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Xia W, Zhang M, Liu C, Wang S, Xu A, Xia Z, Pang L, Cai Y. Exploring the therapeutic potential of tetrahydrobiopterin for heart failure with preserved ejection fraction: A path forward. Life Sci 2024; 345:122594. [PMID: 38537900 DOI: 10.1016/j.lfs.2024.122594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/10/2024] [Accepted: 03/24/2024] [Indexed: 04/02/2024]
Abstract
A large number of patients are affected by classical heart failure (HF) symptomatology with preserved ejection fraction (HFpEF) and multiorgan syndrome. Due to high morbidity and mortality rate, hospitalization and mortality remain serious socioeconomic problems, while the lack of effective pharmacological or device treatment means that HFpEF presents a major unmet medical need. Evidence from clinical and basic studies demonstrates that systemic inflammation, increased oxidative stress, and impaired mitochondrial function are the common pathological mechanisms in HFpEF. Tetrahydrobiopterin (BH4), beyond being an endogenous co-factor for catalyzing the conversion of some essential biomolecules, has the capacity to prevent systemic inflammation, enhance antioxidant resistance, and modulate mitochondrial energy production. Therefore, BH4 has emerged in the last decade as a promising agent to prevent or reverse the progression of disorders such as cardiovascular disease. In this review, we cover the clinical progress and limitations of using downstream targets of nitric oxide (NO) through NO donors, soluble guanylate cyclase activators, phosphodiesterase inhibitors, and sodium-glucose co-transporter 2 inhibitors in treating cardiovascular diseases, including HFpEF. We discuss the use of BH4 in association with HFpEF, providing new evidence for its potential use as a pharmacological option for treating HFpEF.
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Affiliation(s)
- Weiyi Xia
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China
| | - Miao Zhang
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Guangdong, China
| | - Chang Liu
- Department of Anesthesiology, The First Hospital of Jilin University, Jilin, China
| | - Sheng Wang
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aimin Xu
- State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Hong Kong SAR, China; Department of Medicine, The University of Hong Kong, Hong Kong SAR, China; Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong SAR, China
| | - Zhengyuan Xia
- Department of Anesthesiology, Affiliated Hospital of Guangdong Medical University, Guangdong, China
| | - Lei Pang
- Department of Anesthesiology, The First Hospital of Jilin University, Jilin, China.
| | - Yin Cai
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong SAR, China; Research Center for Chinese Medicine Innovation, The Hong Kong Polytechnic University, Hong Kong SAR, China; Research Institute for Future Food, The Hong Kong Polytechnic University, Hong Kong SAR, China.
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A time-out for arterial access. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40:150-151. [DOI: 10.1016/j.carrev.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 11/22/2022]
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Radial Artery Access for Acute Coronary Syndromes: a Review of Current Evidence. Curr Cardiol Rep 2022; 24:383-392. [PMID: 35286661 DOI: 10.1007/s11886-022-01656-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To review the evidence supporting the use of transradial access (TRA) for percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS). RECENT FINDINGS There have been five major randomized controlled trials (RCTs) and two recent meta-analyses comparing outcomes of TRA and femoral access (FA) in ACS. Additional studies have explored the impact of TRA on STEMI door-to-balloon (D2B) times, TRA in high-risk ACS patients, the potential conflict between TRA and coronary artery bypass graft (CABG) surgery employing the radial artery, and distal radial artery (DRA) access. TRA is associated with a reduction in net adverse clinical events, major bleeding, acute renal injury, and access site complications compared to FA in ACS patients undergoing PCI. TRA is not associated with significant delays in STEMI D2B times that impact patient outcomes. Further studies are needed to evaluate the role of TRA in high-risk ACS patients, the interplay between TRA and radial artery CABG, and use of DRA in ACS.
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Wilkinson DA, Majmundar N, Catapano JS, Cole TS, Baranoski JF, Hendricks BK, Cavalcanti DD, Frederickson VL, Ducruet AF, Albuquerque FC. Avoiding the Radial Paradox: Neuroendovascular Femoral Access Outcomes After Radial Access Adoption. Neurosurgery 2022; 90:287-292. [PMID: 34995246 DOI: 10.1227/neu.0000000000001787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 09/19/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transradial access (TRA) for neuroendovascular procedures is increasing in prevalence. The safety benefits of TRA at a patient level may be offset at a population level by a paradoxical increase in transfemoral access (TFA) vascular access site complications (VASCs), the so-called "radial paradox." OBJECTIVE To study the effect of TRA adoption on TFA performance and outcomes in neuroendovascular procedures. METHODS Data were collected for all procedures performed over a 10-mo period after radial adoption at a single center. RESULTS Over the study period, 1084 procedures were performed, including 719 (66.3%) with an intent to treat by TRA and 365 (33.7%) with an intent to treat by TFA. Thirty-two cases (4.4%) crossed over from TRA to TFA, and 2 cases (0.5%) crossed over from TFA to TRA. TFA was performed in older patients (mean [standard deviation] TFA, 63 [15] vs TRA, 56 [16] years) using larger sheath sizes (≥7 French; TFA, 56.2% vs TRA, 2.3%) ( P < .001 for both comparisons). Overall, 29 VASCs occurred (2.7%), including 27 minor (TFA, 4.6% [18/395] vs TRA, 1.3% [9/689], P = .002) and 2 major (TFA, 0.3% [1/395] vs TRA, 0.1% [1/689], P > .99) complications. Independent predictors of VASC included TFA (OR 2.8, 95% confidence interval [CI] 1.1-7.4) and use of dual antiplatelet therapy (OR 4.2, 95% CI 1.6-11.1). CONCLUSION TFA remains an important access route, despite a predominantly radial paradigm, and is disproportionately used in patients at increased risk for VASCs. TFA proficiency may still be achieved in predominantly radial practices without an increase in femoral complications.
