]) or all-cause death (0.1% vs. 0.1% [P=0.96]; aHR 1.51, 95% CI 0.19-9.54 [P=0.67]) between the radial and femoral approaches in the non-HBR group. CONCLUSIONS Compared with transfemoral PCI, transradial PCI was associated with lower risk for 30-day major bleeding and mortality in HBR but not non-HBR patients.
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Affiliation(s)
- Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Hiroki Watanabe
- Division of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Kenji Ando
- Division of Cardiology, Kokura Memorial Hospital
| | | | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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259
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Flumignan RLG, Trevisani VFM, Lopes RD, Baptista-Silva JCC, Flumignan CDQ, Nakano LCU. Ultrasound guidance for arterial (other than femoral) catheterisation in adults. Hippokratia 2020. [DOI: 10.1002/14651858.cd013585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Ronald LG Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
| | - Virginia FM Trevisani
- Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro; Medicina de Urgência and Rheumatology; Rua Botucatu, 740 Vila Clementino São Paulo São Paulo Brazil 04023-900
| | - Renato D Lopes
- Duke University Medical Center; Division of Cardiology; Durham USA
| | - Jose CC Baptista-Silva
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
- Universidade Federal de São Paulo; Evidence Based Medicine, Cochrane Brazil; Rua Borges Lagoa, 564, cj 124 São Paulo São Paulo Brazil 04038-000
| | - Carolina DQ Flumignan
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
| | - Luis CU Nakano
- Universidade Federal de São Paulo; Department of Surgery, Division of Vascular and Endovascular Surgery; Rua Borges Lagoa, 754 São Paulo SP Brazil 04038-001
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260
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Junquera L, Rodés-Cabau J. Response by Junquera and Rodés-Cabau to Letter Regarding Article, "Comparison of Transfemoral Versus Transradial Secondary Access in Transcatheter Aortic Valve Replacement". Circ Cardiovasc Interv 2020; 13:e009194. [PMID: 32279566 DOI: 10.1161/circinterventions.120.009194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lucia Junquera
- Quebec Heart and Lung Institute, Laval University, Canada
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261
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Alkatiri AA, Firman D, Haryono N, Yonas E, Pranata R, Fahri I, Artha IMJR, Pratama V, Widodo WA, Taufiq N, Alkatiri AH, Ng S, Sulastomo H, Soerianata S. Comparison between radial versus femoral percutaneous coronary intervention access in Indonesian hospitals, 2017-2018: A prospective observational study of a national registry. IJC HEART & VASCULATURE 2020; 27:100488. [PMID: 32154360 PMCID: PMC7056720 DOI: 10.1016/j.ijcha.2020.100488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Coronary heart disease is a leading cause of death in Indonesia and percutaneous coronary intervention (PCI) is a routinely performed procedure. The aim of this study is to provide real-world insight on the demographics of coronary artery disease and comparison between radial compared to femoral PCI in Indonesia, which performed radial access whenever possible. METHODS This is a prospective cohort study involving 5420 patients with coronary artery disease who underwent PCI at 9 participating centers in the period of January 2017-December 2018. RESULTS Radial access rate was performed in 4038 (74.5%) patients. Patients receiving femoral access has a higher rate of comorbidities and complex lesions compared to radial access. The incidence of in-hospital mortality, cardiogenic shock, major arrhythmia, and tamponade were higher in femoral group. The incidence of in-hospital mortality was 114 (2.1%). New-onset angina (OR 3.412), chronic renal failure (OR 3.47), RBBB (OR 4.26), LBBB (OR 6.26), left main stenosis PCI (OR 3.58), cardiogenic shock (OR 4.9), and arrhythmia (OR 15.59) were found to be independent predictors of in-hospital mortality. Radial access did not independently affect in-hospital mortality. In propensity-matched cohort, radial access was not associated with lower in-hospital mortality in both bivariable and multivariable model. However, radial access was associated with reduced in-hospital mortality in STEMI subgroup (OR 0.31). CONCLUSION Higher rate of adverse events was noted on the femoral access group. However, it might stem from the fact that patients with more comorbidities and complex lesions are more likely to be assigned to femoral access-group. Neither radial or femoral access is superior in terms of in-hospital mortality upon propensity-score matching/multivariable analysis.
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Key Words
- ACE, Angiotensin Converting Enzyme
- AF, Atrial Fibrillation
- ARB, Angiotensin Receptor Blocker
- AVB, Atrioventricular Block
- CAD, Coronary Artery Disease
- CKD, Chronic Kidney Disease
- CTO, Chronic Total Occlusion
- CVD, Cerebrovascular Disease
- HF, Heart Failure
- Indonesia
- LAD, Left Anterior Descending
- LBBB, Left-bundle Branch Block
- LCX, Left Circumflex Artery
- LM, Left Main
- MI, Myocardial Infarction
- NOAC, Non-vitamin K Antagonist Oral Anticoagulant
- NSTEACS, Non-ST segment Elevation Acute Coronary Syndrome
- National registry
- PCI, Percutaneous Coronary Intervention
- PVD, Peripheral Vascular Disease
- Percutaneous coronary intervention
- RBBB, Right-bundle Branch Block
- RCA, Right Coronary Artery
- Radial access
- TIA, Transient Ischemic Attack
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Affiliation(s)
- Amir Aziz Alkatiri
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Doni Firman
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Nur Haryono
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Emir Yonas
- Indonesian Percutaneous Coronary Intervention Registry, Indonesia
| | - Raymond Pranata
- Indonesian Percutaneous Coronary Intervention Registry, Indonesia
| | - Ismir Fahri
- Department of Cardiology and Vascular Medicine, RSUD Dr. M Yunus, Bengkulu, Indonesia
| | - I Made Junior Rina Artha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Udayana, RSUP Sanglah, Bali, Indonesia
| | - Vireza Pratama
- Department of Cardiology and Vascular Medicine, Gatot Soebroto Central Army Hospital, Jakarta, Indonesia
| | - Wishnu Aditya Widodo
- Department of Cardiology and Vascular Medicine, Jakarta Heart Center, Jakarta, Indonesia
| | - Nahar Taufiq
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada, RSUP Dr. Sardjito, Yogyakarta, Indonesia
| | - Abdul Hakim Alkatiri
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Hasanuddin, RSUP Dr. Wahidin Sudirohusodo, Makassar, Indonesia
| | - Sunanto Ng
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Pelita Harapan, Siloam Hospital Lippo Village, Tangerang, Indonesia
| | - Heru Sulastomo
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Sebelas Maret, RSUP Dr. Moewardi, Surakarta, Indonesia
| | - Sunarya Soerianata
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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262
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Almallouhi E, Al Kasab S, Sattur MG, Lena J, Jabbour PM, Sweid A, Chalouhi N, Gooch MR, Starke RM, Peterson EC, Yavagal DR, Chen SH, Li Y, Gross BA, Tonetti DA, Zussman BM, Stone JG, Jadhav AP, Jankowitz BT, Young CC, Lim DH, Levitt MR, Osbun JW, Spiotta AM. Incorporation of transradial approach in neuroendovascular procedures: defining benchmarks for rates of complications and conversion to femoral access. J Neurointerv Surg 2020; 12:1122-1126. [DOI: 10.1136/neurintsurg-2020-015893] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 01/19/2023]
Abstract
BackgroundThe transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures.MethodsWe reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access.ResultsA total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients.ConclusionIn this early stage of transforming to the ‘radial-first’ approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.
