Radial versus femoral approach for high-speed rotational atherectomy

Rotational atherectomy of calcified coronary lesions: current practice and insights from two randomized trials

With growing experience, technical improvements and use of newer generation drug-eluting stents (DES), recent data showed satisfactory acute and long-term results after rotational atherectomy (RA) in calcified coronary lesions. The randomized ROTAXUS and PREPARE-CALC trials compared RA to balloon-based strategies in two different time periods in the DES era. In this manuscript, we assessed the technical evolution in RA practice from a pooled analysis of the RA groups of both trials and established a link to further recent literature. Furthermore, we sought to summarize and analyze the available experience with RA in different patient and lesion subsets, and propose recommendations to improve RA practice. We also illustrated the combination of RA with other methods of lesion preparation. Finally, based on the available evidence, we propose a simple and practical approach to treat severely calcified lesions.

Rotational atherectomy via the transradial access: success rates, procedural parameters and complications

Radial access is recommended for percutaneous coronary intervention (PCI), but rotational atherectomy remains frequently performed via femoral access. Analyzing the procedural parameters, success rate and complications of rotational atherectomy, performed via radial in comparison to femoral access. We retrospectively analyzed 427 consecutive patients undergoing rotational atherectomy. Procedural parameters and outcome were determined in 171 patients, scheduled for radial and compared to 256 patients with femoral access use. In the radial access group (74 ± 9 years, 84% male), the LAD was most frequently treated (49%). Sheath size was 7F in 59% and 6F in 41%, burr size was 1.5 mm in 46% and 1.25 mm in 14% of patients. A temporary pacemaker was inserted in 14%. Procedural success rate stood at 97%. Access site complications occurred in 4% of patients, which was significantly less frequent than in in 256 patients treated via femoral access (13% p = 0.003). Compared to radial access, femoral access was associated with the use of larger sheaths (p < 0.001), more frequent treatment of non-LAD vessels (58.2% vs. 44.4%, p = 0.013) and a higher rate of temporary pacemaker use (27%; p = 0.001). No differences could be seen in procedural success (p = 0.83) and burr size (p = 0.51). Femoral access (OR 3.33; 95% CI 1.40–7.93), and female sex (OR3.40 95% CI 1.69–6.63) were independent predictors for access site complications. For coronary rotational atherectomy, radial access has a high success rate with overall use of smaller sheaths, but of equally sized burrs as well as a significant lower rate of access site-related complications than femoral access.

[Focus on high speed rotational atherectomy by Rotablator in 2021 and datas from France PCI registry]

Developed in the late 1980s, rotational atherectomy has raised a lot of hope for its innovative principle of selective ablation, allowing volume reduction (instead of redistribution) of atherosclerotic plaque, while sparing healthy tissue. Long shunned for its disappointing results on restenosis, the Rotablator finally reasserted itself in the 2000s; era of drug eluting stents and coronary angioplasty boom, thus generating emergence of complex lesions. Indeed, the Rotablator has demonstrated an undeniable benefit in complex (type C) and calcified lesions preparation (before stenting), with a procedural success rate of 95%. Although these lesions only represent a small amount (2-3%) of percutaneous coronary interventions (PCI), they remain a technical impasse for plain-old balloon angioplasty strategy, making the Rotablator more suitable for these resistant lesions' treatment. Registry data attest the safety of this therapy, with a rate of peri-procedural complications and in-hospital mortality comparable to conventional angioplasty (France PCI register). However, certain specific, rare but serious complications (burr entrapment, broken Rotawire, coronary perforation) justify trained teams, perfect knowledge of the equipment, and strict compliance with good practice guidelines. In 2018, the rise of a new method of atherectomy by intra-vascular lithotripsy (Shockwave) has coincided with Rotablator decreasing activity (this finding being biased by a general decrease in PCI activity due to Covid pandemic). This therapeutic range's enhancement revolutionizes calcified lesions treatment, tending towards precise targeting of each indication, depending in particular on calcium distribution's anatomy in the plaque.

Ultrasound evaluation of the radial artery in young adults - A pilot study

The radial artery is a vessel frequently used in various medical procedures which carry a risk of complications. One such method used to minimize the number of complications is a profound knowledge of the artery's diameter, which allows for appropriate selection of an instrument to use for puncture. The purpose of this study is to determine the diameter of the radial artery and its depth from the skin surface in young adults.