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Affiliation(s)
- D Andrew Wilkinson
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Ng AKY, Ng PY, Ip A, Jim MH, Siu CW. Association Between Radial Versus Femoral Access for Percutaneous Coronary Intervention and Long-Term Mortality. J Am Heart Assoc 2021; 10:e021256. [PMID: 34325533 PMCID: PMC8475672 DOI: 10.1161/jaha.121.021256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
| | - Pauline Yeung Ng
- Department of Adult Intensive Care Queen Mary Hospital Hong Kong SAR, China.,Division of Respiratory and Critical Care Medicine Department of Medicine Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR, China
| | - April Ip
- Division of Respiratory and Critical Care Medicine Department of Medicine Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong SAR, China
| | - Man-Hong Jim
- Cardiac Medical Unit Grantham Hospital Hong Kong SAR, China
| | - Chung-Wah Siu
- Department of Medicine Queen Mary HospitalThe University of Hong Kong Hong Kong SAR, China
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Changal K, Syed MA, Atari E, Nazir S, Saleem S, Gul S, Salman FNU, Inayat A, Eltahawy E. Transradial versus transfemoral access for cardiac catheterization: a nationwide pilot study of training preferences and expertise in The United States. BMC Cardiovasc Disord 2021; 21:250. [PMID: 34020605 PMCID: PMC8139069 DOI: 10.1186/s12872-021-02068-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 05/17/2021] [Indexed: 11/10/2022] Open
Abstract
Background The objective was to assess current training preferences, expertise, and comfort with transfemoral access (TFA) and transradial access (TRA) amongst cardiovascular training fellows and teaching faculty in theUnited States. As TRA continues to dominate the field of interventional cardiology, there is a concern that trainees may become less proficient with the femoral approach. Methods A detailed questionnaire was sent out to academic General Cardiovascular and Interventional Cardiology training programs in the United States. Responses were sought from fellows-in-training and faculty regarding preferences and practice of TFA and TRA. Answers were analyzed for significant differences between trainees and trainers. Results A total of 125 respondents (75 fellows-in-training and 50 faculty) completed and returned the survey. The average grade of comfort for TFA, on a scale of 0 to 10 (10 being most comfortable), was reported to be 6 by fellows-in-training and 10 by teaching faculty (p<0.001). TRA was the first preference in 95% of the fellows-in-training compared to 69% of teaching faculty (p 0.001). While 62% of fellows believed that they would receive the same level of training as their trainers by the time they graduate, only 35% of their trainers believed so (p 0.004). Conclusion The shift from TFA to radial first has resulted in significant concern among cardiovascular fellows-in training and the faculty regarding training in TFA. Cardiovascular training programs must be cognizant of this issue and should devise methods to assure optimal training of fellows in gaining TFA and managing femoral access-related complications.
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Affiliation(s)
- Khalid Changal
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH, USA.
| | | | - Ealla Atari
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
| | - Salik Nazir
- Department of Cardiovascular Medicine, University of Toledo, Toledo, OH, USA
| | - Sameer Saleem
- Department of Cardiovascular Medicine, University of Kentucky, Bowling Green, USA
| | - Sajjad Gul
- Internal Medicine, St. Francis Medical Center, University of Illinois at Peoria, Peoria, USA
| | - F N U Salman
- Internal Medicine, Mercy St. Vincent Medical Center, Toledo, OH, USA
| | - Asad Inayat
- Department of Medicine, Khyber Teaching Hospital, Peshawar, Pakistan
| | - Ehab Eltahawy
- Professor and Program Director of Cardiovascular Medicine and Interventional Cardiology, University of Toledo, 3000 Arlington Ave., MS 1118, Toledo, 43614, OH, USA.
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Stephan T, Felbel D, Rattka M, Rottbauer W, Markovic S. Impact of radial access on contrast-induced acute kidney injury in patients with coronary artery bypass grafts. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 36:123-131. [PMID: 33992588 DOI: 10.1016/j.carrev.2021.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/15/2021] [Accepted: 04/24/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE We investigated the impact of radial access on contrast-induced acute kidney injury (CI-AKI) in patients with coronary artery bypass graft (CABG) undergoing cardiac catheterization. METHODS This retrospective monocenter study included 527 CABG patients undergoing cardiac catheterization via radial (58.1%, N = 306) or femoral access (41.9%, N = 221). Primary outcome measure was CI-AKI defined in accordance with the KDIGO criteria. Independent predictors for CI-AKI were assessed. 1-year mortality was assessed depending on the occurrence of CI-AKI. RESULTS In total, 99 CABG patients (18.8%) developed CI-AKI within 48 h after cardiac catheterization. Compared to patients without CI-AKI, amount of contrast media used (203.1 ± 102.6 ml vs. 204.2 ± 98.2 ml; P = 0.892) as well as procedural times (87.9 ± 44.8 vs. 79.8 ± 37.0; P = 0.190) were similarly. Regarding vascular access, there was no significant difference in the incidence of CI-AKI between radial and femoral approach (19.0% vs. 18.6%; p = 0.907). However, poor left ventricular ejection fraction (odds ratio [OR] = 1.72, P = 0.026), chronic kidney disease (OR = 2.30, P = 0.001) and acute coronary syndrome (OR = 1.64, P = 0.043) were independent predictors for CI-AKI. The occurrence of CI-AKI was significantly associated with an increased 1-year mortality (hazard ratio [HR] = 2.52, P = 0.003). CONCLUSIONS With 18.8%, CI-AKI is a frequent complication in CABG patients undergoing cardiac catheterization. Radial access did not decrease the risk when compared to the femoral approach.
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Affiliation(s)
- Tilman Stephan
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University of Ulm, Ulm, Germany
| | - Dominik Felbel
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University of Ulm, Ulm, Germany
| | - Manuel Rattka
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University of Ulm, Ulm, Germany
| | - Wolfgang Rottbauer
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University of Ulm, Ulm, Germany
| | - Sinisa Markovic
- Department of Cardiology, Angiology, Pneumology and Internal Intensive Care, University of Ulm, Ulm, Germany.
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Radial or femoral access in primary percutaneous coronary intervention (PCI): Does the choice matters? Indian Heart J 2020; 72:166-171. [PMID: 32768015 PMCID: PMC7411101 DOI: 10.1016/j.ihj.2020.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 05/07/2020] [Accepted: 05/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background This study was conducted with the aim of providing a quantitative appraisal of clinical outcomes of trans-radial access for primary percutaneous coronary interventions (PCI) in patients with ST-segment evaluation myocardial infarction (STEMI). Methods In this study, we compared two propensity-matched cohorts of patients who underwent primary PCI via trans-radial (TRA) and trans-femoral access (TFA) in a 1:1 ratio. The profile of two cohorts was matched for gender, age, and body mass index, diabetes, hypertension, family history, and smoking. The outcomes of primary PCI were compared for the two cohorts which included all-cause in-hospital mortality, heart failure, re-infarction, cardiogenic shock, bleeding, transfusion, cerebrovascular accident, and dialysis. Results This analysis was performed on a total of 2316 patients with 1158 patients each in the TRA and TFA group. We observed significantly lower rates of mortality, 0.8% (9) vs. 3.5% (41); p < 0.001 and bleeding, 0.5% (6) vs.1.6% (19); p = 0.009 with shorter hospital stay, 1.61 ± 1.39 vs. 1.98 ± 1.5 days, in trans-radial vs. trans-femoral. However, both fluoroscopic time and contrast volume were significantly higher in the TRA as compared to TFA group 15.57 ± 8.16 vs. 12.79 ± 7.82 min; p < 0.001 and 143.22 ± 45.33 vs. 133.78 ± 45.97; p < 0.001 respectively. Conclusions Compared with TFA access, TRA for primary PCI is safe for patients with STEMI, it was found to be associated with a significant reduction in in-hospital mortality and bleeding complications.
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Lindner SM, McNeely CA, Amin AP. The Value of Transradial: Impact on Patient Satisfaction and Health Care Economics. Interv Cardiol Clin 2020; 9:107-115. [PMID: 31733737 PMCID: PMC7772820 DOI: 10.1016/j.iccl.2019.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This review summarizes the impact of transradial access for cardiac catheterization and percutaneous coronary intervention related to patient satisfaction, patient safety, and health care costs. In studies comparing transradial versus transfemoral approach, transradial access causes less bleeding and less vascular access site complications and provides a mortality benefit in patients with acute coronary syndromes. Transradial access improves patient satisfaction related to site tolerability by reducing pain and discomfort, and facilitating early ambulation with reduced length of stay. Taken in total, the existing randomized and observational data strongly support radial access for improved safety, patient satisfaction, and significant cost savings.
