Transradial approach for coronary angiography and intervention in the elderly: A meta-analysis of 777,841 patients

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Comparison of Transradial Access and Transfemoral Access for Diagnostic Cerebral Angiography in the Elderly Population

OBJECTIVE

Evaluate the efficacy, safety, and patient satisfaction of transradial access (TRA) compared with conventional transfemoral access (TFA) for diagnostic cerebral angiography in elderly patients (≥65 years of age).

METHODS

We performed a retrospective review of patients receiving cerebral angiography via TRA or TFA between October 2020 and December 2021 at 3 institutions. Basic patient characteristics, angiographic data, postoperative complications, and patient satisfaction were collected for analysis.

RESULTS

Of the 357 enrolled elderly patients, 175 were performed through TRA and 182 were performed through TFA. There was no significant difference in mean fluoroscopy time (8.6 ± 3.8 minutes vs. 9.1 ± 3.1 minutes; P = 0.103) and radiation exposure (47.7 ± 10.8 Gy-cm2 vs. 49.8 ± 11.3 Gy-cm2; P = 0.068) between the TRA and TFA groups. However, the TRA group had a shorter procedural time (54.7 ± 6.2 minutes vs. 61.1 ± 5.6 minutes; P < 0.001) and less contrast agent (83.2 ± 28.1 mL vs. 100.1 ± 26.2 mL; P < 0.001) than the TFA group. In terms of safety, the incidence of minor vascular access complications in the TRA group was lower than that in the TFA group (1.7% vs. 8.8%; P = 0.003). The incidence of serious complications and neurologic complications in the TRA group was also lower, although the difference was not statistically significant. Overall patient satisfaction was higher in the TRA group than that in the TFA group.

CONCLUSIONS

TRA was an efficient and safe alternative to conventional TFA in elderly patients who underwent diagnostic cerebral angiography and who underwent TRA were more satisfied. Findings supported the radial-first strategy for cerebral angiography in elderly populations.

Transradial intra-aortic catheter looping in the angioplasty of severe intracranial symptomatic arteriosclerotic diseases

Purpose

This study aims to investigate the effect and feasibility of intra-aortic catheter looping via transradial access in angioplasty for symptomatic intracranial severe (>70%) atherosclerotic stenosis or occlusion of large arteries (SISOLAs).

Materials and methods

Patients with SISOLAs who underwent transradial endovascular angioplasty using the catheter looping technique in the ascending aorta were retrospectively enrolled. The clinical data and treatment outcomes were analyzed.

Results

Fifteen patients aged 48-71 years were enrolled in this study. Left vertebrobasilar artery occlusion was present in 1 (6.7%) patient, severe left middle cerebral artery stenosis in 7 (46.7%) patients, severe left internal carotid artery (ICA) stenosis of the ophthalmic segment in 4 (26.7%) patients, severe left ICA stenosis of the cavernous segment in 2 (13.3%) patients, and severe right middle cerebral artery stenosis in 2 (13.3%) patients. The arterial stenosis ranged from 70 to 92% (mean 86%) before stenting. The looping of a guiding catheter in the ascending aorta via transradial access for angioplasty was successful in all patients (100%). The vertebral artery intracranial segment occlusion was successfully recanalized, while severe stenosis in the remaining 14 patients was successfully eliminated. After endovascular recanalization, the residual stenosis was reduced by 12-26% (median 18%). No puncture-related complications or surgical-related neurological complications occurred in these patients. In the follow-up angiography conducted on 10 (66.7%) patients after 6-25 months, no in-stent restenosis was detected.

Conclusion

Intra-aortic guiding catheter looping via transradial access for endovascular angioplasty of SISOLAs is technically safe, feasible, and effective, especially when the transfemoral artery approach is difficult or impossible to undertake.

Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note

BACKGROUND

Due to prohibitive perioperative risk factors, optimal treatment for chronic subdural hematomas (cSDH) in the elderly remains unclear. Minimally invasive techniques are a viable option and include bedside subdural evacuation port system (SEPS), as well as prevention of recurrence with middle meningeal artery (MMA) embolization. We present a case series of elderly patients undergoing combined transradial MMA embolization and bed-side craniostomy as primary treatment for cSDH.

METHODS

Patients 70 years and older from 2019 to 2020 that underwent single setting, awake transradial MMA embolization with concurrent SEPS placement under local anesthesia were included. Those with prior treatments, interventions performed under general anesthesia, or with less than 60-day follow-up were excluded. Descriptive analyses of baseline characteristics, radiologic parameters, comorbidities, and outcome measures were completed.

RESULTS

Twenty elderly patients (mean age of 81.0 years) with multiple comorbidities underwent 28 MMA embolization+SEPS procedures as primary treatment for cSDH. Mean cSDH thickness was 1.8cm±0.6 cm with 7.3±3.9 mm midline shift. All patients tolerated the procedure well. 1/20 (5.0%) patients died within 30 days of the procedure. A majority of patients were discharged to home (12/20; 60.0%). There was an average of 3.6-month follow-up and one patient (5.0%) developed recurrence in the follow-up period requiring further intervention.

CONCLUSIONS

In select elderly patients with high perioperative risk factors, primary treatment of cSDH using awake transradial MMA embolization+SEPS placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment.

Four French sheath-based transradial cerebral angiographies in the elderly: A single neurointerventionalist's experience

BACKGROUND

Catheter angiography via transradial access (TRA) is better at reducing access site complications and morbidity than via transfemoral access (TFA). The rate of periprocedural complications increases in elderly populations and using a smaller sheath can help reduce access site complications. The aim of this study was to assess the feasibility and safety of 4 F sheath-based TRA cerebral angiography in elderly patients (≥65 years) and compare it to TFA cerebral angiography.