MATERIAL AND METHODS

96 volunteers participated in the study. The average age of the volunteers was 20.43 years. All participants underwent a B-mode ultrasonography to measure the distal radial artery's diameter. Certified anthropometric instruments were used to determine the relation between the artery diameter and the selected basic anthropometric parameters.

RESULTS

The mean right arterial diameter for the entire examined population at the level of the styloid process was mean 1.42 (SD 0.26) mm and its distance to the skin was mean 4.00 (SD1.20) mm. Statistical analysis revealed the presence of moderate positive relationship between the diameter of the radial artery and body weight and between the diameter of the radial artery and BMI. A weak correlation between the artery diameter and the width of the wrist was also present.

CONCLUSION

In the present work, we aimed to determine the dimensions of the distal section of the radial artery in young people free from symptoms of cardiovascular diseases. The obtained initial study results advise selecting instruments for vascular puncture individually, with special attention paid to slender people with slim wrists.

Breaking the deadlock of calcified coronary artery lesions: A contemporary review

Percutaneous coronary intervention (PCI) of severely calcified lesions is known to result in lower procedural success rates, higher complication rates, and worse long-term clinical outcomes compared to noncalcified lesions. Adequate lesion preparation through calcium modification is crucial in ensuring procedural success and reducing adverse cardiovascular outcomes. There are numerous calcium modification devices currently available whose usefulness depends on the nature of the calcific disease and its anatomical distribution. It can be challenging for the interventionists to decide which device is best suited for their patient. There is also emerging evidence for intravascular imaging in guiding selection of calcium modification devices using parameters such as calcium distribution and depth that directly impact on procedural success and clinical outcomes. In this review we aim to discuss the pathophysiology of coronary calcification, evaluate strategies and technologies of calcium modification and propose an A-M-A-S-A algorithm in managing calcified coronary lesions.

Rotational Atherectomy: A Contemporary Appraisal

Rotational atherectomy (RA) is an atheroablative technology that enables percutaneous coronary intervention for complex, calcified coronary lesions. RA works on the principle of 'differential cutting' and preferentially ablates hard, inelastic, calcified plaque. The objective of RA use has evolved from plaque debulking to plaque modification to enable balloon angioplasty and optimal stent expansion. The clinical experience over the past 30 years has informed the current best practices for RA with use of smaller burr sizes, short ablation runs a 'pecking' motion, and avoidance of sudden decelerations. This has led to significant improvements in procedural safety and a reduced rate of associated complications. This article reviews the principles, clinical indications, contemporary evidence, technical considerations and complications associated with the use of RA.

Transradial approach for coronary angiography and percutaneos coronary intervention: personal experience

BACKGROUND

The transradial approach (TRA) has already become popular worldwide, but only recently has gained acceptance among Iraqi interventional cardiologists. The aim of this study is to document single operator experience with TRA and to test the benefit of assessing dual hand circulation before the TRA. It was an observational prospective study. Over a 2-year period (Jan 1, 2015, to Dec 31, 2016), 1561 patients underwent transradial coronary angiography (CAG) and/or percutaneous coronary intervention (PCI) by a single operator. Patients were divided into two groups: A (the first 450 patients), in which dual hand circulation was assessed by Allen's test or plethysmography/oximetry test before TRA, and B (1111 patients) in which TRA was done without assessing dual hand circulation.

RESULTS

A total of 1561 patients were included, 69.1% males and 30.9% females. The mean age was (57 ± 10.0) years. We performed 1684 procedures (1005 CAG and 679 PCIs). The total transradial success rate was 95.6%, and PCI procedural success rate was 96.5%. The crossover rate from radial to femoral access was 4.4%. The primary causes for crossover were severe tortuosity of the aorta and brachiocephalic trunk, radial artery spasm, puncture failure, and radial loop. The main complication was radial artery occlusion (RAO) (3.7%). There were no cases of hand ischemia or complications that need surgical repair or blood transfusion. No statistically significant difference between groups A and B was observed regarding hand ischemia, the incidence of RAO, or the crossover rate.

CONCLUSIONS

TRA is safe and can be applied in the majority of cases. The routine assessment of dual hand circulation before TRA might not be necessary.