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Affiliation(s)
- Samuel M Lindner
- Cardiovascular Division, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Barnes-Jewish Hospital, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
| | - Christian A McNeely
- Cardiovascular Division, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Barnes-Jewish Hospital, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA
| | - Amit P Amin
- Cardiovascular Division, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Barnes-Jewish Hospital, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA; Center for Value and Innovation, Washington University School of Medicine, 660 S Euclid Avenue, Campus Box 8086, St Louis, MO 63110, USA.
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Kopin D, Seth M, Sukul D, Dixon S, Aronow HD, Lee D, Tucciarone M, Pielsticker E, Gurm HS. Primary and Secondary Vascular Access Site Complications Associated With Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 12:2247-2256. [DOI: 10.1016/j.jcin.2019.05.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/01/2019] [Accepted: 05/28/2019] [Indexed: 11/25/2022]
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Radial Approach Expertise and Clinical Outcomes of Percutanous Coronary Interventions Performed Using Femoral Approach. J Clin Med 2019; 8:jcm8091484. [PMID: 31540442 PMCID: PMC6780122 DOI: 10.3390/jcm8091484] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/09/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022] Open
Abstract
We sought to evaluate the impact of experience and proficiency with radial approach (RA) on clinical outcomes of percutaneous coronary interventions (PCI) performed via femoral approach (FA) in the “real-world” national registry. A total of 539 invasive cardiologists performing PCIs in 151 invasive cardiology centers in Poland between 2014 and 2017 were included. Proficiency threshold was set at >300 PCIs during four consecutive years per individual operator. The majority of operators performed >75% of all PCIs via RA (449 (65.4%)), 143 (20.8%) in 50–75% of cases, 62 (9.0%) in 25–50% and only 33 (4.8%) invasive cardiologists were using RA in <25% of all PCIs. Operators with the highest proficiency in RA were associated with increased risk of periprocedural death, stroke and bleeding complications at access site during angiography via FA. Similarly, higher prevalence of periprocedural mortality during PCI with FA was observed in most experienced radial operators as compared to other groups. The detrimental effect of FA utilization by the most experienced radial operators was observed in both stable angina and acute coronary syndromes. Higher experience and utilization of RA might be linked to worse outcomes of PCIs performed via femoral artery in both stable and acute settings.
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Goel S, Pasam RT, Raheja H, Gotesman J, Gidwani U, Ahuja KR, Reed G, Puri R, Khatri JK, Kapadia SR. Left main percutaneous coronary intervention—Radial versus femoral access: A systematic analysis. Catheter Cardiovasc Interv 2019; 95:E201-E213. [DOI: 10.1002/ccd.28451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 07/22/2019] [Accepted: 08/01/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Sunny Goel
- Department of CardiologyMaimonides Medical Center Brooklyn New York
| | - Ravi T. Pasam
- Department of CardiologyMaimonides Medical Center Brooklyn New York
| | - Hitesh Raheja
- Department of CardiologyMaimonides Medical Center Brooklyn New York
| | - Joseph Gotesman
- Department of CardiologyMaimonides Medical Center Brooklyn New York
| | - Umesh Gidwani
- Department of CardiologyIcahn School of Medicine at Mount Sinai New York New York
| | - Keerat R. Ahuja
- Department of CardiologyHeart and Vascular Institute, Cleveland Clinic Cleveland Ohio
| | - Grant Reed
- Department of CardiologyHeart and Vascular Institute, Cleveland Clinic Cleveland Ohio
| | - Rishi Puri
- Department of CardiologyHeart and Vascular Institute, Cleveland Clinic Cleveland Ohio
| | - Jai K. Khatri
- Department of CardiologyHeart and Vascular Institute, Cleveland Clinic Cleveland Ohio
| | - Samir R. Kapadia
- Department of CardiologyHeart and Vascular Institute, Cleveland Clinic Cleveland Ohio
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Alkhawam H, Windish S, Abo-Salem E. Distal radial artery access among cases with radial artery occlusion for primary percutaneous intervention. Future Cardiol 2019; 15:169-173. [PMID: 31148471 DOI: 10.2217/fca-2018-0057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Radial artery access is associated with lower bleeding risks and higher patient satisfactions compared with femoral access. It is currently the preferred access for coronary catheterization and interventions, and increasingly used for peripheral and cranial vascular interventions. Herein, we present a patient who had a recent procedures included right transradial right vertebral artery and peripheral vascular interventions. She was admitted for abdominal aortic bifemoral artery bypass, and was complicated with ST elevation myocardial infarction that required immediate cardiac catheterization. Patient did not have palpable radial access and ultrasonography confirmed a total occlusion of right radial artery with thrombus. Although distal right radial artery - at the anatomical snuff box - was not palpable, artery was patent and could be accessed successfully with ultrasonography guidance.
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Affiliation(s)
- Hassan Alkhawam
- Center for Comprehensive Cardiovascular care, St Louis University, St Louis, MO 63110, USA
| | - Stephanie Windish
- Center for Comprehensive Cardiovascular care, St Louis University, St Louis, MO 63110, USA
| | - Elsayed Abo-Salem
- Center for Comprehensive Cardiovascular care, St Louis University, St Louis, MO 63110, USA
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14
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Kinnaird T, Anderson R, Gallagher S, Cockburn J, Sirker A, Ludman P, de Belder M, Copt S, Nolan J, Zaman A, Mamas M. Vascular Access Site and Outcomes in 58,870 Patients Undergoing Percutaneous Coronary Intervention With a Previous History of Coronary Bypass Surgery: Results From the British Cardiovascular Interventions Society National Database. JACC Cardiovasc Interv 2019. [PMID: 29519382 DOI: 10.1016/j.jcin.2017.12.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Using the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, access site choice and outcomes of patients undergoing PCI with previous coronary artery bypass grafting (CABG) were studied. BACKGROUND Given the influence of access site on outcomes, use of radial access in PCI-CABG warrants further investigation. METHODS Data were analyzed from 58,870 PCI-CABG procedures performed between 2005 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes. RESULTS The number of PCI-CABG cases and the percentage of total PCI increased significantly during the study period. Femoral artery (FA) utilization fell from 90.8% in 2005 to 57.6% in 2014 (p < 0.001), with no differences in the rate of change of left versus right radial use. In contemporary study years (2012 to 2014), female sex, acute coronary syndrome presentation, chronic total occlusion intervention, and lower operator volume were independently associated with FA access. Length of stay was shortened in the radial cohort. Unadjusted outcomes including an access site complication (1.10% vs. 0.30%; p < 0.001), blood transfusion (0.20% vs. 0.04%; p < 0.001), major bleeding (1.30% vs. 0.40%; p < 0.001), and in-hospital death (1.10% vs. 0.60%; p = 0.001) were more likely to occur with FA access compared with radial access. After adjustment, although arterial complications, transfusion, and major bleeding remained more common with FA use, short- and longer-term mortality and major adverse cardiac event rates were similar. CONCLUSIONS In contemporary practice, FA access remains predominant during PCI-CABG with case complexity associated with it use. FA use was associated with longer length of stay, and higher rates of vascular complications, major bleeding, and transfusion.