METHODS

The medical records of elderly patients undergoing diagnostic cerebral angiography with a single neurointerventionalist via TRA (57 cases, from July 2019 to December 2020) versus TFA (69 cases, from January 2018 to June 2019) were retrospectively reviewed. All TRA angiographies were performed via right radial artery access with a 4 F sheath and a 4 F Simmons 2 catheter.

RESULTS

There were no significant differences (TRA vs. TFA) in age (71.1 ± 4.0 vs. 72.1 ± 4.6 years, p = 0.189), accessed vessels (3.9 ± 0.5 vs. 3.9 ± 0.6, p = 0.852), fluoroscopy time (7.1 ± 3.3 vs. 7.6 ± 3.5 min, p = 0.068), and radiation exposure (42.1 ± 15.8 vs. 47.0 ± 13.7 Gy-cm2, p = 0.067). However, the procedure duration was significantly shorter in the TRA group (17.2 ± 3.9 vs. 19.0 ± 6.0 min, p = 0.003). Painful groin hematoma occurred in 2 of the 69 cases (2.9%) in the TFA group. In the TRA group, access site complications were not occurred; however, catheter kinks occurred in 2 of 57 cases (3.5%).

CONCLUSIONS

The 4 F sheath-based TRA is a feasible option for diagnostic cerebral angiography in elderly patients. However, care should be taken during catheter manipulation.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A novel technique to perform cerebral angiography via the left radial approach: An 80 patients series

PURPOSE

To demonstrate that left radial access for diagnostic cerebral angiography with Extra backup and 4F vertebral catheters is feasible and safe.

MATERIALS AND METHODS

This study is a retrospective review of our prospective database on left radial access for cerebral angiography procedures, using an extra backup catheter associated with a 4Fr vertebral catheter, performed between March and September 2019. Patient demographics, procedural and radiographic metrics as well as clinical data were recorded.

RESULTS

Seventy five patients with mean age of 51...years (range 21...73) underwent 80 cerebral angiographies. An average of four vessels were catheterized and mean fluoroscopy times per subject and vessel were was of 13.9 and 3.3...min, respectively. One patient required crossover to transfemoral access because of radial artery spasm. There were one asymptomatic distal radial artery occlusion and one patient presenting with asymptomatic skin blanching area on the forearm, just proximal to the tip of the sheath, that spontaneously resolved within an hour.

CONCLUSION

Diagnostic cerebral angiography via left radial access is feasible and safe and allows to preserve the right radial access for future neurointerventions while providing more comfort to the right handed patient.

Transradial access with intra-aortic catheter looping for the treatment of intracranial aneurysms

Purpose

The study aimed to investigate the feasibility and effect of transradial access with intra-aortic catheter looping for the treatment of intracranial aneurysms.

Materials and methods

This retrospective one-center study was performed on patients with intracranial aneurysms which were embolized through transradial access with intra-aortic catheter looping because of the difficulty of transfemoral access or transradial access without intra-aortic catheter looping. The imaging and clinical data were analyzed.

Results

A total of 11 patients were enrolled, including seven (63.6%) male patients. Most patients were associated with one or two risk factors of atherosclerosis. There were nine aneurysms in the left internal carotid artery system and two aneurysms in the right internal carotid artery system. All 11 patients had complications with different anatomic variations or vascular diseases, which made endovascular operation via the transfemoral artery difficult or a failure. The right transradial artery approach was adopted in all patients, and the success rate of intra-aortic catheter looping was 100%. Embolization of intracranial aneurysms was successfully completed in all patients. No instability of the guide catheter was encountered. No puncture site complications or surgical-related neurological complications occurred.

Conclusion

Transradial access with intra-aortic catheter looping for embolization of intracranial aneurysms is technically feasible, safe, and efficient as an important supplementary approach to the routine transfemoral access or transradial access without intra-aortic catheter looping.

Rate of periprocedural stroke in diagnostic cerebral angiograms comparing transradial versus transfemoral access

PURPOSE

Transradial access for neurointerventional procedures has increased in popularity over the past few years due to data from extrapolated interventional cardiology studies, patient preference, and early reports of feasibility using this approach. Our aim was to evaluate the incidence of periprocedural stroke in patients undergoing transradial versus transfemoral access for diagnostic cerebral angiograms.

METHODS

We retrospectively reviewed our neurointerventional database and identified all patients who underwent a diagnostic angiogram between May 2019 and July 2021. Patients were further divided into transradial versus transfemoral access. In patients with postprocedural stroke, symptoms and National Institute of Health Stroke Scale score were recorded. Pertinent laboratory values and procedural data was reviewed, including COVID status, platelet count, International normalized ratio (INR), Glomerular filtration rate (GFR), vessels catheterized, amount of contrast used, and fluoroscopy time. Imaging work-up for stroke symptoms was reviewed, if available.

RESULTS

Thousand two-hundred thirty eight diagnostic cerebral angiograms with 656 patients (53%) undergoing transradial access. Stroke symptoms after angiogram were only observed in the transradial group (5 patients; 0.4% total and 0.8% among radial access cases, respectively). Symptoms included word finding difficulty, paresthesia, or weakness. Three patients underwent cross-sectional imaging, computed tomography was negative in all three patients. Magnetic resonance imaging showed small, scattered infarcts in two patients. All symptoms resolved without additional hospitalization.