Transradial versus transfemoral approach for diagnostic coronary angiography and percutaneous coronary intervention in people with coronary artery disease

BACKGROUND

Cardiovascular disease (CVD) is the major cause of mortality worldwide. Coronary artery disease (CAD) contributes to half of mortalities caused by CVD. The mainstay of management of CAD is medical therapy and revascularisation. Revascularisation can be achieved via coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Peripheral arteries, such as the femoral or radial artery, provide the access to the coronary arteries to perform diagnostic or therapeutic (or both) procedures.

OBJECTIVES

To assess the benefits and harms of the transradial compared to the transfemoral approach in people with CAD undergoing diagnostic coronary angiography (CA) or PCI (or both).

SEARCH METHODS

We searched the following databases for randomised controlled trials on 10 October 2017: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science Core Collection. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in August 2017. There were no language restrictions. Reference lists were also checked and we contacted authors of included studies for further information.

SELECTION CRITERIA

We included randomised controlled trials that compared transradial and transfemoral approaches in adults (18 years of age or older) undergoing diagnostic CA or PCI (or both) for CAD.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. At least two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We contacted trial authors for missing information. We used risk ratio (RR) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). All analyses were checked by another author.

MAIN RESULTS

We identified 31 studies (44 reports) including 27,071 participants and two ongoing studies. The risk of bias in the studies was low or unclear for several domains. Compared to the transfemoral approach, the transradial approach reduced short-term net adverse clinical events (NACE) (i.e. assessed during hospitalisation and up to 30 days of follow-up) (RR 0.76, 95% CI 0.61 to 0.94; 17,133 participants; 4 studies; moderate quality evidence), cardiac death (RR 0.69, 95% CI 0.54 to 0.88; 11,170 participants; 11 studies; moderate quality evidence). However, short-term myocardial infarction was similar between both groups (RR 0.91, 95% CI 0.81 to 1.02; 19,430 participants; 11 studies; high quality evidence). The transradial approach had a lower procedural success rate (RR 0.97, 95% CI 0.96 to 0.98; 25,920 participants; 28 studies; moderate quality evidence), but was associated with a lower risk of all-cause mortality (RR 0.77, 95% CI 0.62 to 0.95; 18,955 participants; 10 studies; high quality evidence), bleeding (RR 0.54, 95% CI 0.40 to 0.74; 23,043 participants; 20 studies; low quality evidence), and access site complications (RR 0.36, 95% CI 0.22 to 0.59; 16,112 participants; 24 studies; low quality evidence).

AUTHORS' CONCLUSIONS

Transradial approach for diagnostic CA or PCI (or both) in CAD may reduce short-term NACE, cardiac death, all-cause mortality, bleeding, and access site complications. There is insufficient evidence regarding the long-term clinical outcomes (i.e. beyond 30 days of follow-up).

Temporal changes in radial access use, associates and outcomes in patients undergoing PCI using rotational atherectomy between 2007 and 2014: results from the British Cardiovascular Intervention Society national database

AIMS

Access site choice for cases requiring rotational atherectomy (PCI-ROTA) is poorly defined. Using the British Cardiovascular Intervention Society PCI database, temporal changes and contemporary associates/outcomes of access site choice for PCI-ROTA were studied.

METHODS AND RESULTS

Data were analysed from 11,444 PCI-ROTA procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes.

RESULTS

For PCI-ROTA, radial access increased from 19.6% in 2007 to 58.6% in 2014. Adoption of radial access was slower in females, those with prior CABG, and in patients with chronic occlusive (CTO) or left main disease. In 2013/14, the strongest predictors of femoral artery use were age (OR 1.02, [1.005-1.036], P = .008), CTO intervention (OR 1.95, [1.209-3.314], P = .006), and history of previous CABG (OR 1.68, [1.124-2.515], P = .010). Radial access was associated with reductions in overall length of stay, and increased rates of same-day discharge. Procedural success rates were similar although femoral access use was associated with increased access site complications (2.4 vs. 0.1%, P < .001). After adjustment for baseline differences, arterial complications (OR 15.6, P < .001), transfusion (OR 12.5, P = .023) and major bleeding OR 6.0, P < .001) remained more common with FA use. Adjusted mortality and MACE rates were similar in both groups.