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Affiliation(s)
- Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom; Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, United Kingdom.
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Sean Gallagher
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - James Cockburn
- Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Alex Sirker
- Department of Cardiology, University College Hospital, London, United Kingdom
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Mark de Belder
- Department of Cardiology, James Cook University Hospital, Middlesbrough, United Kingdom
| | | | - James Nolan
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom
| | - Azfar Zaman
- Department of Cardiology, Freeman Hospital, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Institute of Applied Clinical Sciences, University of Keele, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke Hospital, University Hospitals of North Midlands, Stoke-on-Trent, United Kingdom
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Affiliation(s)
- Rahman Shah
- Veterans Affairs Medical Center, Division of Cardiovascular Medicine, University of Tennessee, Memphis, TN 38104, USA.
| | - Babar Khan
- Veterans Affairs Medical Center, Division of Cardiovascular Medicine, University of Tennessee, Memphis, TN 38104, USA
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Valgimigli M. The MATRIX trial - Author's reply. Lancet 2019; 393:1803-1804. [PMID: 31057165 DOI: 10.1016/s0140-6736(19)30049-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/03/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Inselspital, University Hospital of Bern, Bern 3010, Switzerland.
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Access Site and Outcomes for Unprotected Left Main Stem Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2018; 11:2480-2491. [DOI: 10.1016/j.jcin.2018.09.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 11/19/2022]
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Changes in Periprocedural Bleeding Complications Following Percutaneous Coronary Intervention in The United Kingdom Between 2006 and 2013 (from the British Cardiovascular Interventional Society). Am J Cardiol 2018; 122:952-960. [PMID: 30131105 DOI: 10.1016/j.amjcard.2018.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/29/2018] [Accepted: 06/01/2018] [Indexed: 11/20/2022]
Abstract
Major bleeding is a common complication after percutaneous coronary intervention (PCI), although little is known about how bleeding rates have changed over time and what has driven this. We analyzed all patients who underwent PCI in England and Wales from 2006 to 2013. Multivariate analyses using logistic regression models were performed to identify predictors of bleeding to identify potential factors influencing bleeding trends over time. 545,604 participants who had PCI in England and Wales between 2006 and 2013 were included in the analyses. Overall bleeding rates decreased from 7.0 (CI 6.2 to 7.8) per 1,000 procedures in 2006 to 5.5 (CI 4.7 to 6.2) per 1,000 in 2013. Increasing age, female sex, GPIIb/IIIa inhibitors use, and circulatory support were independently associated with increased risk of bleeding complications whereas radial access and vascular closure device use were independently associated with decreases in risk. Decreases in bleeding rates over time were associated with radial access site, and changes in pharmacology, but this was offset by greater proportion of ACS cases and the adverse patient clinical demographics. In conclusion, major bleeding complications after PCI have decreased due to changes in access site practice and decreased usage of GPIIb/IIIa inhibitors, but this is offset by the increase of patients with higher propensity to bleed. Changes in access site practice nationally have the potential to significantly reduce major bleeding after PCI.
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Abstract
OBJECTIVE Patients with previous stroke are increasing among patients receiving percutaneous coronary intervention (PCI) with drug-eluting stents (DES); however, data about the influence of previous stroke on patient outcomes are limited. We evaluated whether previous stroke is associated with increased risk for mortality in coronary artery disease. PATIENTS AND METHODS A total of 18 650 patients with coronary artery disease undergoing PCI with DES were enrolled. Databases from three real-world PCI registries were merged for a patient-level meta-analysis. The primary outcome was death from any cause. The secondary outcomes were death from a cardiac cause, myocardial infarction, stent thrombosis, stroke, or repeat revascularization. RESULTS Patients with previous stroke (n=1361), compared with those without previous stroke (n=17 289), were older and had a higher prevalence of risk factors or comorbidities. At a median follow-up of 47.0 months, patients with previous stroke had a higher risk for death from any cause [adjusted hazard ratio (HR)=1.623; 95% confidence interval (CI): 1.342-1.962; P<0.001], death from a cardiac cause (adjusted HR=1.686; 95% CI: 1.339-2.124; P<0.001), and stroke (adjusted HR=2.456; 95% CI: 1.853-3.255; P<0.001). There were no significant differences in the risks for myocardial infarction, stent thrombosis, or repeat revascularization. CONCLUSION Patients with previous stroke showed higher risks for all-cause death and stroke after PCI with DES than those without stroke. Previous stroke should be considered a risk factor for all-cause death and stroke in this patient population.
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Shah R, Askari R, Haji SA, Rashid A. Mortality and operator experience with vascular access for percutaneous coronary intervention in patients with acute coronary syndromes: A pairwise and network meta-analysis of randomized controlled trials. Int J Cardiol 2018; 248:114-119. [PMID: 28942869 DOI: 10.1016/j.ijcard.2017.05.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 02/27/2017] [Accepted: 05/05/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recently, several meta-analyses of randomized controlled trials (RCTs) have shown that transradial access (TRA) reduces mortality compared to transfemoral access (TFA). However, a critical appraisal of these RCTs suggests that the findings could have resulted from a greater incidence of adverse events in the TFA groups rather than a beneficial effect of TRA. METHODS Scientific databases and websites were searched for RCTs. Patients were divided into groups based on access type and whether the operator was a radial expert (RE) or non-radial expert (NRE). The groups were TFA-RE, TFA-NRE, TRA-RE, and TRA-NRE. Both a traditional meta-analysis and a network meta-analysis using mixed-treatment comparison models were performed. RESULTS Data from 13 trials including 15,615 patients were analyzed. The mortality rate for TFA-RE (3.54%) was more than double compared to TFA-NRE (1.61%). In pairwise meta-analysis, TFA-RE was associated with increased risk of mortality (RR: 1.72, 95% CI: 1.13-2.62; p=0.011) compared to TFA-NRE. In subgroup analysis, TFA-RE was associated with increased mortality (RR: 1.70, 95% CI: 1.24-2.34; p=0.001) compared to TRA, but TRA-NRE was not. Similarly, in mixed comparison models, TFA-RE was associated with increased mortality compared to TRA-NRE, TRA-RE, and TFA-NRE, but TFA-NRE was not, compared to TRA-RE and TRA-NRE. CONCLUSION Recently-reported survival differences between TRA and TFA may have been driven by adverse events in the TFA groups of the RCTs rather than a beneficial effect of TRA. This issue needs further investigation before labeling radial access a lifesaving procedure in invasively-managed patients with ACS.