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263
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Hamandi M, Saad M, Hasan R, Megaly M, Abbott JD, Dib C, Szerlip M, Potluri S, Lotfi A, Kiemeneij F, Al-Azizi KM. Distal Versus Conventional Transradial Artery Access for Coronary Angiography and Intervention: A Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1209-1213. [PMID: 32321695 DOI: 10.1016/j.carrev.2020.03.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 03/09/2020] [Accepted: 03/11/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Distal transradial artery access (dTRA) through the anatomical snuffbox is a novel approach for performing coronary angiography and interventions. However, the safety and efficacy of dTRA as compared to conventional TRA (cTRA) remains unknown. We aim to evaluate the outcomes of dTRA versus cTRA for coronary angiography and intervention. METHODS Electronic search of the National Library of Medicine PubMed and Cochrane Library databases was performed until April 2019 for studies comparing the clinical outcomes of dTRA approach versus conventional TRA (cTRA) approach in coronary angiography and interventions. Random-effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was failure of access site utilization. Other outcomes included access site hematoma, radial artery spasm, dissection, and occlusion. RESULTS Five studies (4 observational and 1 randomized controlled) with a total of 6746 patients (dTRA n = 3209 and cTRA n = 3537) were available for analysis. The failure rate was similar in dTRA and cTRA groups (5.26% versus 3.75%; RR = 1.36; 95%CI 0.41-4.48; p = 0.62). Similarly, no difference was observed between dTRA and cTRA in regards to access site hematoma (1.20% versus 1.24%, RR = 1.01; 95%CI 0.49-2.07; p = 0.99), radial artery spasm (1.42 versus 3.84%, RR = 0.91; 95%CI 0.32-2.62; p = 0.86), or radial artery dissection (0.11 versus 0.20%, RR = 0.63; 95%CI 0.18-2.16; p = 0.46). The rate of radial artery occlusion was lower with dTRA (2.30 versus 4.86%, RR = 0.51; 95%CI 0.32-0.81; p = 0.004) as compared to cTRA. CONCLUSION Distal TRA appears to be a safe and effective alternative to conventional TRA. The outcomes of this novel technique warrant further randomized studies.
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Affiliation(s)
- Mohanad Hamandi
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Marwan Saad
- Division of Cardiovascular Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Rimsha Hasan
- Department of Medicine, Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael Megaly
- Department of Cardiovascular Medicine, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI, USA
| | - Chad Dib
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Molly Szerlip
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Srinivasa Potluri
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA
| | - Amir Lotfi
- Interventional Cardiology, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA, USA
| | - Ferdinand Kiemeneij
- Interventional Cardiology, Cardiologie Kliniek Flevoland, Lelystad, Netherlands
| | - Karim M Al-Azizi
- Department of Interventional Cardiology, Baylor Scott & White-The Heart Hospital, Plano, TX, USA.
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264
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Gunduz Y, Gunduz H, Ayhan LT, Ciner M, Cakmak A, Saribiyik B, Akcay C, Ilguz E, Cosansu K. The Ulnar Artery as a Favorable Primary or Alternative Access Site for Coronary Angiography and Interventions. Angiology 2020; 71:417-424. [PMID: 32166958 DOI: 10.1177/0003319720907031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The transulnar approach (TUA) has been considered both as primary access and as a secondary access site after transradial access (TRA) failure for coronary invasive procedures. However, there is little evidence supporting the use of the TUA as the first approach to diagnostic coronary angiography (CAG) or interventions. Patients (n = 587) who underwent CAG and/or angioplasty (292 patients via TRA, 295 patients via TUA) were included. The primary end points of the study were major adverse cardiac events and major vascular events (hematoma, vascular occlusion, vasospasm), and secondary end points included angiographic success, crossover rate, and angiographic procedural times. The mean age was 60 ± 21 years. The composite primary end points occurred in 34 (11.6%) patients in the TRA and 22 (7.4%) patients in the TUA arm (P < .001). More arterial occlusion and more arterial spasm than in the TUA and similar urgent target vessel revascularization were observed in the TRA group in 48 hours. Based on previous studies and our clinical experience, we speculated that the TUA performed by an experienced operator has equal status with the TRA for coronary catheterization, especially in patients with a palpable ulnar pulse.
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Affiliation(s)
- Yasemin Gunduz
- Medical Faculty, Radiology Department, Sakarya University, Sakarya, Turkey
| | - Huseyin Gunduz
- Medical Faculty, Cardiology Department, Sakarya University, Sakarya, Turkey
| | - Lacin Tatli Ayhan
- Medical Faculty, Radiology Department, Sakarya University, Sakarya, Turkey
| | - Mahmut Ciner
- Medical Faculty, Radiology Department, Sakarya University, Sakarya, Turkey
| | - Ahmetcan Cakmak
- Medical Faculty, Cardiology Department, Sakarya University, Sakarya, Turkey
| | - Betul Saribiyik
- Medical Faculty, Cardiology Department, Sakarya University, Sakarya, Turkey
| | - Cagla Akcay
- Medical Faculty, Cardiology Department, Sakarya University, Sakarya, Turkey
| | - Ersin Ilguz
- Medical Faculty, Cardiology Department, Sakarya University, Sakarya, Turkey
| | - Kahraman Cosansu
- Medical Faculty, Cardiology Department, Sakarya University, Sakarya, Turkey
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265
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Raelson C, Ahmed B. Prevention and Management of Radial Access Complications. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-0808-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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266
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Manning P, Abbott JD. Radial access: So much progress but a way to go. Catheter Cardiovasc Interv 2020; 95:684-685. [PMID: 32159293 DOI: 10.1002/ccd.28794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/13/2020] [Indexed: 11/09/2022]
Abstract
Transradial access is the key bleeding avoidance strategy in percutaneous coronary intervention. This study showed a marked adoption of transradial access over a 10-year period, however, women had a significantly lower rate compared to men and overall bleeding events did not decrease over time. Strategies to overcome barriers to radial access in women and to maintaining competency in femoral access in all patients are needed.
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Affiliation(s)
- Patrick Manning
- Division of Cardiology, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island
| | - J Dawn Abbott
- Division of Cardiology, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island
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267
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Abstract
Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. As fractures and ligamentous disruption result in increased pelvic volume, retroperitoneal hemorrhage can spiral and progress to hemorrhagic shock. Due to the extensive collateral supply and limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management. This article will discuss typical injuries seen in pelvic trauma, treatment modalities available to the interventional radiologist, and common angiographic treatment strategies and techniques.