CONCLUSIONS

In contemporary practice, radial access for PCI-ROTA results in similar procedural success when compared to femoral access but is associated with shorter length of stay, and lower rates of vascular complication, major bleeding and transfusion.

In patients undergoing percutaneous coronary intervention with rotational atherectomy radial access is safer and as efficient as femoral access

INTRODUCTION

Transfemoral approach (TFA) may be preferred access site in order to facilitate complex percutaneous procedures such as rotational atherectomy (RA). Notwithstanding, there is a growing evidence that transradial approach (TRA) is associated with lower access site complication rates and even lower mortality. The aim was to assess in-hospital and 1-year outcomes in patients undergoing RA using TRA, in comparison to TFA.

METHODS

A single center observational study included all consecutive patients, who underwent RA from 2010 to 2015. Primary endpoints were procedural success, in-hospital mortality and major adverse cardiovascular events (MACE). Secondary endpoints were 1-year all-cause mortality and MACE.

RESULTS

The study included 177 patients, 69% in TRA group and 31% in TFA group. Except for male sex and logistic Euroscore II there were no differences in common risk factors. There was no difference in procedural success (95% vs 87%, P = 0.07) with even a trend in favor of TRA. Performing RA via TRA lower amount of contrast volume (P = 0.009) was used and hospital stay after the procedure was shorter (P = 0.004). Periprocedural complication rates were similar, however patients with TFA had significantly higher rate of major access site bleedings (13% vs 1%, P = 0.001), with no differences in mortality and other adverse events both in-hospital and during 1-year observation.

CONCLUSIONS

Even though RA is a demanding technique, when performed via TRA allows to maintain the same procedural success and long-term results in comparison to TFA, reduces in-hospital major access site bleedings, lowers the amount of contrast media and shortens hospital stay.

Radial Versus Femoral Access for Rotational Atherectomy

Background—

Rotational atherectomy (RA) is an important interventional tool for heavily calcified coronary lesions. We compared the early clinical outcomes in patients undergoing RA using radial or femoral access.

Methods and Results—

We identified all patients in England and Wales who underwent RA between January 1, 2005, and March 31, 2014. Eight thousand six hundred twenty-two RA cases (3069 radial and 5553 femoral) were included in the analysis. The study primary outcome was 30-day mortality. Propensity scores were calculated to determine the factors associated with treatment assignment to radial or femoral access. Multivariable logistic regression analysis, using the calculated propensity scores, was performed. Thirty-day mortality was 2.2% in the radial and 2.3% in the femoral group ( P =0.76). Radial access was associated with equivalent 30-day mortality (adjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.77–1.46; P =0.71), procedural success (OR, 1.04; 95% CI, 0.84–1.29; P =0.73), major adverse cardiac and cerebrovascular events (OR, 1.05; 95% CI, 0.80–1.38; P =0.72), and net adverse clinical events (OR, 0.90; 95% CI, 0.71–1.15; P =0.41), but lower rates of in-hospital major bleeding (OR, 0.62; 95% CI, 0.40–0.98; P =0.04) and major access site complications (OR, 0.05; 95% CI, 0.01–0.38; P =0.004), compared with femoral access.

Conclusions—

In this large real-world study of patients undergoing RA, radial access was associated with equivalent 30-day mortality and procedural success, but reduced major bleeding and access site complications, compared with femoral access.

Controversies in complex percutaneous coronary intervention: radial versus femoral

INTRODUCTION

Evolution in the technology used in the cardiac catheterization laboratory has permitted a migration from the femoral to radial artery access for many interventional procedures while concurrently improving outcomes. As a disruptive technology, transradial access has been associated with several controversies including a dichotomous relationship with femoral access. Areas covered: Several different patient subsets along with perceived technical challenges in interventional cardiology are reviewed with regard to the issue of access site. Evolving technological improvements germane to transradial techniques are also discussed as garnered from the literature of recent clinical trials and reports. Expert commentary: Radial techniques have been enhanced by newer technology and the spread of knowledge. Fusion of radial techniques with those of the femoral approach is evolving into a unifying concept of using the access that is most appropriate for the patient. No one access technique can cover all clinical subsets of patients. There is a need for complimentary access skillsets for even the most advanced cardiovascular technology used in the cardiac catheterization laboratory if the patients' outcomes are to be idealized.