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Affiliation(s)
- Rahman Shah
- Section of Cardiology, University of Tennessee, School of Medicine, Memphis, TN, United States; Veterans Affairs Medical Center, Memphis, TN, United States.
| | - Reza Askari
- Section of Cardiology, University of Tennessee, School of Medicine, Memphis, TN, United States
| | - Showkat A Haji
- Section of Cardiology, University of Tennessee, School of Medicine, Memphis, TN, United States
| | - Abdul Rashid
- Jackson Clinic, University of Tennessee, Jackson, TN, United States
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Ardati AK, Cohen DJ. Transradial Percutaneous Coronary Intervention... Works Great! Less Billing! Circ Cardiovasc Qual Outcomes 2018; 11:e004667. [PMID: 29743164 DOI: 10.1161/circoutcomes.118.004667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amer Kasim Ardati
- Department of Medicine, Division of Cardiology, University of Illinois Chicago, College of Medicine and Jesse Brown Veterans Affairs Medical Center Chicago (A.K.A.).
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, School of Medicine (D.J.C.)
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Mamas MA, Tosh J, Hulme W, Hoskins N, Bungey G, Ludman P, de Belder M, Kwok CS, Verin N, Kinnaird T, Bennett E, Curzen N, Nolan J, Kontopantelis E. Health Economic Analysis of Access Site Practice in England During Changes in Practice: Insights From the British Cardiovascular Interventional Society. Circ Cardiovasc Qual Outcomes 2018; 11:e004482. [PMID: 29743163 DOI: 10.1161/circoutcomes.117.004482] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/29/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with a reduced risk of mortality compared with transfemoral access, access site-related bleeding complications, and shorter length of stay. The budget impact from a healthcare system that has largely transitioned to TRA for PCI has not been previously published. METHODS AND RESULTS Data from 323 656 patients undergoing PCI between 2010 and 2014 were obtained from the British Cardiovascular Intervention Society database. Costs for TRA and transfemoral access PCI were estimated based on procedure cost, length of stay, and differences in the rates of complications (major bleeding and vascular complications). In the base case, a propensity-matched data set between transfemoral access and TRA was used to directly compare the cost per PCI, whereas in the real-world analysis, the full data set was used. Across all indications and all years, TRA offered an average cost saving of £250.59 per procedure (22% reduction) versus transfemoral access with the majority of cost saving derived from reduced length of stay (£190.43) rather than direct costs of complications (£3.71). In the real-world analysis, adoption of TRA was estimated to have provided cost savings of £13.31 million across England between 2010 and 2014; however, if operators in all regions had adopted TRA at the rate of the region with the highest utilization, cost savings of £33.40 million could have been achieved. CONCLUSIONS The transition to TRA in England has been associated with significant cost savings across the national healthcare system, in addition to the well-established clinical benefits.
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Affiliation(s)
- Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stokeon-Trent, United Kingdom (M.A.M., C.S.K., J.N.).
| | - Jon Tosh
- DRG Abacus, Bicester, Oxfordshire, United Kingdom (J.T., N.H., G.B., E.B.)
| | - Will Hulme
- Health eResearch Centre, Farr Institute for Health Informatics Research and Faculty of Medical and Human Sciences, University of Manchester, United Kingdom (W.H., E.K.)
| | - Nicki Hoskins
- DRG Abacus, Bicester, Oxfordshire, United Kingdom (J.T., N.H., G.B., E.B.)
| | - George Bungey
- DRG Abacus, Bicester, Oxfordshire, United Kingdom (J.T., N.H., G.B., E.B.)
| | - Peter Ludman
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, United Kingdom (P.L.)
| | - Mark de Belder
- Department of Cardiology, The James Cook University Hospital, Middlesbrough, United Kingdom (M.d.B.)
| | - Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stokeon-Trent, United Kingdom (M.A.M., C.S.K., J.N.)
| | | | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom (T.K.)
| | - Ewan Bennett
- DRG Abacus, Bicester, Oxfordshire, United Kingdom (J.T., N.H., G.B., E.B.)
| | - Nick Curzen
- Department of Cardiology, University Hospital Southampton and Faculty of Medicine, University of Southampton, United Kingdom (N.C.)
| | - James Nolan
- Keele Cardiovascular Research Group, Keele University, and Department of Cardiology, Royal Stoke Hospital, University Hospital North Midlands, Stokeon-Trent, United Kingdom (M.A.M., C.S.K., J.N.)
| | - Evangelos Kontopantelis
- Health eResearch Centre, Farr Institute for Health Informatics Research and Faculty of Medical and Human Sciences, University of Manchester, United Kingdom (W.H., E.K.)
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Kinnaird T, Cockburn J, Gallagher S, Choudhury A, Sirker A, Ludman P, de Belder M, Copt S, Mamas M, de Belder A. 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. Am Heart J 2018; 198:46-54. [PMID: 29653648 DOI: 10.1016/j.ahj.2018.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Abstract
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.
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Transradial Access for Primary Percutaneous Coronary Intervention: Catching On and Catching Up. JACC Cardiovasc Interv 2017; 10:2255-2257. [PMID: 29102574 DOI: 10.1016/j.jcin.2017.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 11/24/2022]
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25
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Rashid M, Rushton CA, Kwok CS, Kinnaird T, Kontopantelis E, Olier I, Ludman P, De Belder MA, Nolan J, Mamas MA. Impact of Access Site Practice on Clinical Outcomes in Patients Undergoing Percutaneous Coronary Intervention Following Thrombolysis for ST-Segment Elevation Myocardial Infarction in the United Kingdom. JACC Cardiovasc Interv 2017; 10:2258-2265. [DOI: 10.1016/j.jcin.2017.07.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/05/2017] [Accepted: 07/24/2017] [Indexed: 10/18/2022]
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26
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Valle JA, Kaltenbach LA, Bradley SM, Yeh RW, Rao SV, Gurm HS, Armstrong EJ, Messenger JC, Waldo SW. Variation in the Adoption of Transradial Access for ST-Segment Elevation Myocardial Infarction: Insights From the NCDR CathPCI Registry. JACC Cardiovasc Interv 2017; 10:2242-2254. [PMID: 29102582 DOI: 10.1016/j.jcin.2017.07.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/26/2017] [Accepted: 07/02/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The study sought to define patient, operator, and institutional factors associated with transradial access (TRA) in ST-segment elevation myocardial infarction (STEMI) percutaneous coronary intervention (PCI), the variation in use across operators and institutions, and the relationship with mortality and bleeding. BACKGROUND TRA for PCI in STEMI is underutilized. Factors associated with TRA are not well described, nor is there variation across operators and institutions or their relationship with outcomes. METHODS The authors used hierarchical logistic regression to identify patient, operator, and institutional characteristics associated with TRA use as well as determine the variation in TRA for STEMI PCI from 2009 to 2015. They also described the relationship between operator- and institution-level use and risk-adjusted bleeding and mortality. RESULTS Among 692,433 patients undergoing STEMI PCI, 12% (n = 82,618) utilized TRA. TRA increased from 2% to 23% from 2009 to 2015, but with significant geographic variation. Age, sex, cardiogenic shock, cardiac arrest, operators entering practice before 2012, and nonacademically affiliated institutions were associated with lower rates of TRA. There was significant operator and institutional variation, wherein identical patients would have >8-fold difference in odds of TRA for STEMI PCI by changing operators (median odds ratio: 8.7), and >5-fold difference by changing institutions (median odds ratio: 5.1). Greater TRA use across operators was associated with reduced bleeding (rho = -0.053), whereas TRA use across institutions was associated with reduced mortality (rho = -0.077). CONCLUSIONS Transradial access for STEMI PCI is increasing, but remains underutilized with significant geographic, operator, and institutional variation. These findings suggest an ongoing opportunity to standardize STEMI care.