CONCLUSION

In our experience, using transradial access for diagnostic cerebral angiograms was associated with a low but not negligible incidence of periprocedural strokes. Patient anatomy should be evaluated prior to selection of vascular access. Patients should be made aware of a slightly higher periprocedural stroke risk with transradial access.

Age Considerations in the Invasive Management of Acute Coronary Syndromes

The elderly constitute a major proportion of patients admitted with acute coronary syndrome (ACS) in the US. Due to pre-existing comorbidities, frailty, and increased risk of complications from medical and invasive therapies, management of ACS in the elderly population poses challenges. In patients with ST-elevation MI, urgent revascularization with primary percutaneous coronary intervention remains the standard of care irrespective of age. However, an early invasive approach in elderly patients with non-ST-elevation MI is based on individual evaluation of risks versus benefits. In this review, the authors discuss the unique characteristics of elderly patients presenting with ACS, specific geriatric conditions that need to be considered while making treatment decisions in these situations, and available evidence, current guidelines, and future directions for invasive management of elderly patients with ACS.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Comparison of radiation exposure and clinical outcomes between transradial and transfemoral diagnostic cerebral approaches: a retrospective study

OBJECTIVE

To identify and compare patient and procedural variables that are associated with a high radiation dose exposure and worse clinical outcomes between transradial arterial (TRA) and transfemoral arterial (TFA) approaches.

DESIGN

This was a retrospective analysis.

SETTING

A community hospital during the initial phase of adopting a TRA-first approach.

PARTICIPANTS

A resultant 215 subjects who only underwent diagnostic cerebral angiograms (DCA) after excluding all therapeutic procedures and patients under 18 years.

INTERVENTIONS

Only DCA from 1 May 2018 to 31 January 2021.

MAIN OUTCOME MEASURES

We compared radiation exposure parameters (total fluoroscopy time (FT), total radiation dose (TD) and dose area product (DAP), number of vessels injected and Patient-Reported Global Health Physical and Mental Outcome Scores (PROGHS) at 30 days postprocedure between groups.

RESULTS

FT was significantly greater in TRA compared with TFA (p<0.001). In addition, TRA had a significantly higher TD (p=0.002) and DAP (p=0.005) when compared with TFA. Analysis of only 6-vessel DCAs also showed that TRA had a significantly higher FT, DAP and TD in comparison to TFA. Despite observing a longer FT in TRA, results showed fewer vessels injected and a notably lower success rate in acquiring a 6-vessel DCA using the TRA. Further analysis of the effect of vessel number on FT using general linear models showed that with every increase of one vessel, the FT increases by 2.2 min for TRA (p<0.001; 95% CI 1.03 to 3.36) and by 1.3 min for TFA (p<0.001; 95% CI 0.72 to 1.83). There was no significant difference between groups in PROGHS mental and physical t-scores at 30 days postprocedure, even though our cohort showed a significantly greater percentage of TRA procedures done in the outpatient setting.

CONCLUSIONS

Adopting a TRA first approach for DCAs may be initially associated with a higher radiation dose for the patient. Better strategies and devices are needed to mitigate this effect.

Complications of transradial versus transfemoral access for neuroendovascular procedures: a meta-analysis

BACKGROUND

Transradial access (TRA) has gained increased usage among neurointerventionalists. However, the overall safety profile of access site complications (ASCs) and non-access site complications (NASCs) of TRA versus transfemoral access (TFA) for neuroendovascular procedures remains unclear.

METHODS

A systematic literature review and meta-analysis using a random effects model was conducted to investigate the pooled odds ratios (OR) of ASCs and NASCs. Randomized, case-control, and cohort studies comparing access-related complications were analyzed. An assessment of study heterogeneity and publication bias was also completed.

RESULTS

Seventeen comparative studies met the inclusion criteria for final analysis. Overall, there was a composite ASC rate of 1.8% (49/2767) versus 3.2% (168/5222) for TRA and TFA, respectively (P<0.001). TRA was associated with a lower odds of ASC compared with TFA (OR 0.42; 95% CI 0.25 to 0.68, P<0.001, I²=31%). There was significantly lower odds of complications within the intervention and diagnostic subgroups. For NASC, TRA had a lower composite incidence of complications than TFA at 1.2% (31/2586) versus 4.2% (207/4909), P<0.001). However, on meta-analysis, we found no significant difference overall between TRA and TFA for NASCs (OR 0.79; 95% CI 0.51 to 1.22, P=0.28, I²=0%), which was also the case on subgroup analysis.

CONCLUSION

On meta-analysis, the current literature indicates that TRA is associated with a lower incidence of ASCs compared with TFA, but is not associated with a lower rate of NASCs.

Association Between Radial Versus Femoral Access for Percutaneous Coronary Intervention and Long-Term Mortality

Background

Percutaneous coronary intervention with radial arterial access has been associated with fewer occurrences of major bleeding. However, published data on the long‐term mortality and major adverse cardiac events after percutaneous coronary intervention with radial or femoral arterial access are inconclusive.

Method and Results

This was a territory‐wide retrospective cohort study including 26 022 patients who underwent first‐ever percutaneous coronary intervention between January 1, 2010 and December 31, 2017 in Hong Kong. Among the 14 614 patients matched by propensity score (7307 patients in each group), 558 (7.6%) and 787 (10.8%) patients died during the observation period in the radial group and femoral group, respectively, resulting in annualized all‐cause mortality rates of 2.69% and 3.87%, respectively. The radial group had a lower risk of all‐cause mortality compared with the femoral group up to 3 years after percutaneous coronary intervention (hazard ratio [HR], 0.70; 95% CI, 0.63–0.78; P<0.001). Radial access was associated with a lower risk of major adverse cardiac events (HR, 0.78; 95% CI, 0.73–0.83, P<0.001), myocardial infarction after hospital discharge (HR, 0.78; 95% CI, 0.70–0.87, P<0.001), and unplanned revascularization (HR, 0.76; 95% CI, 0.68–0.85, P<0.001). The risks of stroke were similar across the 2 groups (HR, 0.96; 95% CI, 0.82–1.13, P=0.655).