Treatment of calcified coronary artery lesions

Heavily calcified coronary plaques represent a complex lesion subset and a challenge to the interventional cardiologist, as they are often resistant to simple plaque modification with conventional balloon angioplasty. Inadequate plaque modification can lead to stent underdeployment, which itself predisposes to in-stent restenosis and stent thrombosis. Over the years, a number of mechanical devices ranging from modified angioplasty balloons to atherectomy devices have become available in order to tackle such lesions. Here we review these devices concentrating on the evidence behind their use.

Access site practice and procedural outcomes in relation to clinical presentation in 439,947 patients undergoing percutaneous coronary intervention in the United kingdom

OBJECTIVES

This study sought to determine the relationships among access site practice, clinical presentation, and procedural outcomes in a large patient population.

BACKGROUND

Transradial access (TRA) has been associated with improved patient outcomes in selected populations in randomized trials. It is unclear whether these outcomes are achievable in clinical practice.

METHODS

Using the BCIS (British Cardiovascular Intervention Society) database, we investigated outcomes for percutaneous coronary intervention procedures undertaken between 2007 and 2012 according to access site practice. Patients were categorized as stable, non-ST-segment elevation acute coronary syndrome (NSTEACS) and ST-elevation acute coronary syndrome (STEACS). The impact of access site on 30-day mortality, major adverse cardiac events, bleeding, and arterial access site complications was studied.

RESULTS

Data from 210,260 TRA and 229,687 transfemoral access procedures were analyzed. Following multivariate analysis, TRA was independently associated with a reduction in bleeding in all presenting syndromes (stable odds ratio [OR]: 0.24, p < 0.001; NSTEACS OR: 0.35, p < 0.001; STEACS OR: 0.47, p < 0.001) as well as access site complications (stable OR: 0.21, p < 0.001; NSTEACS OR: 0.19; STEACS OR: 0.16, p < 0.001). TRA was associated with reduced major adverse cardiac events only in patients with unstable syndromes (stable OR: 1.08, p = 0.25; NSTEACS OR: 0.72, p < 0.001; STEACS OR: 0.70, p < 0.001). TRA was associated with improved outcomes compared with a transfemoral access (TFA) with a vascular closure device in a propensity matched cohort.

CONCLUSIONS

In this large study, TRA is associated with reduced percutaneous coronary intervention-related complications in all patient groups and may reduce major adverse cardiac events and mortality in ACS patients. TRA is superior to transfemoral access with closure devices. Use of TRA may lead to important patient benefits in routine practice. TRA should be considered the preferred access site for percutaneous coronary intervention.

Rotational atherectomy: Technical update

Percutaneous coronary intervention is currently the most common form of revascularization for symptomatic coronary artery disease. In elderly, diabetic and renal patients, there is an increased prevalence of calcified coronary disease. Rotational atherectomy (RA) can be useful in the treatment of these lesions. Plaque removal was initially proposed as an alternative to balloon angioplasty, hence RA required high-velocity protocols with large-sized burrs (over 2.0 mm). With a high incidence of acute complications and disappointing restenosis rates, the use of RA dwindled. However, the advent of drug-eluting stents, which significantly decreased the rate of restenosis, led to the repositioning of RA as an adjunctive technique in the preparation of densely calcified lesions, improving stent delivery and expansion. In recent years, a better understanding of the mechanism of action of RA has changed it from a plaque debulking to a compliance modifying technique. As a result, RA has become less aggressive, using smaller size burrs and lower rotational speeds. This conservative approach has improved immediate results, with increased safety and better long-term outcomes. In this review paper, the technique of RA is explained in the light of current knowledge.

Complete "in situ" avulsion of the radial artery complicating transradial coronary rotational atherectomy

BACKGROUND

Transradial percutaneous access (TR) is promoted because of increased patient comfort and convenience as well as a lower risk of access site and cardiac complications in the literature. Increased use of the TR purports a new set of possible complications for which the vascular surgeon must be capable to recognize and manage.

METHODS

A 48-year-old, devout Jehovah's Witness, woman with a history of coronary artery bypass surgery presented with a non-ST-segment elevation acute myocardial infarction. Pretransfer catheterization demonstrated a heavily calcified, 90% distal left main stenosis with an occluded left internal mammary artery graft to the left anterior descending coronary artery. To minimize the risk of bleeding requiring a blood transfusion, a coronary rotational atherectomy via a TR was performed. A nonhydrophilic, 7F sheath was used to accommodate the larger rotational atherectomy burr sizes. The coronary procedure was successful, but the sheath removal was complicated by significant resistance to pullback while the patient complained of severe pain. Post procedure she developed a hematoma with motor and neurological deficits of her hand.