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Affiliation(s)
- Javier A Valle
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Robert W Yeh
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sunil V Rao
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Hitinder S Gurm
- Division of Cardiovascular Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Ehrin J Armstrong
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado; Section of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado
| | - Stephen W Waldo
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado; Section of Cardiology, Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.
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Schernthaner C, Hammerer M, Harb S, Heigert M, Hoellinger K, Lassnig E, Maurer E, Schuler J, Siostrzonek P, Ulmer H, Winter A, Altenberger J. Radial versus femoral access site for percutaneous coronary intervention in patients suffering acute myocardial infarction. Wien Klin Wochenschr 2017; 130:182-189. [DOI: 10.1007/s00508-017-1260-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/18/2017] [Indexed: 11/24/2022]
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Vascular Access Site and Outcomes Among 26,807 Chronic Total Coronary Occlusion Angioplasty Cases From the British Cardiovascular Interventions Society National Database. JACC Cardiovasc Interv 2017; 10:635-644. [DOI: 10.1016/j.jcin.2016.11.055] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 11/30/2016] [Indexed: 11/21/2022]
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Efficacy of Radial Versus Femoral Access in the Acute Coronary Syndrome: Is it the Operator or the Operation That Matters? JACC Cardiovasc Interv 2016; 8:1405-1409. [PMID: 26404191 DOI: 10.1016/j.jcin.2015.06.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 06/23/2015] [Indexed: 11/23/2022]
Abstract
In the recently published MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX) trial, the use of transradial access (TRA) compared to transfemoral access (TFA) during percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) was associated with a reduction in net adverse cardiovascular events. However, the results of MATRIX must be interpreted with caution due to several limitations including the strong modulating effect of operator/center experience on the relative efficacy of TRA and the inclusion of 2 distinct patient populations (ST-segment elevation and non-ST-segment elevation ACS). Therefore, although important, the results of MATRIX have strong limitations and are not sufficient to definitively identify an approach of choice during PCI for ACS. Further research is needed before strong, evidence-based recommendations regarding the approach of choice during PCI for ACS can be made.
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Chang M, Lee CW, Ahn JM, Cavalcante R, Sotomi Y, Onuma Y, Zeng Y, Park DW, Kang SJ, Lee SW, Kim YH, Park SW, Serruys PW, Park SJ. Coronary Artery Bypass Grafting Versus Drug-Eluting Stents Implantation for Previous Myocardial Infarction. Am J Cardiol 2016; 118:17-22. [PMID: 27181565 DOI: 10.1016/j.amjcard.2016.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/06/2016] [Accepted: 04/06/2016] [Indexed: 11/25/2022]
Abstract
Patients with previous myocardial infarction (MI) have a high risk of recurrence. Little is known about the effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in patients with a previous MI and left main or multivessel coronary artery disease (CAD). We compared long-term outcomes of these 2 strategies in 672 patients with previous MI and left main or multivessel CAD, who underwent CABG (n = 349) or PCI with DES (n = 323). A pooled database from the BEST, PRECOMBAT, and SYNTAX trials was analyzed, and the primary outcome was a composite of death from any causes, MI, or stroke. Baseline characteristics were similar between the 2 groups. The median follow-up duration was 59.8 months. The rate of the primary outcome was significantly lower with CABG than PCI (hazard ratio [HR] 0.59, 95% CI 0.42 to 0.82; p = 0.002). This difference was driven by a marked reduction in the rate of MI (HR 0.29, 95% CI 0.16 to 0.55, p <0.001). The benefit of CABG over PCI was consistent across all major subgroups. The individual risks of death from any causes or stroke were comparable between the 2 groups. Conversely, the rate of repeat revascularization was significantly lower with CABG than PCI (HR 0.34, 95% CI 0.22 to 0.51, p <0.001). In conclusion, in the patients with previous MI and left main or multivessel CAD, compared to PCI with DES, CABG significantly reduces the risk of death from any causes, MI, or stroke.
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31
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Shah R. Invasive strategy in acute coronary syndrome. Lancet 2016; 387:2503. [PMID: 27353677 DOI: 10.1016/s0140-6736(16)30791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Rahman Shah
- School of Medicine, Section of Cardiovascular Medicine, Veterans Affairs Medical Center, University of Tennessee, Memphis, TN 38014, USA.
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Azzalini L, Jolicœur EM. The wise radialist's guide to optimal transfemoral access: Selection, performance, and troubleshooting. Catheter Cardiovasc Interv 2016; 89:399-407. [DOI: 10.1002/ccd.26577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/22/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Lorenzo Azzalini
- Interventional Cardiology; San Raffaele Scientific Institute; Milan Italy
| | - E. Marc Jolicœur
- Dept. of Medicine; Montreal Heart Institute, Université de Montréal; Québec Canada
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McCullough PA, Fallahzadeh MK, Tecson KM. Predicting Acute Kidney Injury in the Catheterization Laboratory ∗. J Am Coll Cardiol 2016; 67:1723-4. [DOI: 10.1016/j.jacc.2016.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/08/2016] [Indexed: 11/26/2022]
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Azzalini L, Jolicœur EM. Reply: A Remedy to the Paradoxical Increase of Femoral Access Complications: A Full Switch to the Radial Route for Cardiac Catheterization. JACC Cardiovasc Interv 2016; 9:505-6. [PMID: 26965942 DOI: 10.1016/j.jcin.2016.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 01/14/2016] [Indexed: 11/15/2022]
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Mamas MA, Nolan J, de Belder MA, Zaman A, Kinnaird T, Curzen N, Kwok CS, Buchan I, Ludman P, Kontopantelis E. Changes in Arterial Access Site and Association With Mortality in the United Kingdom: Observations From a National Percutaneous Coronary Intervention Database. Circulation 2016; 133:1655-67. [PMID: 26969759 DOI: 10.1161/circulationaha.115.018083] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 02/19/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The transradial access (TRA) site has become the default access site for percutaneous coronary intervention in the United Kingdom, with randomized trials and national registry data showing reductions in mortality associated with TRA use. This study evaluates regional changes in access site practice in England and Wales over time, examines whether changes in access site practice have been uniform nationally and across different patient subgroups, and provides national estimates for the potential number of lives saved or lost associated with regional differences in access site practice. METHODS AND RESULTS Using the British Cardiovascular Intervention Society database, we investigated outcomes for growth of TRA in different regions in England and Wales in 448 853 patients who underwent percutaneous coronary intervention from 2005 to 2012. Multiple logistic regression was used to quantify the effect of TRA on 30-day mortality and quantify lives saved and lost by differences in TRA adoption. TRA use increased from 14.0% to 58.6% in 417 038 PCI patients with large variations in different parts of the country. TRA was independently associated with a decreased risk of 30-day mortality (odds ratio=0.70; 95% confidence interval=0.66-0.74), with significant but small differences observed across different regions. The number of estimated lives saved was 450 (95% confidence interval=275-650), and we estimate that an additional 264 (95% confidence interval=153-399) lives would have been saved if TRA adoption were uniform nationally. CONCLUSIONS TRA has become the dominant percutaneous coronary intervention approach in the United Kingdom, with a wide variation in different parts of the country. Changes in practice have contributed to mortality reductions, and inequalities have resulted in missed opportunities for further improvements.