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Affiliation(s)
- Derek F. Franco
- Department of Radiology, University of Chicago Medicine, Chicago, Illinois
| | - Steven M. Zangan
- Department of Radiology, University of Chicago Medicine, Chicago, Illinois
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268
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Junquera L, Urena M, Latib A, Muñoz-Garcia A, Nombela-Franco L, Faurie B, Veiga-Fernandez G, Alperi A, Serra V, Regueiro A, Fischer Q, Himbert D, Mangieri A, Colombo A, Muñoz-García E, Vera-Urquiza R, Jiménez-Quevedo P, de la Torre JM, Pascual I, Garcia Del Blanco B, Sabaté M, Mohammadi S, Freitas-Ferraz AB, Guimarães L, Couture T, Côté M, Rodés-Cabau J. Comparison of Transfemoral Versus Transradial Secondary Access in Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2020; 13:e008609. [PMID: 32089002 DOI: 10.1161/circinterventions.119.008609] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Transfemoral approach has been commonly used as secondary access in transcatheter aortic valve replacement (TAVR). Scarce data exist on the use and potential clinical benefits of the transradial approach as secondary access during TAVR procedures. The objective of the study is to determine the occurrence of vascular complications (VC) and clinical outcomes according to secondary access (transfemoral versus transradial) in patients undergoing TAVR. METHODS This was a multicenter study including 4949 patients who underwent TAVR (mean age, 81±8 years, mean Society of Thoracic Surgeons score, 4.9 [3.3-7.5]). Transfemoral and transradial approaches were used as secondary access in 4016 (81.1%) and 933 (18.9%) patients, respectively. The 30-day clinical events (vascular and bleeding complications, stroke, acute kidney injury, and mortality) were evaluated and defined according to Valve Academic Research Consortium-2 criteria. Clinical outcomes were analyzed according to the secondary access (transfemoral versus transradial) in the overall population and in a propensity score-matched population involving 2978 transfemoral and 928 transradial patients. RESULTS Related-access VC occurred in 834 (16.9%) patients (major VC, 5.7%) and were related to the secondary access in 172 (3.5%) patients (major VC, 1.3%). The rate of VC related to the secondary access was higher in the transfemoral group (VC, 4.1% versus 0.9%, P<0.001; major VC, 1.6% versus 0%, P<0.001). In the propensity score-matched population, VC related to the secondary access remained higher in the transfemoral group (4.7% versus 0.9%, P<0.001; major VC, 1.8% versus 0%, P<0.001), which also exhibited a higher rate of major/life-threatening bleeding events (1.0% versus 0%, P<0.001). Significant differences between secondary access groups were observed regarding the rates of 30-day stroke (transfemoral: 3.1%, transradial: 1.6%; P=0.043), acute kidney injury (transfemoral: 9.9%, transradial: 5.7%; P<0.001), and mortality (transfemoral: 4.0%, transradial: 2.4%, P=0.047). CONCLUSIONS The use of transradial approach as secondary access in TAVR procedures was associated with a significant reduction in vascular and bleeding complications and improved 30-day outcomes. Future randomized studies are warranted.
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Affiliation(s)
- Lucía Junquera
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada (L.J., S.M., A.B.F.-F., L.G., T.C., M.C., J.R.-C.)
| | - Marina Urena
- Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France (M.U., Q.F., D.H.)
| | - Azeem Latib
- San Raffaele Scientific Institute, Milan, Italy (A.L., A.M., A.C.).,Montefiore Medical Center, New York, NY (A.L.)
| | | | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain (L.N.-F., R.V.U., P.J.-Q.)
| | - Benjamin Faurie
- Groupe Hospitalier Mutualiste de Grenoble, Institut Cardiovasculaire,Grenoble, France (B.F.)
| | | | - Alberto Alperi
- Hospital Universitario Central de Asturias, Spain (A.A., I.P.)
| | - Vicenç Serra
- Hospital Universitari Vall d'Hebron, Barcelona, Spain (V.S., B.G.d.B.)
| | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (A.R., M.S.)
| | - Quentin Fischer
- Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France (M.U., Q.F., D.H.)
| | - Dominique Himbert
- Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France (M.U., Q.F., D.H.)
| | - Antonio Mangieri
- San Raffaele Scientific Institute, Milan, Italy (A.L., A.M., A.C.).,Maria Cecilia GVM Hospital, Cotignola, Italy (A.M., A.C.)
| | - Antonio Colombo
- San Raffaele Scientific Institute, Milan, Italy (A.L., A.M., A.C.).,Maria Cecilia GVM Hospital, Cotignola, Italy (A.M., A.C.)
| | - Erika Muñoz-García
- Hospital Universitario Virgen de la Victoria, Málaga, Spain (A.M.-G., E.M.-G.)
| | - Rafael Vera-Urquiza
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain (L.N.-F., R.V.U., P.J.-Q.)
| | - Pilar Jiménez-Quevedo
- Instituto Cardiovascular, Hospital Clinico San Carlos, IdISSC, Madrid, Spain (L.N.-F., R.V.U., P.J.-Q.)
| | | | - Isaac Pascual
- Hospital Universitario Central de Asturias, Spain (A.A., I.P.)
| | | | - Manel Sabaté
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain (A.R., M.S.)
| | - Siamak Mohammadi
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada (L.J., S.M., A.B.F.-F., L.G., T.C., M.C., J.R.-C.)
| | - Afonso B Freitas-Ferraz
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada (L.J., S.M., A.B.F.-F., L.G., T.C., M.C., J.R.-C.)
| | - Leonardo Guimarães
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada (L.J., S.M., A.B.F.-F., L.G., T.C., M.C., J.R.-C.)
| | - Thomas Couture
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada (L.J., S.M., A.B.F.-F., L.G., T.C., M.C., J.R.-C.)
| | - Melanie Côté
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada (L.J., S.M., A.B.F.-F., L.G., T.C., M.C., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada (L.J., S.M., A.B.F.-F., L.G., T.C., M.C., J.R.-C.)
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269
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Shah SR, Kiemeneij F, Khuddus MA. Distal arteriovenous fistula formation after percutaneous coronary intervention: An old complication of a new access site. Catheter Cardiovasc Interv 2020; 97:278-281. [DOI: 10.1002/ccd.28772] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 01/02/2020] [Accepted: 01/29/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Syed Raza Shah
- North Florida Regional Medical Center University of Central Florida Gainesville Florida
| | | | - Matheen A. Khuddus
- North Florida Regional Medical Center University of Central Florida Gainesville Florida
- The Cardiac and Vascular Institute Gainesville Florida
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270
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Valle FH, Wainstein RV, Matte BS, Gonçalves SC, Bergoli LCC, Krepsky AMR, Pivatto Junior F, de Araujo GN, Machado GP, Wainstein MV. Ultrasound-guided antecubital vein approach for right heart catheterisation in a Brazilian tertiary centre. Open Heart 2020; 7:e001181. [PMID: 32153790 PMCID: PMC7046939 DOI: 10.1136/openhrt-2019-001181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 01/02/2020] [Accepted: 01/05/2020] [Indexed: 11/24/2022] Open
Abstract
Objective As a parallel to the radial approach for left heart catheterisation, forearm veins may be considered for the performance of right heart catheterisation. However, data regarding the application of this technique under ultrasound guidance are scarce. The current study aims to demonstrate the feasibility of right heart catheterisation through ultrasound-guided antecubital venous approach in the highly heterogeneous population usually referred for right heart catheterisation. Methods Data from consecutive right heart catheterisations performed at an academic centre in Brazil, between January 2016 and March 2017 were prospectively collected. Results Among 152 performed right heart catheterisations, ultrasound-guided antecubital venous approach was attempted in 127 (84%) cases and it was made feasible in 92.1% of those. Yet, there was no immediate vascular complication with the antecubital venous approach in this prospective series. Conclusions Ultrasound-guided antecubital venous approach for the performance of right heart catheterisation was feasible in the vast majority of cases in our study, without occurrence of vascular complications.