RESULTS

Emergent surgical exploration with fasciotomy was planned. The radial artery was explored and found to be redundant and pulseless, prompting proximal evaluation and revealing complete avulsion of the radial artery at its origin. An intraoperative arteriogram revealed that the brachial and ulnar arteries and interosseous branches were patent and filled the palmar arch and surgical ligation of the radial artery was conducted.

CONCLUSION

Vascular surgeons need to be aware of potential complications related to TR which are likely to increase as this method is more widely disseminated.

Transradial approach to cardiovascular interventions: an update

Background Since the first cardiac catheterization in 1929, the procedure has continually evolved with advances in understanding, capabilities, and ease of operation. Though historically performed by cut down of the brachial artery, cardiologists soon learned that transfemoral access was both easier to perform and more efficacious with regard to patient outcome. In the last 20 years, the transradial approach has been adopted, and is being utilized with increasing frequency. Methods We conducted a survey of literature published concerning safety, efficacy, cost-effectiveness, and global uptake of transradial catheterization with specific attention to how transradial interventions compare with transfemoral interventions. Results This review of literature indicates that when performed by an experienced interventionalist, radial catheterization is as effective as femoral catheterization and has additional benefits of shorter length of hospital stay and reduced patient costs. Transradial access is superior to transfemoral access in some, but not all, clinical scenarios; in addition, it is an effective alternative for catheterization in patients contraindicated for transfemoral procedures. Adoption of radial access in the United States is at a faster rate than previously expected, though rate of use varies drastically worldwide. Conclusion The transradial approach is an excellent option for carrying out cardiovascular interventions, and will be adopted by more cardiologists in the upcoming years.

Percutaneous transluminal rotational atherectomy for coronary artery disease

BACKGROUND

This is an update of the review on 'Percutaneous transluminal rotational atherectomy for coronary artery disease' first published in The Cochrane Library Issue 4, 2003. Percutaneous transluminal coronary rotational atherectomy (PTCRA) debulks atherosclerotic plaque from coronary arteries using an abrasive burr. On rotation, the burr selectively removes hard tissue. PTCRA has been used both as an alternative to and in conjunction with balloon angioplasty to open up blocked coronary arteries. Its ongoing effectiveness and safety compared with other modes of removing atherosclerotic plaques is reviewed. 

OBJECTIVES

To assess the effects of PTCRA for coronary artery disease in patients with non-complex and complex lesions (e.g. ostial, long or diffuse lesions or those arising from in-stent re-stenosis) of the coronary arteries.

SEARCH METHODS

For the original review, we searched the Heart Group Specialised Register; The Cochrane Library to Issue 2, 2001; and MEDLINE, CINAHL, EMBASE and Current Contents to December 2002 and reviewed reference lists for relevant articles. For the current review, we searched the same registries from 2002 to 2012 and reviewed reference lists for relevant articles. 

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials of PTCRA compared with placebo, no treatment or another intervention and excluded cross-over trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of the studies identified. Data were extracted independently by two review authors. We asked authors of trials to provide information when missing data were encountered. Statistical summaries used risk ratios (RR) and weighted mean differences.