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Affiliation(s)
- Mamas A Mamas
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.).
| | - James Nolan
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Mark A de Belder
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Azfar Zaman
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Tim Kinnaird
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Nick Curzen
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Chun Shing Kwok
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Iain Buchan
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Peter Ludman
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
| | - Evangelos Kontopantelis
- From Keele Cardiovascular Research Group, University of Keele, Stoke-on-Trent, UK (M.A.M., J.N.); Farr Institute (M.A.M., I.B., E.K.) and Cardiovascular Institute (M.A.M., C.S.K.), University of Manchester, UK; University Hospital of North Midlands, Stoke-on-Trent, United Kingdom (M.A.M., J.N.); James Cook University Hospital, Middleborough, UK (M.A.d.B.); Freemans Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle-Upon-Tyne, UK (A.Z.); Department of Cardiology, University Hospital of Wales, Cardiff, UK (T.K.); University Hospital Southampton & Faculty of Medicine, University of Southampton, UK (N.C.); and Queen Elizabeth Hospital, Edgbaston, Birmingham, UK (P.L.)
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36
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Radial Access for Rescue Percutaneous Coronary Intervention: Underutilized and Underappreciated. JACC Cardiovasc Interv 2015; 8:1877-9. [PMID: 26718517 DOI: 10.1016/j.jcin.2015.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/05/2015] [Indexed: 10/22/2022]
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37
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Azzalini L, Tosin K, Chabot-Blanchet M, Avram R, Ly HQ, Gaudet B, Gallo R, Doucet S, Tanguay JF, Ibrahim R, Grégoire JC, Crépeau J, Bonan R, de Guise P, Nosair M, Dorval JF, Gosselin G, L'Allier PL, Guertin MC, Asgar AW, Jolicœur EM. The Benefits Conferred by Radial Access for Cardiac Catheterization Are Offset by a Paradoxical Increase in the Rate of Vascular Access Site Complications With Femoral Access: The Campeau Radial Paradox. JACC Cardiovasc Interv 2015; 8:1854-64. [PMID: 26604063 DOI: 10.1016/j.jcin.2015.07.029] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 07/30/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purpose of this study was to assess whether the benefits conferred by radial access (RA) at an individual level are offset by a proportionally greater incidence of vascular access site complications (VASC) at a population level when femoral access (FA) is performed. BACKGROUND The recent widespread adoption of RA for cardiac catheterization has been associated with increased rates of VASCs when FA is attempted. METHODS Logistic regression was used to calculate the adjusted VASC rate in a contemporary cohort of consecutive patients (2006 to 2008) where both RA and FA were used, and compared it with the adjusted VASC rate observed in a historical control cohort (1996 to 1998) where only FA was used. We calculated the adjusted attributable risk to estimate the proportion of VASC attributable to the introduction of RA in FA patients of the contemporary cohort. RESULTS A total of 17,059 patients were included. At a population level, the VASC rate was higher in the overall contemporary cohort compared with the historical cohort (adjusted rates: 2.91% vs. 1.98%; odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.17 to 1.89; p = 0.001). In the contemporary cohort, RA patients experienced fewer VASC than FA patients (adjusted rates: 1.44% vs. 4.19%; OR: 0.33, 95% CI: 0.23 to 0.48; p < 0.001). We observed a higher VASC rate in FA patients in the contemporary cohort compared with the historical cohort (adjusted rates: 4.19% vs. 1.98%; OR: 2.16, 95% CI: 1.67 to 2.81; p < 0.001). This finding was consistent for both diagnostic and therapeutic catheterizations separately. The proportion of VASCs attributable to RA in the contemporary FA patients was estimated at 52.7%. CONCLUSIONS In a contemporary population where both RA and FA were used, the safety benefit associated with RA is offset by a paradoxical increase in VASCs among FA patients. The existence of this radial paradox should be taken into consideration, especially among trainees and default radial operators.
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Affiliation(s)
- Lorenzo Azzalini
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Kunle Tosin
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Robert Avram
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Hung Q Ly
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Benoit Gaudet
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Richard Gallo
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Serge Doucet
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Réda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Jean C Grégoire
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Jacques Crépeau
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Raoul Bonan
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Pierre de Guise
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Mohamed Nosair
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Gilbert Gosselin
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Anita W Asgar
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - E Marc Jolicœur
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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38
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Desai NR, Bradley SM, Parzynski CS, Nallamothu BK, Chan PS, Spertus JA, Patel MR, Ader J, Soufer A, Krumholz HM, Curtis JP. Appropriate Use Criteria for Coronary Revascularization and Trends in Utilization, Patient Selection, and Appropriateness of Percutaneous Coronary Intervention. JAMA 2015; 314:2045-53. [PMID: 26551163 PMCID: PMC5459470 DOI: 10.1001/jama.2015.13764] [Citation(s) in RCA: 181] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Appropriate Use Criteria for Coronary Revascularization were developed to critically evaluate and improve patient selection for percutaneous coronary intervention (PCI). National trends in the appropriateness of PCI have not been examined. OBJECTIVE To examine trends in PCI utilization, patient selection, and procedural appropriateness following the introduction of Appropriate Use Criteria. DESIGN, SETTING, AND PARTICIPANTS Multicenter, longitudinal, cross-sectional analysis of patients undergoing PCI between July 1, 2009, and December 31, 2014, at hospitals continuously participating in the National Cardiovascular Data Registry CathPCI registry over the study period. MAIN OUTCOMES AND MEASURES Proportion of nonacute PCIs classified as inappropriate at the patient and hospital level using the 2012 Appropriate Use Criteria for Coronary Revascularization. RESULTS A total of 2.7 million PCI procedures from 766 hospitals were included. Annual PCI volume of acute indications was consistent over the study period (377,540 in 2010; 374,543 in 2014), but the volume of nonacute PCIs decreased from 89,704 in 2010 to 59,375 in 2014. Among patients undergoing nonacute PCI, there were significant increases in angina severity (Canadian Cardiovascular Society grade III/IV angina, 15.8% in 2010 and 38.4% in 2014), use of antianginal medications prior to PCI (at least 2 antianginal medications, 22.3% in 2010 and 35.1% in 2014), and high-risk findings on noninvasive testing (22.2% in 2010 and 33.2% in 2014) (P < .001 for all), but only modest increases in multivessel coronary artery disease (43.7% in 2010 and 47.5% in 2014, P < .001). The proportion of nonacute PCIs classified as inappropriate decreased from 26.2% (95% CI, 25.8%-26.6%) to 13.3% (95% CI, 13.1%-13.6%), and the absolute number of inappropriate PCIs decreased from 21,781 to 7921. Hospital-level variation in the proportion of PCIs classified as inappropriate persisted over the study period (median, 12.6% [interquartile range, 5.9%-22.9%] in 2014). CONCLUSIONS AND RELEVANCE Since the publication of the Appropriate Use Criteria for Coronary Revascularization in 2009, there have been significant reductions in the volume of nonacute PCI. The proportion of nonacute PCIs classified as inappropriate has declined, although hospital-level variation in inappropriate PCI persists.