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Affiliation(s)
- Felipe Homem Valle
- Cardiology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Cardiology, Mount Sinai Hospital/University Health Network, Toronto, Ontario, Canada
| | - Rodrigo Vugman Wainstein
- Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- Postgraduate Program in Cardiology and Cardiovascular Sciences, UFRGS, Porto Alegre, Brazil
| | - Bruno Silva Matte
- Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | | | | | - Gustavo Neves de Araujo
- Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- Postgraduate Program in Cardiology and Cardiovascular Sciences, UFRGS, Porto Alegre, Brazil
| | | | - Marco Vugman Wainstein
- Cardiology, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- Postgraduate Program in Cardiology and Cardiovascular Sciences, UFRGS, Porto Alegre, Brazil
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271
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Khuddus MA, Truesdell AG, Kirtane AJ. Leveraging the Power of Marginal Gains to Improve Outcomes in Interventional Cardiology. JAMA Cardiol 2020; 5:121-123. [DOI: 10.1001/jamacardio.2019.4278] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Matheen A. Khuddus
- The Cardiac and Vascular Institute, Gainesville, Florida
- The University of Central Florida, Orlando
| | | | - Ajay J. Kirtane
- Columbia University Irving Medical Center, New York–Presbyterian Hospital, New York
- Associate Editor, JAMA Cardiology
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272
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Amro A, Mansoor K, Amro M, Hirzallah H, Sobeih A, Kusmic D, Abuhelwa Z, Kanbour M, Elhamdani A, Aqtash O, Elhamdani M. Transradial Versus Transfemoral Approach for Coronary Angiography in Females with Prior Bypass Surgery. Cureus 2020; 12:e6797. [PMID: 32140355 PMCID: PMC7045992 DOI: 10.7759/cureus.6797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/28/2020] [Indexed: 12/04/2022] Open
Abstract
Background Multiple studies have shown that trans-radial access (TRA) for women undergoing coronary angiography/intervention (CA/I) has a lower risk of vascular access site complications as compared with trans-femoral access (TFA). In patients who had previously undergone coronary artery bypass grafting (CABG), studies also showed no significant difference between TRA and TFA in terms of contrast amount (CA), procedure time (PT), and fluoroscopy time (FT). However, those studies mainly included men. Limited information is available on the relative merits of TRA as compared with TFA for cardiac catheterization in females who previously undergone CABG. The purpose of this study was to determine the efficacy and safety of TRA versus TFA in women with prior CABG surgery who are undergoing CA/I in regard to CA, PT, and FT. Methods In this single-center retrospective cohort study, females with a history of CABG who underwent CA/I in the period from January 2013 to September 2016 were included. A total of 584 patients were included and divided into two groups: TRA group (49 patients) and TFA group (535 patients). The primary endpoints were CA, PT, and FT. The means for the primary outcomes were compared between the two using the independent t-score test. Results A total of 584 female patients with a history of CABG had cardiac catheterization from January 2013 to September 2016 at our center. Trans-femoral access accounted for 91.6% (n=535) of the patients while trans-radial access accounted for 8.4% (n=49) of the patients. A comparison of procedural variables between TRA and TFA revealed that there was no statistical significance in procedure time, fluoroscopy time, or the contrast volume. The access site crossover rate was 6.12% (n=3) from radial to femoral while there was a 0% rate in the femoral to radial access. Conclusion The key findings of this study suggest that in female patients with a prior history of CABG, TRA is an equally reliable and efficacious approach for both diagnostic angiography and intervention compared to TFA.
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Affiliation(s)
- Ahmed Amro
- Cardiology, Marshall University, Huntington, USA
| | - Kanaan Mansoor
- Internal Medicine, Marshall University Joan C. Edwards School of Medicine, Huntington, USA
| | - Mohammad Amro
- Internal Medicine, Misr University for Science and Technology, Cairo, EGY
| | | | - Amal Sobeih
- Internal Medicine, Al-Najah University, Nablus, PSE
| | - Damir Kusmic
- Internal Medicine, Marshall University, Huntington, USA
| | - Ziad Abuhelwa
- Internal Medicine, An-Najah National University, Nablus, PSE
| | - Majd Kanbour
- Cardiology, Marshall University, Huntington, USA
| | - Adee Elhamdani
- Internal Medicine, Allegheny Health Network, Pittsburgh, USA
| | - Obadah Aqtash
- Internal Medicine, Marshall University, Huntington, USA
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273
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Bharadwaj AS, Swamy PM, Mamas MA. Outcomes of percutaneous coronary interventions in cancer patients. Expert Rev Cardiovasc Ther 2020; 18:25-32. [PMID: 31951772 DOI: 10.1080/14779072.2020.1718493] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Introduction: There are numerous shared risk factors in the etiopathogenesis of coronary artery disease (CAD) and cancer both at epidemiologic and molecular level. Additionally, different modalities of treatment of cancer such as radiation, chemotherapy, immunotherapy, and hormonal therapies further increase the risk of CAD and acute coronary syndrome. Most large database analysis and single-center experiences have shown that cancer patients undergoing PCI are at an increased risk of in-hospital mortality, bleeding, repeat revascularization.Areas covered: In this review article the authors discuss the associations between CAD and cancer, challenges for PCI in cancer patients and outcome data.Expert opinion: Interventionists performing PCI on cancer patients should be cognizant of the heightened risk of bleeding, thrombosis, possible need for interruption of dual-antiplatelet therapy, and the increased risk of target lesion revascularization in this cohort. These risks may be partially mitigated by utilization of best practices such as the use of radial artery access, intravascular imaging for lesion assessment and stent optimization and avoidance of complex stenting strategies. Finally, it is of paramount importance to have a multidisciplinary approach consisting of the treating cardiologist, medical and/or surgical oncologist, and palliative medicine, and involve the patient and their family in making informed decisions.
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Affiliation(s)
| | - Pooja M Swamy
- Division of Cardiology, Loma Linda University, CA, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
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274
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Coghill EM, Johnson T, Morris RE, Megson IL, Leslie SJ. Radial artery access site complications during cardiac procedures, clinical implications and potential solutions: The role of nitric oxide. World J Cardiol 2020; 12:26-34. [PMID: 31984125 PMCID: PMC6952722 DOI: 10.4330/wjc.v12.i1.26] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/05/2019] [Accepted: 11/26/2019] [Indexed: 02/06/2023] Open
Abstract
Percutaneous coronary intervention for the treatment of coronary artery disease is most commonly performed in the UK through the radial artery, as this is safer than the femoral approach. However, despite improvements in technology and techniques, complications can occur. The most common complication, arterial spasm, can cause intense pain and, in some cases, procedural failure. The incidence of spasm is dependent on several variables, including operator experience, artery size, and equipment used. An anti-spasmolytic cocktail can be applied to reduce spasm, which usually includes an exogenous nitric oxide (NO) donor (glyceryl trinitrate). NO is an endogenous local vasodilator and therefore is a potential target for anti-spasm intervention. However, systemic administration can result in unwanted side-effects, such as hypotension. A method that adopts local delivery of NO might be advantageous. This review article describes the mechanisms involved in radial artery spasm, discusses the advantages and disadvantages of current strategies to reduce spasm, and highlight the potential of NO-loaded nanoporous materials for use in this setting.