MAIN RESULTS

We included 12 trials enrolling 3474 patients. The overall risk of bias was unclear for the majority of articles due to a lack of reported data; however, the authors determined that this would be unlikely to impact negatively as most data outcomes were objective (e.g. death vs. no death). There was no evidence of the effectiveness in improving patient outcomes of PTCRA in non-complex lesions. In complex lesions, there were no statistically significant differences in re-stenosis rates at six months (RR 1.05; 95% confidence interval (CI) 0.83 to 1.33) and at one year (RR 1.21; 95% CI 0.95 to 1.55) in those receiving PTCRA with adjunctive balloon angioplasty (PTCA) (PTCRA/PTCA) compared to those receiving PTCA alone. Morphological characteristics distinguishing complex lesions have not been examined in parallel-arm randomised controlled trials. The evidence for the effectiveness of PTCRA in in-stent re-stenosis is unclearCompared to angioplasty alone, PTCRA/PTCA did not result in a statistically significant increase in the risk of major adverse cardiac events (myocardial infarction (MI), emergency cardiac surgery or death) during the in-hospital period (RR 1.27; 95% CI 0.86 to 1.90). Compared to angioplasty, PTCRA was associated with nine times the risk of an angiographically detectable vascular spasm (RR 9.23; 95% CI 4.61 to 18.47), four times the risk of perforation (RR 4.28; 95% CI 0.92 to 19.83) and about twice the risk of transient vessel occlusions (RR 2.49; 95% CI 1.25 to 4.99) while angiographic dissections (RR 0.48; 95% CI 0.34 to 0.68) and stents used as a bailout procedure (RR 0.29; 95% CI 0.09 to 0.87) were less common.

AUTHORS' CONCLUSIONS

When conventional PTCA is feasible, PTCRA appears to confer no additional benefits. There is limited published evidence and no long-term data to support the routine use of PTCRA in in-stent re-stenosis. Compared to angioplasty alone, PTCRA/PTCA did not result in a higher incidence of major adverse cardiac events, but patients were more likely to experience vascular spasm, perforation and transient vessel occlusion. In certain circumstances (e.g. patients ineligible for cardiac surgery, those with architecturally complex lesions, or those with lesions that fail PTCA), PTCRA may achieve satisfactory re-vascularisation in subsequent procedures.

[The indispensable instrument for rotational atherectomy]

Rotational atherectomy is the treatment of choice for calcified coronary lesions. It should not be used routinely but only in some appropriate cases, especially when the successful deployment of a stent may be uncertain. Complications are rare but serious. Several cases of "off label" use, however, have been reported in the literature without additional complications.

Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis

BACKGROUND

Despite lower risks of access site-related complications with transradial approach (TRA), its clinical benefit for percutaneous coronary intervention (PCI) is uncertain. We conducted a systematic review and meta-analysis of clinical studies comparing TRA and transfemoral approach (TFA) for PCI.

METHODS

Randomized trials and observational studies (1993-2011) comparing TRA with TFA for PCI with reports of ischemic and bleeding outcomes were included. Crude and adjusted (for age and sex) odds ratios (OR) were estimated by a hierarchical Bayesian random-effects model with prespecified stratification for observational and randomized designs. The primary outcomes were rates of death, combined incidence of death or myocardial infarction, bleeding, and transfusions, early (≤ 30 days) and late after PCI.

RESULTS

We collected data from 76 studies (15 randomized, 61 observational) involving a total of 761,919 patients. Compared with TFA, TRA was associated with a 78% reduction in bleeding (OR 0.22, 95% credible interval [CrI] 0.16-0.29) and 80% in transfusions (OR 0.20, 95% CrI 0.11-0.32). These findings were consistent in both randomized and observational studies. Early after PCI, there was a 44% reduction of mortality with TRA (OR 0.56, 95% CrI 0.45-0.67), although the effect was mainly due to observational studies (OR 0.52, 95% CrI 0.40-0.63, adjusted OR 0.49 [95% CrI 0.37-0.60]), with an OR of 0.80 (95% CrI 0.49-1.23) in randomized trials.

CONCLUSION

Our results combining observational and randomized studies show that PCI performed by TRA is associated with substantially less risks of bleeding and transfusions compared with TFA. Benefit on the incidence of death or combined death or myocardial infarction is found in observational studies but remains inconclusive in randomized trials.

Successful removal of an entrapped rotablation burr by extracting drive shaft sheath followed by balloon dilatation

Burr entrapment is a rare but serious complication during rotational atherectomy (RA). Although emergent surgical removal is a reliable option for this complication, surgical removal is invasive and takes several hours. Balloon inflation just proximal to the burr was the previously-reported nonsurgical option for burr removal. However, this method needed large guide catheter lumen (≥8 Fr). We present a case of 67-year-old male on chronic hemodialysis. During RA for severe stenosis of the right coronary artery, the RA burr was entrapped. We cut off the drive shaft, the drive shaft sheath, and the RA wire together near the advancer, and then we removed the drive shaft sheath. After removing the drive shaft sheath, the 2.5 mm balloon easily entered the 7-Fr guide catheter. We inflated that balloon to a pressure of 18 atm. The burr was easily removed immediately after balloon deflation. Removal of the drive shaft sheath following balloon dilatation is a new, nonsurgical bailout method for a burr that becomes entrapped during RA. Since removal of the drive shaft sheath following balloon dilatation can be applied to 7 Fr as well as 6 Fr guide systems, this method may be of considerable benefit when operators use 7 Fr or 6 Fr systems.