Conclusions

Radial access was associated with a significant reduction in all‐cause mortality at 3 years compared with femoral access. Radial access was associated with reduced risks of myocardial infarction and unplanned revascularization, but not stroke. The benefits were sustained beyond the early postoperative period.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Anatomic Snuffbox (Distal Radial Artery) and Radial Artery Access for Treatment of Intracranial Aneurysms with FDA-Approved Flow Diverters

BACKGROUND AND PURPOSE

Transradial access for neurointerventional procedures has been proved a safer and more comfortable alternative to femoral artery access. We present our experience with transradial (distal radial/anatomic snuffbox and radial artery) access for treatment of intracranial aneurysms using all 3 FDA-approved flow diverters.

MATERIALS AND METHODS

This was a high-volume, dual-center, retrospective analysis of each institution's data base between June 2018 and June 2020 and a collection of all patients treated with flow diversion via transradial access. Patient demographic information and procedural and radiographic data were obtained.

RESULTS

Seventy-four patients were identified (64 female patients) with a mean age of 57.5 years with a total of 86 aneurysms. Most aneurysms were located in the anterior circulation (93%) and within the intracranial ICA (67.4%). The mean aneurysm size was 5.5 mm. Flow diverters placed included the Pipeline Embolization Device (Flex) (PED, n = 65), the Surpass Streamline Flow Diverter (n = 8), and the Flow-Redirection Endoluminal Device (FRED, n = 1). Transradial access was successful in all cases, but femoral crossover was required in 3 cases (4.1%) due to tortuous anatomy and inadequate support of the catheters in 2 cases and an inability to navigate to the target vessel in a patient with an aberrant right subclavian artery. All 71 other interventions were successfully performed via the transradial approach (95.9%). No access site complications were encountered. Asymptomatic radial artery occlusion was encountered in 1 case (3.7%).

CONCLUSIONS

Flow diverters can be successfully placed via the transradial approach with high technical success, low access site complications, and a low femoral crossover rate.

Distal radial artery (snuffbox) access for carotid artery stenting - Technical pearls and procedural set-up

PURPOSE

To report use of distal radial artery (dRA) access for carotid artery stenting (CAS) and to discuss procedural setup and technical considerations for a successful intervention.

METHODS

A retrospective review of our prospective neurointerventional database of CAS was conducted between May 2019 and March 2020. All CAS cases via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data was collected.

RESULTS

22 CAS procedures in 20 patients via dRA were identified. Patients' mean age was 69.4 years (range 53-87 years). 3 patients were female. Mean radial artery diameter was 2.1 mm (range 1.6-2.8 mm). dRA access was achieved in all cases. Conversion to femoral access was required in 2 cases (9.1%) due to persistent radial artery vasospasm resulting in patient discomfort despite multiple additional doses of intraarterial vasodilators and added intravenous sedation as well as tortuous vessel anatomy and limited support of the catheters in a type 3 aortic arch for left CAS.

CONCLUSION

Our preliminary experience with dRA access for CAS suggests this approach to be feasible and safe for patients. Technical considerations are important and preprocedural planning is necessary for a successful intervention. Catheter systems and devices specifically designed for radial access are needed to enable more interventionalists to safely perform neurointerventional procedures via wrist access.

Distal radial artery (snuffbox) access for carotid artery stenting - Technical pearls and procedural set-up

PURPOSE

To report use of distal radial artery (dRA) access for carotid artery stenting (CAS) and to discuss procedural setup and technical considerations for a successful intervention.

METHODS

A retrospective review of our prospective neurointerventional database of CAS was conducted between May 2019 and March 2020. All CAS cases via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data was collected.

RESULTS

22 CAS procedures in 20 patients via dRA were identified. Patients' mean age was 69.4 years (range 53-87 years). 3 patients were female. Mean radial artery diameter was 2.1 mm (range 1.6-2.8 mm). dRA access was achieved in all cases. Conversion to femoral access was required in 2 cases (9.1%) due to persistent radial artery vasospasm resulting in patient discomfort despite multiple additional doses of intraarterial vasodilators and added intravenous sedation as well as tortuous vessel anatomy and limited support of the catheters in a type 3 aortic arch for left CAS.

CONCLUSION

Our preliminary experience with dRA access for CAS suggests this approach to be feasible and safe for patients. Technical considerations are important and preprocedural planning is necessary for a successful intervention. Catheter systems and devices specifically designed for radial access are needed to enable more interventionalists to safely perform neurointerventional procedures via wrist access.

Transradial approach for diagnostic cerebral angiograms in the elderly: a comparative observational study

Background

The transradial approach (TRA) reduces mortality, morbidity, access site complications, hospital cost, and length of stay while maximizing patient satisfaction. We aimed to assess the technical success and safety of TRA for elderly patients (aged ≥75 years).

Methods

A retrospective chart review and comparative analysis was performed for elderly patients undergoing a diagnostic cerebral angiogram performed via TRA versus transfemoral approach (TFA). Also, a second comparative analysis was performed among the TRA cohort between elderly patients and their younger counterparts.