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Affiliation(s)
- Emma M Coghill
- Free Radical Research Facility, Division of Biomedical Sciences, University of the Highlands and Islands, Inverness IV2 3JH, United Kingdom
| | - Timothy Johnson
- Johnson Matthey Technology Centre, Blount’s Court, Sonning Common, Reading RG4 9NH, United Kingdom
| | - Russell E Morris
- School of Chemistry, University of St. Andrews, St Andrews KY16 9ST, United Kingdom
| | - Ian L Megson
- Free Radical Research Facility, Division of Biomedical Sciences, University of the Highlands and Islands, Inverness IV2 3JH, United Kingdom
| | - Stephen J Leslie
- Department of Cardiology, NHS Highland, Inverness IV2 3UJ, United Kingdom
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275
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Stone JG, Zussman BM, Tonetti DA, Brown M, Desai SM, Gross BA, Jadhav A, Jovin TG, Jankowitz B. Transradial versus transfemoral approaches for diagnostic cerebral angiography: a prospective, single-center, non-inferiority comparative effectiveness study. J Neurointerv Surg 2020; 12:993-998. [DOI: 10.1136/neurintsurg-2019-015642] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 12/27/2022]
Abstract
BackgroundInterventional cardiology produced level 1 evidence recommending radial artery-first for coronary angiography given lower vascular complications. Neuroendovascular surgeons have not widely adopted the transradial approach. This prospective, single center, non-inferiority comparative effectiveness study aims to compare the transradial and transfemoral approaches for diagnostic cerebral angiography with respect to efficacy, safety and patient satisfaction.MethodsConsecutive patients presenting for diagnostic cerebral angiography were selected to undergo right radial or femoral access based on date of presentation. Primary outcome was ability to answer the predefined diagnostic goal of the cerebral angiogram using the initial access site and was assessed with a non-inferiority design. Secondary outcomes included technical success per vessel, complications, procedure times and patient satisfaction.ResultsA total of 312 patients were enrolled, 158 and 154 for right radial and femoral access, respectively. The diagnostic goal of the angiogram was achieved in 152 of 154 (99%) patients who underwent attempted femoral access compared with 153 of 158 (97%) patients who underwent radial access, confirming non-inferiority of the transradial approach. Secondary outcomes showed equivalent technical success by vessel, no major complications, and similar frequency of minor complications between the two approaches. In-room time was similar between approaches, though post-procedure recovery room time was significantly shorter for transradial patients. Patient satisfaction results significantly favored the radial approach.ConclusionsIn patients undergoing diagnostic cerebral angiography, transfemoral and transradial access achieve procedural goals with similar effectiveness and safety, though patients strongly prefer the radial approach. Findings support consideration of adopting a radial-first strategy for diagnostic cerebral angiography.
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276
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Distal Radial and Ulnar Arteries: the Alternative Forearm Access. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:1. [DOI: 10.1007/s11936-020-0801-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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277
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Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, Prescott E, Storey RF, Deaton C, Cuisset T, Agewall S, Dickstein K, Edvardsen T, Escaned J, Gersh BJ, Svitil P, Gilard M, Hasdai D, Hatala R, Mahfoud F, Masip J, Muneretto C, Valgimigli M, Achenbach S, Bax JJ. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 2020; 41:407-477. [PMID: 31504439 DOI: 10.1093/eurheartj/ehz425] [Citation(s) in RCA: 3855] [Impact Index Per Article: 963.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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278
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Akl E, Rashid MK, Alshatti A, Jolly SS. Transradial Angiography and Intervention in Acute Coronary Syndromes. Interv Cardiol Clin 2020; 9:33-40. [PMID: 31733739 DOI: 10.1016/j.iccl.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Considerable evidence supports transradial angiography and intervention in patients with acute coronary syndrome, with an emphasis on decreasing major bleeding and access site vascular complications. Patients undergoing invasive treatment are at greatest risk of bleeding and have the most to gain. The radial advantage has consistently been shown to translate into reduced mortality in pooled data analyses. The benefits of transradial access have been demonstrated across the acute coronary syndrome spectrum and in both sexes. A radial-first strategy should be the default approach and continuous efforts should be made to increase operator expertise of transradial access in these patients.
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Affiliation(s)
- Elie Akl
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Mohammed K Rashid
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Ahmad Alshatti
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Sanjit S Jolly
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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279
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Lindner SM, McNeely CA, Amin AP. The Value of Transradial: Impact on Patient Satisfaction and Health Care Economics. Interv Cardiol Clin 2020; 9:107-115. [PMID: 31733737 PMCID: PMC7772820 DOI: 10.1016/j.iccl.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This review summarizes the impact of transradial access for cardiac catheterization and percutaneous coronary intervention related to patient satisfaction, patient safety, and health care costs. In studies comparing transradial versus transfemoral approach, transradial access causes less bleeding and less vascular access site complications and provides a mortality benefit in patients with acute coronary syndromes. Transradial access improves patient satisfaction related to site tolerability by reducing pain and discomfort, and facilitating early ambulation with reduced length of stay. Taken in total, the existing randomized and observational data strongly support radial access for improved safety, patient satisfaction, and significant cost savings.
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Affiliation(s)
- Samuel M Lindner
- Cardiovascular Division, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Barnes-Jewish Hospital, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
| | - Christian A McNeely
- Cardiovascular Division, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Barnes-Jewish Hospital, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
| | - Amit P Amin
- Cardiovascular Division, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Barnes-Jewish Hospital, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Center for Value and Innovation, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA.
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280
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Shroff AR, Gulati R, Drachman DE, Feldman DN, Gilchrist IC, Kaul P, Lata K, Pancholy SB, Panetta CJ, Seto AH, Speiser B, Steinberg DH, Vidovich MI, Woody WW, Rao SV. SCAI expert consensus statement update on best practices for transradial angiography and intervention. Catheter Cardiovasc Interv 2019; 95:245-252. [DOI: 10.1002/ccd.28672] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 12/12/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Adhir R. Shroff
- Division of CardiologyDepartment of Medicine, University of Illinois at Chicago Chicago, IL
| | - Rajiv Gulati
- Cardiovascular DiseasesMayo Clinic Rochester Minnesota
| | | | - Dmitriy N. Feldman
- Weill Cornell Medical CollegeNew York Presbyterian Hospital New York New York
| | - Ian C. Gilchrist
- Milton S. Hershey Medical CenterPenn State University Hershey Pennsylvania
| | | | - Kusum Lata
- CardiologySutter Health Tracy, Sacramento California
| | - Samir B. Pancholy
- CardiologyNorth Penn Cardiovascular Specialists Clarks Summit Pennsylvania
| | | | - Arnold H. Seto
- CardiologyUniversity Of California Irvine Orange California
| | | | | | - Mladen I. Vidovich
- Division of CardiologyDepartment of Medicine, University of Illinois at Chicago Chicago, IL
| | - Walter W. Woody
- CardiologyBaptist Memorial Hospital‐North MS Oxford Mississippi
| | - Sunil V. Rao
- Department of MedicineDuke Clinical Research Institute Durham North Carolina
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281
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Walker M, Levitt MR. Complex regional pain syndrome after transradial cerebral intervention. BMJ Case Rep 2019; 12:12/12/e015099. [PMID: 31874841 DOI: 10.1136/bcr-2019-015099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Access site complications from transradial approaches for endovascular interventions are uncommon and many are preventable. Complications described in the literature include hematoma, radial artery occlusion, vasospasm, and even compartment syndrome. Mild post-procedure discomfort reported by patients is typically self-limited and managed symptomatically with oral analgesics. Pain that has no obvious structural correlate and is unresponsive to intravenous narcotics is very unusual. We describe the diagnosis and management of a case of complex regional pain syndrome of the upper extremity after transradial stent-assisted coil embolization of a cerebral aneurysm.