Drilling through impacted ureteral stones: use of the atherectomy rotablator device for urolithiasis

BACKGROUND AND PURPOSE

The Rotablator is an angioplasty device that is passed over a wire. It uses a high-speed rotational "burr" (2 mm in diameter) that is coated with microscopic diamond particles and cooled by saline. It rotates at high speed (approximately 200,000 rpm) breaking up endovascular blockage into minute (smaller than red blood cells) fragments. We investigated, in vitro and ex vivo, the possible use of the Rotablator for urinary stone disease.

MATERIALS AND METHODS

Human stones of different sizes and composition were used for the experiment. Stone impaction in vitro was modeled by wedging the stones into the proximal part of a 16F silicone Foley catheter. Likewise, an ex-vivo study was performed on stones placed into a freshly harvested swine ureter using a nitinol basket. Data regarding the drill time, remaining stone size, and ureteral damage were collected.

RESULTS

Overall, 15 stones were treated (10 in vitro and 5 ex vivo). The device successfully drilled through all the stones, along the path of the guidewire, allowing complete passage of the burr. The pretreatment mean stone size for the silicone and ureteral testing was 65 mm(3) and 34 mm(3), respectively (both P < 0.01). The post-treatment size was 54 mm(3) and 24 mm(3), respectively. Average treatment time was 100 seconds. No visual macroscopic ureteral damage or perforation was observed.

CONCLUSIONS

In vitro, the Rotablator is capable of drilling through stones with minimal damage. Drilling, however, occurred alongside the stone in which the guidewire was located and, thus, stone fragmentation appears to be minimal. Further studies are necessary to investigate other burr configurations and the use of the Rotablator for the fluoroscopic-guided passage of ureteral impaction in difficult clinical settings.

Brachial Approach for Coronary Angiography and Intervention: Totally Obsolete, or a Feasible Alternative When Radial Access is Not Possible?

Introduction: This study aims to assess the safety and feasibility of brachial arterial puncture for coronary procedures when radial access is not possible. Radial arterial approach is the usual option for coronary procedures in our hospital. Whenever radial access is not possible, the brachial approach is preferred instead of the femoral approach. As many clinicians considered percutaneous brachial coronary angiography as an obsolete and hazardous procedure, we carried out this study to compare the outcomes of the brachial approach to the femoral approach in our centre. Materials and Methods: We retrospectively evaluated all cases of brachial artery puncture and femoral artery puncture in our centre from 1 January 2007 to 31 March 2009 through a prospectively collected database and looked for all complications which occurred in both groups. Results: The femoral group had a slightly higher incidence of major complications – 3 out of 121 cases (2.5%) in the femoral group and 1 out of 180 cases (0.6%) in the brachial group, even though this was not statistically significant (P = 0.15). There was also no difference between these 2 groups for minor complications: 8 patients (4.4%) in the brachial group and 6 patients (5%) in the femoral group developed haematoma that did not require any blood transfusion or surgery. There was no incidence of brachial artery thrombosis and no puncture-related neurological deficit documented in the brachial group. Conclusion: Brachial artery puncture and catheterisation may be a viable, safe and efficient alternative to the transfemoral approach in a centre that is experienced with the arm approach, when radial access is not possible. Key words: Angiography, Complications, Diagnostic cardiac catheterisation, Percutaneous coronary intervention

[Radial difficulties during percutaneous coronary intervention]

The transradial approach is the main route in France to perform percutaneous coronary intervention, reaching nearly 60% of the cases in 2008. Its proven benefit in reducing bleeding complications and therefore its impact on morbidity and mortality are now well documented. However, a definite learning curve is necessary in relation with specifics challenges. Radial spasm and anatomical variations are the main reasons to explain failures encountered during its implementation. In order to increase success procedure, these difficulties and the ways to overcome them must be well-known. Finally, success rate is now comparable to the classical femoral approach.