Results

Comparative analysis in the elderly (TRA vs TFA) showed no significant differences for contrast dose per vessel (43.7 vs 34.6 mL, P=0.106), fluoroscopy time per vessel (5.7 vs 5.2 min, P=0.849), procedure duration (59.8 vs 65.2 min, P=0.057), conversion rate (5.8% vs 2.9%, P=0.650), and access site complications (2.3% vs 2.9%, P=1.00). Radiation exposure per vessel (18.9 vs 51.9 Gy cm2, P=0.001) was significantly lower in the elderly TRA group.

The second comparison (TRA in elderly vs TRA in the young) showed no significant differences for contrast dose per vessel (43.7 vs 37.8 mL, P=0.185), radiation exposure per vessel (18.9 vs 16.5 Gy cm2, P=0.507), procedure duration (59.8 vs 58.3 min, P=0.788), access site complication (2.3% vs 1.7%, P=0.55), and conversation rate (5.8% vs 1.8%, P=0.092). A trend for prolonged fluoroscopy time per vessel (5.7 vs 4.7 min, P=0.050) was observed in the elderly TRA group.

Conclusions

TRA is a technically feasible and safe option for diagnostic neurointerventional procedures in the elderly. Our small elderly cohort was not powered enough to show a significant difference in terms of access site complications between TRA and TFA.

Shunting away from transradial arterial access?

Due to its increased safety and decrease in significant vascular complications and bleeding events, the use of the radial artery for percutaneous coronary intervention (PCI) is increasing. Transradial access (TRA), however, is not without consequence. TRA arteries when used for coronary artery bypass grafting (CABG) are associated with decreased graft patency rates. Here we comment on a case report in which a patient developed a clinically significant arteriovenous fistula following TRA treated with surgical ligation. We offer insights on the increased use of the radial artery in both PCI and CABG.

Transradial access for flow diversion of intracranial aneurysms: Case series

BACKGROUND

Transradial access for neurointerventions offers advantages of fewer access-site complications, reduced procedure time, and greater patient comfort over transfemoral access. Data about transradial access for flow diversion are limited. We share our early experience with transradial access for flow diversion in a relatively large case series.

METHODS

Consecutive patients who underwent Pipeline embolization device (Medtronic) deployment via transradial access were included in the study, irrespective of location and laterality of the intracranial aneurysm. The cases were performed between July 2016 and October 2019. Demographics, aneurysm characteristics, and procedure-related details (including catheter systems used) were recorded and statistically evaluated.

RESULTS

Thirty-five transradial flow diversion procedures were attempted in 32 patients, of which 33 procedures were successful. In two cases involving left common carotid artery and internal carotid artery access, guide catheter herniation into the aortic arch led to abandonment of transradial access in favor of transfemoral access. The most common aneurysm locations in the transradial access procedures were the posterior communicating artery (n = 7), ophthalmic artery (n = 7), and superior hypophyseal artery (n = 7). Most transradial access procedures (66.7%) were performed using a biaxial catheter system. 6-French Benchmark (Penumbra) and Phenom 27 (Medtronic) were the most commonly utilized guide- and microcatheters, respectively. One patient had intraprocedural subarachnoid hemorrhage. No access-site complications occurred.

CONCLUSION

This study demonstrates safety and feasibility of transradial access for Pipeline embolization device deployment and shows the versatility of this approach for different catheter systems. Tortuosity and acute angulation of the left common carotid artery and internal carotid artery were associated with approach failure.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Distal radial access in the anatomical snuffbox for neurointerventions: a feasibility, safety, and proof-of-concept study

PURPOSE

To report the first use of distal radial artery (dRA) access for a variety of neurointerventions and to demonstrate the safety and feasibility of this approach.

METHODS

A retrospective review of our prospective neurointerventional database of endovascular interventions was conducted and, between May and October 2019, all patients in whom the intervention was performed via dRA in the anatomical snuffbox were identified. Patient demographics, clinical information, procedural and radiographic data were collected.

RESULTS

48 patients with a mean age of 64.4 years (range 35-84 years) were included. 27 patients were female. dRA access was achieved in all cases. Conversion to femoral access was required in five cases (10.4%) due to tortuous vessel anatomy and limited support of the catheters in the aortic arch. Interventions performed included aneurysm treatment (with flow diverters, Woven EndoBridge device placement, coiling or stent-assisted coiling), arteriovenous malformation and dural arteriovenous fistula embolization, carotid artery stentings, stroke thrombectomy, thrombolysis for central retinal artery occlusion, intracranial stenting, middle meningeal artery embolization, vasospasm treatment, and spinal angiography with embolization. Radial artery vasospasm was seen in two cases and successfully treated with antispasmolytic medication. No symptomatic radial artery occlusion or ischemic event was observed.

CONCLUSION

dRA access is safe and effective for a variety of neurointerventions. Our preliminary experience with this approach is very promising and shows high patient satisfaction.

The Value of Transradial: Impact on Patient Satisfaction and Health Care Economics

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.

Transitioning to Transradial Access for Cerebral Aneurysm Embolization

BACKGROUND AND PURPOSE

Despite several retrospective studies showing the safety and efficacy of transradial access for cerebral angiography, neurointerventionalists are apprehensive about implementing TRA for neurointerventions. This reluctance is mainly due to anatomic factors, technical factors, and a long learning curve (relative to transfemoral access). We present here our experience of TRA transition for cerebral aneurysm embolization. Our aim was to demonstrate the feasibility and safety of radial access for consecutive embolizations of ruptured and unruptured cerebral aneurysms.