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Affiliation(s)
- Melanie Walker
- Department of Neurological Surgery and Stroke and Applied Neuroscience Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, Radiology and Mechanical Engineering and Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
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282
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Catapano JS, Fredrickson VL, Fujii T, Cole TS, Koester SW, Baranoski JF, Cavalcanti DD, Wilkinson DA, Majmundar N, Lang MJ, Lawton MT, Ducruet AF, Albuquerque FC. Complications of femoral versus radial access in neuroendovascular procedures with propensity adjustment. J Neurointerv Surg 2019; 12:611-615. [PMID: 31843764 DOI: 10.1136/neurintsurg-2019-015569] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND The transradial artery (TRA) approach for neuroendovascular procedures continues to gain popularity, but neurointerventionalists still lag behind interventional cardiologists in the adoption of a TRA-first approach. This study compares the complications and efficiency of the TRA approach to the standard transfemoral artery (TFA) approach at our institution during our initial phase of adopting a TRA-first approach. METHODS A retrospective analysis was performed on all consecutive neuroangiographic procedures performed at a large cerebrovascular center from October 1, 2018 to June 30, 2019. The standard TFA approach was compared with TRA access, with the primary outcome of complications analyzed via a propensity-adjusted analysis. RESULTS A total of 1050 consecutive procedures were performed on 877 patients during this 9-month period; 206 (20%) procedures were performed via TRA and 844 (80%) via TFA. The overall complication rate was significantly higher with the TFA procedures than with the TRA procedures (7% (60/844) vs 2% (4/206), respectively; p=0.003). A propensity-adjusted analysis showed that the TFA approach was a significant risk factor for a complication (OR 3.6, 95% CI 1.3 to 10.2, p=0.01). However, the propensity analysis showed that fluoroscopy times were on average 4 min less for TFA procedures than for TRA procedures (p=0.003). CONCLUSION The TRA approach for neuroendovascular procedures appears to be safer than the TFA approach. Although a steep learning curve is initially encountered when adopting the TRA approach, the transition to a TRA-first practice can be performed safely for neurointerventional procedures and may reduce complications.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Vance L Fredrickson
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Tatsuhiro Fujii
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Califronia, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Daniel D Cavalcanti
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Neil Majmundar
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael J Lang
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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283
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Arterial Access Site Complications in Transradial Neurointerventions. Clin Neuroradiol 2019; 30:639-642. [DOI: 10.1007/s00062-019-00866-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/25/2019] [Indexed: 10/23/2022]
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284
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Use of Prospective Radiobrachial Angiography in Transradial Cardiac Catheterization and Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:797-803. [PMID: 31786141 DOI: 10.1016/j.carrev.2019.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 09/17/2019] [Accepted: 10/02/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study examined the utility of prospective radiobrachial angiography (pRBA) in transradial coronary angiography and intervention as a method for reducing procedural complications. BACKGROUND A growing body of evidence has supported the transradial approach (TRA) as superior to the transfemoral approach (TFA) due to advantages such as reduced bleeding and improved outcomes in high-risk patients. However, TRA has a higher failure rate than TFA, and has seen slow rates of adoption among United States operators. METHODS This was a retrospective, single center, case-control analysis of coronary angiography procedures, performed by two experienced operators at the University of Chicago Medical Center between October 28, 2015 and July 21, 2017. Operator 1 began using pRBA during the study, whereas Operator 2 used pRBA in all TRA procedures. There were 567 patients stratified into three groups based on operator and pRBA use. Comparisons of procedural outcomes for Operator 1 before and after adoption of pRBA, and of outcomes between Operator 1 and Operator 2 were made. RESULTS Use of pRBA was associated with reduced overall procedural complication rates (2.5% versus 10.4%, p = 0.004), driven primarily by reflexive radiobrachial angiography (rRBA) after resistance or pain was encountered (8.6% versus 0.0%, p = 0.0001) for Operator 1. A slight reduction in contrast associated with pRBA for Operator 1 was noted, but no difference in procedural time, radiation dose, or additional equipment used across groups was found. No significant difference in adverse procedural outcomes between the pRBA groups of Operator 1 and Operator 2 were observed. In patients with radiobrachial variants in anatomy, use of pRBA was associated with shorter times to cross anatomic lesions, shorter procedure times, reduced use of extra catheters, and less perforations and crossovers compared to patients requiring rRBA. Lack of pRBA was associated with higher procedural complications (hazard ratio 1.08, 95% CI, 1.03-1.13, p = 0.004). CONCLUSION pRBA may be a useful tool for mitigating procedural complications, reducing time needed to cross difficult radiobrachial anatomy, and reducing the need to utilize additional equipment in TRA. pRBA may offer operators a tool to improve outcomes and increase adoption of this approach.
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285
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Walker M, Levitt MR, Ghodke BV. Knot my problem: Overcoming transradial catheter complications. Clin Case Rep 2019; 7:2596-2597. [PMID: 31893113 PMCID: PMC6935611 DOI: 10.1002/ccr3.2537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 09/07/2019] [Accepted: 10/08/2019] [Indexed: 11/07/2022] Open
Abstract
Not all complications from transradial access can be prevented, even with diligent patient selection and preprocedure planning. This brief visual report offers technical suggestions to reverse knots and kinks encountered during catheter manipulation for endovascular transradial cerebral procedures.
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Affiliation(s)
- Melanie Walker
- Department of Neurological SurgeryUniversity of Washington School of MedicineSeattleWashington
- Stroke and Applied Neuroscience CenterUniversity of Washington School of MedicineSeattleWashington
| | - Michael R. Levitt
- Stroke and Applied Neuroscience CenterUniversity of Washington School of MedicineSeattleWashington
- Departments of Neurological Surgery, Radiology and Mechanical EngineeringUniversity of Washington School of MedicineSeattleWashington
| | - Basavaraj V. Ghodke
- Departments of Radiology and Neurological SurgeryUniversity of Washington School of MedicineSeattleWashington
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286
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Coomes EA, Haghbayan H, Cheema AN. Distal transradial access for cardiac catheterization: A systematic scoping review. Catheter Cardiovasc Interv 2019; 96:1381-1389. [PMID: 31785083 DOI: 10.1002/ccd.28623] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/11/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Systematically review the literature for cardiac catheterization and coronary angiography via distal transradial access (dTRA) and its outcomes. BACKGROUND dTRA, via anatomical snuffbox, may have several advantages over conventional transradial access (cTRA) for percutaneous cardiac procedures, including easier left-sided access for aorto-coronary grafts, future proximal radial artery preservation, and patient and operator comfort. However, its procedural characteristics and safety profile remain unclear. METHODS Ovid MEDLINE and EMBASE were searched from inception to September 2018. Two authors independently performed two-stage selection and data extraction. Reports assessing the dTRA approach for cardiac intervention in adults reporting any outcomes were eligible. Descriptive summary statistics were calculated from pooled data. RESULTS A total of 19 publications comprising 4,212 participants undergoing dTRA were included. Mean age was 63.8 years, and 23.0% were female. dTRA was primarily undertaken for assessment of stable coronary artery disease (87.6%), with 41.7% for diagnostic procedures and 46.9% undergoing percutaneous coronary intervention. The overall success rate for undertaking the dTRA approach was 95.4% (69-100%). Complications occurred in 2.4% of cases, of which the leading complications were bleeding/hematoma (18.2%). Complication rates did not significantly differ between dTRA and cTRA. The occurrence of radial artery occlusion in patients undergoing dTRA was low (1.7%). CONCLUSIONS Observational data demonstrate that dTRA is a safe and feasible method for percutaneous cardiac procedures, with high rates of procedural success and low rates of complication. As data comparing dTRA with cTRA remain limited, future high-quality randomized comparative studies are required.
