"Combo" technique for the use of 7F guide catheter system during transradial approach

Sex differences in transradial access failure in ST segment elevation myocardial infarction

BACKGROUND

Transradial access (TRA) is now the default access site for PPCI, but technically is a more challenging approach mostly due to anatomic challenges connected to the RA.

AIMS

To assess the differences according to sex in radial artery (RA) access site characteristics during primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI).

MATERIAL AND METHODS

All 5092 consecutive STEMI patients from our center in the period from March 2011 until December 2017 were examined. The right proximal radial was the "intention-to-treat" access in all patients. Preprocedural RA angiography was performed in all patients. Clinical and procedure characteristics, type of radial anatomy variants, need to use another arterial access sites (the primary endpoint for this study), and procedure time were analyzed by sex. Using logistic regression, we selected predictors of radial crossover. Access site bleeding complications and vascular complications were also recorded.

RESULTS

The STEMI population in this period included 1326 females and 3766 male patients. Females were older (65 ± 11 years) than males (59 ± 11 years, p < 0.0001). Among standard risk factors, hypertension and diabetes mellitus were more common in women and smoking less common. RA anomalies were more frequent in the females (8.8% vs. 6.5%, p < 0.0001), with complex RA loop and tortuous RA twice as frequent in women. Failure of TRA access as the initially chosen site occurred in 4.6% (61) of females versus 2.5% (97) of male STEMI patients (p = 0.0003). The most common subsequent access site was right ulnar access in both groups (57 and 61% respectively). Access site bleeding complications were more common in women 4.4% versus 3.2%, mirrored in hematomas with EASY score III to V. Clinical RA spasm (RAS) was significantly more frequent in females (5.7% vs. 2.2%, p < 0.0001). Multiple regression analysis identified 5 independent predictors for TRA access crossover: previous TRA, anomalous RA, RAS, along with female sex and diabetes.

CONCLUSION

Female sex is a significant predictor of more complex TRA in STEMI. Understanding sex differences and predictors for TRA crossover will strengthen the use of different procedural modalities that can help in preserving a successful wrist access in female STEMI patients.

Vascular Assisted Tracking for Challenging Transradial Percutaneous Intervention

BACKGROUND

TRA is recommended as the preferred approach to perform coronary angiography and PCI. Despite this, TRA-PCI is burdened by a high access site crossover rate. Assisted-tracking techniques (balloon-assisted tracking and pigtail-assisted tracking) have showed to solve some of the issues related with challenging TRA procedures, but few data exist about procedural outcomes. Aim of the study was to evaluate the efficacy and safety of the assisted-tracking (AsTra) techniques during transradial (TRA) percutaneous coronary intervention (PCI).

METHODS

From January 2016 to December 2019, 1682 TRA-PCI procedures were performed. Starting from January 2018, AsTra techniques were adopted in 72 cases of challenging TRA-PCI, and clinical data, procedural results and 30 days follow-up data were retrospectively collected. Because not all interventionalists used AsTra techniques, we had the opportunity to evaluate if their utilization influenced TRA-PCI rates. To this purpose, we identified two groups of interventionalists and tested the hypothesis that these techniques could lead to a significant improvement in TRA-PCI rates.

RESULTS

Between January 2016 and December 2019, TRA-PCI rates increased from 68.5% to 95%. The TRA-PCI success rate increased significantly for interventionalists who adopted assisted-tracking techniques (p-value < 0.0001 for year 2019; p-value = 0.003 for year 2018).

CONCLUSIONS

Assisted-tracking techniques appear to be effective in increasing TRA-PCI rates. Their use is associated with low complication and low access crossover rates.

Transradial Artery Access in Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock

Early revascularization is the gold standard for management of patients with ST-elevation myocardial infarction (STEMI) and cardiogenic shock (CS). The use of transradial artery access (TRA) in percutaneous coronary intervention (PCI) has increased in recent years and has emerged as a safe and effective approach to PCI in high-risk patients, with advantages in reduced major bleeding events, other peri-procedural complications, and all-cause mortality when compared with transfemoral artery access (TFA). Multiple randomized clinical trials have demonstrated these advantages of TRA vs. TFA PCI in STEMI patients. Although there remains a lack of dedicated randomized trials in CS, observational data suggest benefits on the same endpoints as in STEMI with TRA vs. TFA PCI in CS. This review summarizes the existing literature on the use of TRA compared to TFA for STEMI and CS patients; the reduction of major bleeding events, other peri-procedural complications, and mortality associated with TRA in STEMI and CS; and technical considerations and challenges in the care of these high-risk patient populations.