MATERIALS AND METHODS

We performed a retrospective review of a prospective data base on cerebral aneurysm embolizations. Between April and December 2018, radial access was considered for all consecutive patients referred to our institution for cerebral aneurysm embolization. Technical success was defined as radial access with insertion of the sheath and completion of the intervention without a crossover to conventional femoral access. The primary safety end point was the in-hospital plus 30-day incidence of radial artery occlusion. Secondary end points included intraoperative complications and neurologic complications at discharge and in the following 30 days.

RESULTS

Seventy-one patients with a cerebral aneurysm underwent 73 embolization procedures at our institution. The first-choice access route was the radial artery in 62 patients (87.3%) and the femoral artery in 9 (12.6%). Thirty-four embolizations were performed using coils, 22 used a balloon-assisted coil technique, 6 used a stent-assisted coil technique, and 2 used a flow diverter. Crossover to femoral access was observed in 2 patients (3.1%). Four patients developed coil-induced thrombi requiring intra-arterial tirofiban injections. In 1 case, an aneurysm ruptured during the operation but did not have a clinical impact. No cases of radial artery occlusion or hand ischemia were observed.

CONCLUSIONS

A transition to radial access for cerebral aneurysm embolization is feasible and does not increase the level of risk associated with the procedure.

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.

Efficacy and Safety of a Novel Catheter for Transradial Cerebral Angiography

BACKGROUND

The goal of this study is to evaluate the safety and efficacy of a novel catheter for right radial artery approach cerebral angiography.

METHODS

Patients from the Neurology Department of The Second Affiliated Hospital of Guangxi Traditional Chinese Medical University who underwent diagnostic cerebral angiography of either the left vertebral artery dominant type or balanced type were enrolled in this study.

RESULTS

A total of 167 patients were treated between February 2016 and December 2017, of whom 44 were excluded based on study exclusion criteria and 123 were enrolled in the present analysis. Bilateral subclavian artery catheterization and bilateral common carotid artery catheterization were conducted successfully in all 123 patients. The success rate of selective catheterization of the left vertebral artery was 87.8% (108/123). The success rate of selective catheterization of the right vertebral artery using the novel catheter was 89.0% (73/82). The average fluoroscopy time was 6.5 ± 3.4 min, the average operation duration was 47 ± 3.7 (range 50-90) min, and the average dosage of contrast agent was 112.3 ± 8.1 mL. One patient exhibited an absence of pulse in the punctual radial artery after the removal of the arterial compression band, but there was no evidence of ischemia of the distal hand. One patient who was undergoing dual anti-platelet drug treatment suffered from bleeding at the puncture point when deflated for 2 hr after operation; this patient was re-pressurized and re-timed.

CONCLUSIONS

This novel catheter improved the success rate of selective left vertebral artery catheterization, and allowed for simplification of the relevant surgical steps. The controllability of this novel catheter was satisfactory, and its associated surgical risk was found to be low.

Randomized Comparison of Terumo® Coated Slender™ versus Terumo® Noncoated Traditional Sheath during Radial Angiography or Percutaneous Coronary Intervention

Background

The transradial approach is generally associated with few complications. However, periprocedural pain is still a common issue, potentially related to sheath insertion and/or arterial spasm, and may result in conversion to femoral access. Radial artery occlusion (RAO) following the procedure is also a potential risk. We evaluate whether the design of the sheath has any impact on these variables.

Methods

A total of 1,000 patients scheduled for radial CAG or PCI were randomized (1:1) to the use of a Slender or a Standard sheath during the procedure. Randomization was stratified according to chosen sheath size (5, 6, 7 French) and gender. A radial band was used to obtain hemostasis after the procedure, employing a rapid deflation technique. A reverse Barbeau test was performed to evaluate radial artery patency after removal of the radial band, and level of pain was assessed using a numeric rating scale (NRS).

Results

Use of the Slender sheath was associated with less pain during sheath insertion (median NRS 1 versus 2, p=0.02), whereas no difference was observed in pain during the procedure, radial procedural success rates, use of analgesics and sedatives during the procedure, and radial artery patency following the procedure. Rate of RAO was 1.5% with no difference between groups.

Conclusion

The use of the hydrophilic coated Slender sheath during radial CAG or PCI was associated with less pain during sheath insertion, whereas no difference in other endpoints was observed. A rapid deflation technique was associated with RAO of only 1.5%.

Palmar Warming for Radial Artery Vasodilation to Facilitate Transradial Access: A Randomized Controlled Trial

PURPOSE

To investigate the efficacy of palmar warming to induce radial artery vasodilation.

MATERIALS AND METHODS

After informed consent was obtained, healthy volunteers (n = 45) were randomized 2:1 in palmar warming and control groups, respectively, for this prospective, randomized, single-blind clinical trial (NCT03620383). The palmar warming group was given a warm, commercially available, air-activated heat pack (Kobayashi Consumer Products LLC, Dalton, Georgia) to hold in the left hand for palmar warming. The control group was given a deactivated version of the same heat pack. Left radial artery cross-sectional area (CSA) measurements were obtained at baseline and in 5-minute intervals up to 20 minutes in both groups. Differences in the trends of changes in the radial artery CSA between palmar warming and control groups were examined with the age- and sex-adjusted repeated measure analysis of variance. Propensity score-matched treatment effect analysis was conducted to quantify the effect of heat on radial artery CSA.

RESULTS

The palmar warming group and the control group were significantly different in terms of subject sex (males/females: 7/23 and 10/5, respectively; P = .005) and baseline CSA (2.5±0.2 mm² vs 3.2±0.3 mm², respectively; P = .014). Radial artery CSA showed an increasing trend over time in the palmar warming group compared to a stable trend over time in the control group (P < .0001). Propensity score-matched comparison showed a 43.9% increase (95% confidence interval: 34.1%-53.8%) in CSA in the palmar warming group compared to the control group (P < .0001).