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Affiliation(s)
- Eric A Coomes
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hourmazd Haghbayan
- Division of Cardiology, London Health Sciences Centre, Western University, London, Ontario, Canada.,Department of Social and Preventive Medicine, Université Laval, Québec, Québec, Canada
| | - Asim N Cheema
- Terrence Donnelly Heart Centre, St. Michael's Hospital, Toronto, Ontario, Canada
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287
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Villablanca PA, Frisoli T, O'Neill W, Eng M. Using the Arm for Structural Interventions: Case Selection or Wave of the Future. Interv Cardiol Clin 2019; 9:63-74. [PMID: 31733742 DOI: 10.1016/j.iccl.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The transradial approach has emerged as the preferred alternative to the traditional transfemoral approach owing to the increased evidence of its safety and efficacy. The field of structural heart disease is rapidly evolving; however, periprocedural complications related to access site remain a major determinant of morbidity and mortality. The transradial approach as primary or secondary access site in structural heart interventions like transcatheter aortic valve replacement, balloon aortic valvuloplasty, alternative access, alcohol septal ablations, paravalvular leak, valve snaring, coronary protection, and ventricular septal defect is feasible, safe, with lower vascular complications and high procedural success.
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Affiliation(s)
- Pedro A Villablanca
- Center for Structural Heart Disease, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
| | - Tiberio Frisoli
- Center for Structural Heart Disease, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - William O'Neill
- Center for Structural Heart Disease, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Marvin Eng
- Center for Structural Heart Disease, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA
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288
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Davies RE, Kearney KE, McCabe JM. RadialFirst in CHIP and Cardiogenic Shock. Interv Cardiol Clin 2019; 9:41-52. [PMID: 31733740 DOI: 10.1016/j.iccl.2019.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This article highlights the advantages and disadvantages of transradial arterial (TRA) access for a variety of presentations including acute coronary syndromes; cardiogenic shock; unprotected left main, heavily calcified coronaries; bifurcations; and chronic total occlusions. It includes techniques for overcoming challenges of using TRA access, including spasm and the need for larger bore guides. In addition, the authors review the use of ultrasound for access, percutaneous hemodynamic support via axillary approach, and tips and tricks to performing right heart catheterizations from the antecubital vein.
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Affiliation(s)
- Rhian E Davies
- Division of Cardiology, University of Washington, 1959 Northeast Pacific Street Box 356422, Seattle, WA 98195, USA
| | - Kathleen E Kearney
- Division of Cardiology, University of Washington, 1959 Northeast Pacific Street Box 356422, Seattle, WA 98195, USA
| | - James M McCabe
- Division of Cardiology, University of Washington, 1959 Northeast Pacific Street Box 356422, Seattle, WA 98195, USA.
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289
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Abstract
Over the past 2 decades, radial artery access has increasingly become the standard approach for coronary angiography and intervention. Compared with femoral arteries, transradial access is associated with better hemostasis. Transradial access has increased patient preference, facilitates early ambulation, and is cost-effective. An important limitation of transradial access is access site failure, and it carries a crossover rate of 3% to 7% in randomized prospective trials comparing radial with femoral artery access among experienced operators. Crossover rates for failed primary radial artery access can be reduced with ultrasonography guidance and increased familiarity with alternative access sites in the wrist.
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Affiliation(s)
- Sridevi R Pitta
- Cox Health System, University of Missouri School of Medicine, 3800 S National Avenue, Suite # 700, Springfield, MO 65807, USA.
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
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290
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Parikh A, Gilchrist IC. The pulseless radial artery in transradial catheterization: challenges and solutions. Expert Rev Cardiovasc Ther 2019; 17:827-836. [DOI: 10.1080/14779072.2019.1691917] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Analkumar Parikh
- Interventional Cardiology, Pennsylvania State University, College of Medicine, Penn State Heart & Vascular Institute, M.S. Hershey Medical center, Hershey, PA, USA
| | - Ian C Gilchrist
- Interventional Cardiology, Pennsylvania State University, College of Medicine, Penn State Heart & Vascular Institute, M.S. Hershey Medical center, Hershey, PA, USA
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291
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Kumar K, Reddy S, Acharya D, Lotun K. Novel technique of performing multivessel PCI through an Impella sheath. Catheter Cardiovasc Interv 2019; 96:117-120. [PMID: 31696630 DOI: 10.1002/ccd.28583] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 10/01/2019] [Accepted: 10/26/2019] [Indexed: 11/07/2022]
Abstract
A 69-year-old woman with diabetes was found to have multi-vessel coronary artery disease and underwent 5-vessel coronary artery bypass grafting. Patient had persistent cardiogenic shock postoperatively despite intra-aortic balloon pump and escalating pressor requirements. Electrocardiogram showed new ischemic changes and the patient was urgently taken to the catheterization lab for coronary angiography and placement of an Impella CP for higher degree of hemodynamic support via the left femoral artery. Due to limitations in vascular access the Impella CP sheath was utilized for vascular access for diagnostic angiography and coronary intervention concurrently with ongoing Impella CP support. The first obtuse marginal had severe proximal disease and was treated with percutaneous coronary intervention (PCI) with a drug eluting stent. To our knowledge, this case is the first in which successful diagnostic angiography as well as multi-vessel PCI was performed via an Impella sheath while concurrently using the percutaneous mechanical circulatory support system of the Impella CP. Multiple guide catheters and a pigtail catheter were successfully passed via the Impella CP sheath to perform PCI. This novel method of vascular access could be an important tool to use in high-risk patients with limitations in access sites and decrease potential bleeding complications by limiting the number of arterial punctures.
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Affiliation(s)
- Kris Kumar
- Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Sridhar Reddy
- Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Deepak Acharya
- Sarver Heart Center, University of Arizona, Tucson, Arizona
| | - Kapildeo Lotun
- Sarver Heart Center, University of Arizona, Tucson, Arizona
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292
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Nelson AJ, Ardissino M, Psaltis PJ. Current approach to the diagnosis of atherosclerotic coronary artery disease: more questions than answers. Ther Adv Chronic Dis 2019; 10:2040622319884819. [PMID: 31700595 PMCID: PMC6826912 DOI: 10.1177/2040622319884819] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/03/2019] [Indexed: 01/10/2023] Open
Abstract
Despite its commonality in routine clinical practice, the approach to a diagnosis of atherosclerotic coronary artery disease remains complex and, in part, contentious. The traditional dogma linking ischaemia to hard clinical outcomes has been questioned and reframed over the years; rather than being a predictor of hard clinical outcomes, the degree of ischaemia may simply be a marker of atherosclerotic disease burden. A renewed interest in the imaging of plaque burden has spawned the contemporary role of CT imaging for not only diagnosis and prognosis, but also for dictating downstream management. As the technology develops and evidence expands, decisions on investigative modalities remain centred around patient factors, local availability, test performance and cost. This review summarizes the available methods for diagnosis in the symptomatic patient and provides an overview of the current evidence behind functional and anatomical approaches.
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Affiliation(s)
- Adam J. Nelson
- Duke Clinical Research Institute, Durham, NC, USA
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Maddalena Ardissino
- Duke Clinical Research Institute, Durham, NC, USA
- School of Medicine, Imperial College, London, UK
| | - Peter J. Psaltis
- South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5005, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, Australia
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293
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Abstract
Transradial access (TRA) is favored over transfemoral access for performing coronary angiography and percutaneous coronary intervention due to the reduced risk for vascular and bleeding complications and the documented survival benefit in ST-segment–elevation myocardial infarction patients who undergo primary percutaneous coronary intervention. TRA complications can be categorized as intra- or postprocedural and further categorized as related to bleeding or nonbleeding issues. Major intra- and postprocedural complications such as radial artery perforation and compartment syndrome are rare following TRA. Their occurrence, however, can be associated with morbid consequences, including requirement for surgical intervention if not identified and treated promptly. Nonbleeding complications such as radial artery spasm and radial artery occlusion are typically less morbid but occur much more frequently. Strategies to prevent TRA complications are essential and include the use of contemporary access techniques that limit arterial injury. This document summarizes contemporary techniques to prevent, identify, and manage TRA complications.