CONCLUSIONS

The palmar warming technique is effective at dilating the radial artery and may be a beneficial technique to facilitate transradial access.

Distal transradial access in the anatomical snuffbox for diagnostic cerebral angiography

BACKGROUND

The transradial approach for endovascular angiography and interventional procedures is superior to the traditional transfemoral approach in several metrics, including lower access-site complication rates, higher patient satisfaction, and lower hospital costs. Interventional cardiologists have begun to adopt the distal transradial approach (dTRA) for coronary interventions as it has an improved safety profile and improved procedural ergonomics. Adaptation of dTRA for neuroendovascular procedures promises similar benefit, but requires a learning curve.

OBJECTIVE

To report the first use of dTRA for diagnostic cerebral angiography and demonstrate the feasibility and safety of a dTRA.

METHODS

A retrospective review of our prospective institutional database of consecutive cases of cerebral DSA performed via dTRA between August 2018 and December 2018 was performed. Patient demographics, procedural and radiographic metrics, and clinical data were recorded.

RESULTS

85 patients were identified with an average age of 53.8 years (range 18-82); 67 (78.8%) patients were female. 78 patients underwent successful dTRA diagnostic cerebral angiography, with a mean of five vessels catheterized and average fluoroscopy time of 12.0 min, or 2.6 min for each vessel. Seven patients required conversion to transfemoral access, with the most common reason being inability to advance the wire and radial artery spasm. There were no complications.

CONCLUSION

dTRA is associated with decreased rates of radial artery occlusion, ischemic hand events, as well as improved patient comfort, faster periprocedural management, and cost benefits. Our preliminary experience with dTRA for diagnostic cerebral angiography demonstrates excellent feasibility and safety in combination with relative efficiency.

Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: comparison of technical and clinical outcomes

Background

A transradial approach (TRA) is associated with fewer access site complications than a transfemoral technique (TFA).However, there is concern that performing mechanical thrombectomy (MT) via TRA may lead to longer revascularization times and thus worse outcomes. Nonetheless, TRA may confer added benefits in MT since navigation of challenging aortic arch and carotid anatomy is often facilitated by a right radial artery trajectory.

Objective

To compare outcomes in patients who underwent MT via TRA versus TFA.

Methods

We performed a retrospective review of our institutional database to identify 51 patients with challenging vascular anatomy who underwent MT for anterior circulation large vessel occlusion between February 2015 and February 2018. Patient characteristics, procedural techniques, and outcomes were recorded. TFA and TRA cohorts were compared.

Results

Of the 51 patients, 18 (35%) underwent MT via TRA. There were no significant cohort differences in patient characteristics, clot location, or aortic arch type and presence of carotid tortuosity. There were no significant differences in outcomes between the two cohorts, including single-pass recanalization rate (54.5% vs 55.6%, p=0.949) and average number of passes (1.9 vs 1.7, p=0.453). Mean access-to-reperfusion time (61.9 vs 61.1 min, p=0.920), successful revascularization rates (Thrombolysis in Cerebral Infarction score ≥2b 87.9% vs 88.9%, p=1.0) and functional outcomes (modified Rankin Scale score≤2, 39.4% vs 33.3%, p=0.669) were similar between TFA and TRA cohorts, respectively.

Conclusions

Our results demonstrate equivalence in efficacy and efficiency between TRA and TFA for MT of anterior circulation large vessel occlusion in patients with challenging vascular anatomy. TRA may be better than TFA in well-selected patients undergoing MT.

Transradial approach for flow diversion treatment of cerebral aneurysms: a multicenter study

Background

The transradial approach (TRA) to endovascular procedures decreases access site morbidity and mortality in comparison with the traditional transfemoral technique (TFA). Despite its improved safety profile, there is a concern that TRA is less favorable for neurointerventional procedures that require large coaxial systems to manage the small tortuous cerebral vessels.

Objective

To report our experience with TRA for flow diverter placement for treatment of unruptured cerebral aneurysms.

Methods

We performed a retrospective review of prospective institutional databases at two high-volume centers to identify 49 patients who underwent flow diversion for aneurysm treatment via primary TRA between November 2016 and November 2018. Patient demographics, procedural techniques, and clinical data were recorded.

Results

Of the 49 patients, 39 underwent successful flow diversion placement by TRA. Ten patients were converted to TFA after attempted TRA. There were no procedural complications. Reasons for failure included tortuosity in eight patients and severe radial artery spasm in two.

Conclusions

In the largest reported series to date of flow diverter deployment via TRA for aneurysm treatment, we demonstrate the technical feasibility and safety of the method. The most common reason for failure of TRA was an acute angle of left common carotid artery origin or left internal carotid artery tortuosity. Overall, our data suggest that increasing adoption of TRA is merited given its apparent equivalence to the current TFA technique and its documented reduction in access site complications.

[Radial approach in the elderly]

Due to the steady increase in life expectancy, the number of patients over 80 years of age proposed for coronary angioplasty is increasing significantly. The elderly patient is a patient at high cardiovascular risk and high risk of bleeding; whose severity of prognosis depends of comorbidities. The radial approach presents particularities and technical difficulties that have to be known in this part of the population, but reduce vascular and hemorrhagic complications, as well as mortality. Because of greater safety, the radial approach is therefore the first choice for the elderly.