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Affiliation(s)
- Yader Sandoval
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Malcolm R. Bell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Rajiv Gulati
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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294
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The Use of Radial Access for Cardiac Catheterization. JACC Cardiovasc Interv 2019; 12:2257-2259. [DOI: 10.1016/j.jcin.2019.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/25/2019] [Indexed: 11/21/2022]
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295
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Kopin D, Seth M, Sukul D, Dixon S, Aronow HD, Lee D, Tucciarone M, Pielsticker E, Gurm HS. Primary and Secondary Vascular Access Site Complications Associated With Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 12:2247-2256. [DOI: 10.1016/j.jcin.2019.05.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/01/2019] [Accepted: 05/28/2019] [Indexed: 11/25/2022]
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296
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Bernat I, Aminian A, Pancholy S, Mamas M, Gaudino M, Nolan J, Gilchrist IC, Saito S, Hahalis GN, Ziakas A, Louvard Y, Montalescot G, Sgueglia GA, van Leeuwen MA, Babunashvili AM, Valgimigli M, Rao SV, Bertrand OF. Best Practices for the Prevention of Radial Artery Occlusion After Transradial Diagnostic Angiography and Intervention. JACC Cardiovasc Interv 2019; 12:2235-2246. [DOI: 10.1016/j.jcin.2019.07.043] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 12/15/2022]
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297
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Left Distal Transradial Approach for Coronary Intervention: Insights from Early Clinical Experience and Future Directions. Cardiol Res Pract 2019; 2019:8671306. [PMID: 31781385 PMCID: PMC6874980 DOI: 10.1155/2019/8671306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/17/2019] [Accepted: 09/05/2019] [Indexed: 12/21/2022] Open
Abstract
Left distal transradial approach is a novel technique for coronary intervention. This technique is convenient for specialists to operate and welcomed for right-handed patients. The anatomical snuffbox and the first intermetacarpal are two available puncture sites on the basis of hand anatomy. In technical aspects, main differences between left distal transradial approach and conventional transradial approach are patient's special position, puncture procedure, sheath choice, and hemostasis methods. According to the preliminary data, this technique is feasible and safe and it has low rate of complications including radial artery occlusion in forearm. Left distal transradial approach is a quite promising strategy of coronary intervention and deserves further exploration. In this review article, we describe the main technical characteristics and the results obtained from early clinical experiences. We also discuss the main challenges and future perspectives on this novel technique.
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298
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Chen SH, Brunet MC, Sur S, Yavagal DR, Starke RM, Peterson EC. Feasibility of repeat transradial access for neuroendovascular procedures. J Neurointerv Surg 2019; 12:431-434. [DOI: 10.1136/neurintsurg-2019-015438] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/23/2019] [Accepted: 09/24/2019] [Indexed: 01/30/2023]
Abstract
IntroductionTransradial artery access (TRA) for cerebrovascular angiography is increasing due to decreased access site complications and overwhelming patient preference. While interventional cardiologists have reported up to 10 successive TRA procedures via the same radial access site, this is the first study examining successive use of the same artery for repeat procedures in neurointerventional procedures.1
MethodsWe reviewed our prospective institutional database for all patients who underwent a transradial neurointerventional procedure between 2015 and 2019. Index procedures were defined as procedures performed via TRA after which there was a second TRA procedure attempted. Reasons for conversion to a transfemoral approach (TFA) for subsequent procedures were identified.Results104 patients underwent 237 procedures (230 TRA, 7 TFA). 97 patients underwent ≥2 TRA procedures, 20 patients >3, four patients >4, three patients >5, and two patients >6 TRA procedures. The success rate was 94.7% (126/133) with 52% (66/126) of successive procedures performed via the same radial access site (snuffbox vs antebrachial) while the alternate radial artery segment was used for access in 48% (60/126) of subsequent procedures. There were seven (5.3%) cases requiring crossover to TFA, six cases for radial artery occlusion (RAO) and one for radial artery narrowing.ConclusionSuccessive TRA is both technically feasible and safe for neuroendovascular procedures in up to six procedures. The low failure rate (5.3%) was primarily due to RAO. Thus, even without clinical consequences, strategies to minimize RAO should be optimized for patients to continue to benefit from TRA in future procedures.
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299
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Chen SH, Brunet MC, Jankowitz BT, Jabbour P, Peterson EC. Letter: Commentary: Radial Artery Access for Treatment of Posterior Circulation Aneurysms Using the Pipeline Embolization Device: Case Series. Oper Neurosurg (Hagerstown) 2019; 17:E186-E187. [PMID: 31361017 DOI: 10.1093/ons/opz206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stephanie H Chen
- Department of Neurological Surgery Miller School of Medicine University of Miami Miami, Florida
| | - Marie-Christine Brunet
- Department of Neurological Surgery Miller School of Medicine University of Miami Miami, Florida
| | - Brian T Jankowitz
- Department of Neurosurgery University of Pittsburgh Medical Center Pittsburgh, Pennsylvania
| | - Pascal Jabbour
- Department of Neurological Surgery Thomas Jefferson University Philadelphia, Pennsylvania
| | - Eric C Peterson
- Department of Neurological Surgery Miller School of Medicine University of Miami Miami, Florida
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300
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Osbun JW, Patel B, Levitt MR, Yahanda AT, Shah A, Dlouhy KM, Thatcher JP, Chicoine MR, Kim LJ, Zipfel GJ. Transradial intraoperative cerebral angiography: a multicenter case series and technical report. J Neurointerv Surg 2019; 12:170-175. [PMID: 31484699 DOI: 10.1136/neurintsurg-2019-015207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Use of the radial artery as an access site for neurointerventional procedures is gaining popularity after several studies in interventional cardiology have demonstrated superior patient safety, decreased length of stay, and patient preference compared with femoral artery access. The transradial approach has yet to be characterized for intraoperative cerebral angiography. OBJECTIVE To report a multicenter experience on the use of radial artery access in intraoperative cerebral angiography, including case series and discussion of technical nuances. METHODS 27 patients underwent attempted transradial cerebral angiography betweenMay 2017 and May 2019. Data were collected regarding technique, patient positioning, vessels selected, technical success rate, and access site complications. RESULTS 24 of the 27 patients (88.8%) underwent successful transradial intraoperative cerebral angiography. 18 patients (66.7%) were positioned supine, 6 patients (22.2%) were positioned prone, 1 patient (3.7%) was positioned lateral, and 2 patients (7.4%) were positioned three-quarters prone. A total of 31 vessels were selected including 13 right carotid arteries (8 common, 1 external, 4 internal), 11 left carotid arteries (9 common and 2 internal), and 6 vertebral arteries (5 right and 1 left). Two patients (7.4%) required conversion to femoral access in order to complete the intraoperative angiogram (1 due to arterial vasospasm and 1 due to inadvertent venous catheterization). One procedure (3.7%) was aborted because of inability to obtain the appropriate fluoroscopic views due to patient positioning. No patient experienced stroke, arterial dissection, or access site complication. CONCLUSIONS Transradial intraoperative cerebral angiography is safe and feasible with potential for improved operating room workflow ergonomics, faster patient mobility in the postoperative period, and reduced costs.
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Affiliation(s)
- Joshua W Osbun
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Bhuvic Patel
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Michael R Levitt
- Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Alexander T Yahanda
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Amar Shah
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Kathleen M Dlouhy
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Joshua P Thatcher
- Mallinckrodt Institute of Radiology, Washington University, St Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Gregory J Zipfel
- Department of Neurosurgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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