Transradial Approach for Complex Anterior and Posterior Circulation Interventions: Technical Nuances and Feasibility of Using Current Devices

BACKGROUND

Despite several studies analyzing the safety of transradial access (TRA) for neurointervention compared to transfemoral approach (TFA), neurointerventionalists are apprehensive about implementing TRA. From our positive institutional experience, we now utilize TRA first line for a majority of our cases. Here, we present our single-institution experience.

OBJECTIVE

To determine safety and feasibility of TRA for neurointervention.

METHODS

Through retrospective review of patients receiving TRA for anterior and posterior circulation cerebrovascular interventions at our institution between December 2015 and January 2018, we present our experience regarding this transition, while focusing on technique, complications, feasibility, indications, and limitations.

RESULTS

One hundred five procedures were performed on 92 patients (anterior circulation: 77%; posterior circulation: 23%). Radial artery access was achieved in all patients. Twenty-nine cases constituted mechanical thrombectomy, 33 cases represented intracranial aneurysms treatments, and 33 cases included interventions like angioplasty, balloon test occlusion, chemotherapy delivery, and thrombolysis. TRA was used as second-line access to TFA in 5 instances due to aortic arch anomalies and atherosclerotic disease. Minor access-site complications were seen in 2.85% of patients. Ten procedures (9.0%) could not be completed with TRA, with crossover to TFA occurring in 7 cases.

CONCLUSION

TRA is safe and feasible for the majority of neurointerventional procedures and provides decreased risk of major access-site complications compared to TFA. Perceived limitations of TRA can likely be eliminated via operator experience and engineering ingenuity; thus, there is a role for TRA for neurointervention, especially in patients with increased risk of access-site complications from TFA.

Antiplatelet agents in uncertain clinical scenarios-a bleeding nightmare

Despite over 40 years since the first percutaneous coronary intervention (PCI) was performed, the optimal dual antiplatelet therapy (DAPT) regime poses a significant challenge for clinicians, especially in certain scenarios. DAPT is the standard of care in PCI following an acute coronary syndrome (ACS) or for elective patients with obstructive coronary artery disease (CAD). There remains significant uncertainty regarding DAPT in patients at high risk of bleeding, such as the elderly and patients requiring anticoagulation. More and more clinicians are faced with a dilemma of weighing risks and benefits from the increasing list of potent, new antiplatelet agents and direct oral anticoagulants (DOACs) in a growing, aging population. Historically, most studies failed to recognize bleeding risk, instead focusing on ischemic risk. In recent years however, bleeding has been recognized as a very significant driver of morbidity and mortality in patients undergoing PCI. There is a paucity of data in this cohort leading to divergent and sometimes conflicting recommendations, largely based on expert consensus of opinion. In the current review, we critically evaluate the available evidence in these uncertain scenarios.

Efficacy of a one-catheter concept for transradial coronary angiography

INTRODUCTION

Transradial coronary angiography (TRC) can be performed with a one-catheter approach for the right and left coronary ostium (R/LCO). We investigated the performance of a special diagnostic catheter widely used for the one-catheter-approach, the Tiger (Tiger II, TerumoTM).

METHODS

In a dual center registry we analyzed 1412 TRC-procedures exclusively performed by experienced TRC-operators. We compared the performance of the Tiger with Judkins catheters by retrospectively judging ostial catheter stability during contrast injection, and by measuring contrast use, fluoroscopy time (FT) and complication rate.

RESULTS

Poor or failed ostial engagement was found in 40.5% in the Tiger group, compared to 46.6% with the use of Judkins catheters (p<0.183). Ostial instability of the Tiger was found more often during engagement of the LCO than the RCO (34.4% vs. 10.8%, p<0.001), whereas it was similar in the LCO and RCO for Judkins catheters (27.4% vs. 26.7%, p = 0.840). TRC-procedures performed with Tiger catheters were associated with less contrast volume (63.48 ± 29.83mL vs. 82.51 ± 56.58mL, p<0.004) and shorter FT than with Judkins catheters. (198.27 ± 194.8sec vs. 326.85 ± 329.70sec). Forearm hematomas occurred less often with the Tiger (1.2% vs. 6.6%, p< 0.02).

CONCLUSION

The Tiger employed as a single catheter in TRC is an effective tool to achieve lower contrast volume and fluoroscopy time at a low complication rate. Unstable engagement affects predominantly the left coronary artery, but its overall frequency is similar for both, the Tiger and Judkins catheters.

Safety and Efficacy of Percutaneous Coronary Intervention via Transradial Versus Transfemoral Approach in Bypass Grafts

We compared the efficacy and safety of the transradial approach percutaneous coronary intervention (TRA-PCI) and transfemoral approach percutaneous coronary intervention (TFA-PCI) for bypass grafts lesions. Patients (n = 184) were retrospectively enrolled. Less contrast was used during the procedure in the TRA group than in the TFA group, 201.5 (45.5) mL versus 221.5 (49.1) mL, P = .004, although fluoroscopy time was longer in the TRA group, 22.5 (6.3) minutes versus 20.3 (6.1) minutes; P = .017. The incidence of net adverse clinical events (NACEs) was lower in the TRA group than in the TFA group (3.1% vs 8.8%, respectively, P = .111). The incidence of Bleeding Academic Research Consortium type 3 and 5 bleeding (0% vs 5.5%, respectively, P = .022) was significantly lower in the TRA group than in the TFA group. For 1-year outcomes, there was no difference in the incidence of major adverse cardiovascular events (7.5% vs 9.9%, respectively, P = .569). In conclusion, TRA-PCI was associated with a lower rate of in-hospital NACEs mainly attributed to lower rates of major bleeding. The TRA-PCI showed comparable feasibility and efficacy in bypass grafts as compared with TFA-PCI when carried out by experienced operators.