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Affiliation(s)
- Nihar R Desai
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Steven M Bradley
- Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver4Department of Medicine, University of Colorado School of Medicine at the Anschutz Medical Campus, Aurora
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | | | - Paul S Chan
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri7Department of Medicine, University of Missouri-Kansas City
| | - John A Spertus
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri7Department of Medicine, University of Missouri-Kansas City
| | - Manesh R Patel
- Division of Cardiovascular Medicine, Duke Heart Center, Duke Clinical Research Institute, Duke Medicine, Durham, North Carolina
| | - Jeremy Ader
- Yale School of Medicine, New Haven, Connecticut
| | - Aaron Soufer
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut2Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
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39
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Gurm HS, Sanz-Guerrero J, Johnson DD, Jensen A, Seth M, Chetcuti SJ, Lalonde T, Greenbaum A, Dixon SR, Shih A. Using simulation for teaching femoral arterial access: A multicentric collaboration. Catheter Cardiovasc Interv 2015; 87:376-80. [PMID: 26489781 DOI: 10.1002/ccd.26256] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/16/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the impact of simulation training on complications associated with femoral arterial access obtained by first year cardiology fellows. BACKGROUND Prior studies demonstrate a higher incidence of arterial access related complications among patients undergoing invasive cardiac procedures. METHODS First year cardiology fellows at four teaching hospitals in Michigan tracked their femoral access experience and any associated complications between July 2011 and June 2013. Fellows starting their academic training in July 2012 were first trained on a specially developed simulator before starting their rotation in the catheterization laboratory. The primary outcome was access proficiency, defined as five successful femoral access attempts without any complication or need to seek help from a more experienced team member. RESULTS A total of 1,278 femoral access attempts were made by 21 fellows in 2011-2012 compared with 869 femoral access attempts made by 21 fellows in 2012-2013. There was a lower rate of access related complications in patients undergoing access attempts by first year fellows in year 2 compared with year 1 (2.1% versus 4.5%, P = 0.003). The number of procedures to achieve procedural proficiency was significantly higher in year 1 compared with year 2 (median 20 versus 10, P = 0.007). CONCLUSIONS Incorporation of simulation in the training of first year fellows was associated with an improvement in proficiency and a clinically meaningful reduction in vascular complications.
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Affiliation(s)
- Hitinder S Gurm
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jorge Sanz-Guerrero
- Facultades De Ingenieria Medicina Y Ciencias Biologicas, Instituto De Ingenieria Biologica Y Medica, Pontificia Universidad Catolica De Chile, Santiago, Chile.,Department of Mechanical Engineering, Wu Manufacturing Research Center University of Michigan, Ann Arbor, Michigan
| | - Daniel D Johnson
- Department of Mechanical Engineering, Wu Manufacturing Research Center University of Michigan, Ann Arbor, Michigan
| | - Andrea Jensen
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Milan Seth
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Stanley J Chetcuti
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Thomas Lalonde
- Department of Cardiovascular Medicine, St. John Hospital, Detroit, Michigan
| | - Adam Greenbaum
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Hospital, Royal Oak, Michigan
| | - Albert Shih
- Department of Mechanical Engineering, Wu Manufacturing Research Center University of Michigan, Ann Arbor, Michigan.,Biomedical Engineering, University of Michigan, Ann Arbor
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40
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Uddin M, Bundhoo S, Mitra R, Ossei-Gerning N, Morris K, Anderson R, Kinnaird T. Femoral Access PCI in a Default Radial Center Identifies High-Risk Patients With Poor Outcomes. J Interv Cardiol 2015; 28:485-92. [DOI: 10.1111/joic.12226] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Muezz Uddin
- Department of Cardiology; University Hospital of Wales, Heath Park, Cardiff CF14 4XW; United Kingdom
| | - Shantu Bundhoo
- Department of Cardiology; University Hospital of Wales, Heath Park, Cardiff CF14 4XW; United Kingdom
| | - Rito Mitra
- Department of Cardiology; University Hospital of Wales, Heath Park, Cardiff CF14 4XW; United Kingdom
| | - Nicholas Ossei-Gerning
- Department of Cardiology; University Hospital of Wales, Heath Park, Cardiff CF14 4XW; United Kingdom
| | - Keith Morris
- Cardiff Metropolitan University, Cardiff CF5 2YB; United Kingdom
| | - Richard Anderson
- Department of Cardiology; University Hospital of Wales, Heath Park, Cardiff CF14 4XW; United Kingdom
| | - Tim Kinnaird
- Department of Cardiology; University Hospital of Wales, Heath Park, Cardiff CF14 4XW; United Kingdom
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41
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Valgimigli M, Gagnor A, Calabró P, Frigoli E, Leonardi S, Zaro T, Rubartelli P, Briguori C, Andò G, Repetto A, Limbruno U, Cortese B, Sganzerla P, Lupi A, Galli M, Colangelo S, Ierna S, Ausiello A, Presbitero P, Sardella G, Varbella F, Esposito G, Santarelli A, Tresoldi S, Nazzaro M, Zingarelli A, de Cesare N, Rigattieri S, Tosi P, Palmieri C, Brugaletta S, Rao SV, Heg D, Rothenbühler M, Vranckx P, Jüni P. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet 2015; 385:2465-76. [PMID: 25791214 DOI: 10.1016/s0140-6736(15)60292-6] [Citation(s) in RCA: 888] [Impact Index Per Article: 98.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND It is unclear whether radial compared with femoral access improves outcomes in unselected patients with acute coronary syndromes undergoing invasive management. METHODS We did a randomised, multicentre, superiority trial comparing transradial against transfemoral access in patients with acute coronary syndrome with or without ST-segment elevation myocardial infarction who were about to undergo coronary angiography and percutaneous coronary intervention. Patients were randomly allocated (1:1) to radial or femoral access with a web-based system. The randomisation sequence was computer generated, blocked, and stratified by use of ticagrelor or prasugrel, type of acute coronary syndrome (ST-segment elevation myocardial infarction, troponin positive or negative, non-ST-segment elevation acute coronary syndrome), and anticipated use of immediate percutaneous coronary intervention. Outcome assessors were masked to treatment allocation. The 30-day coprimary outcomes were major adverse cardiovascular events, defined as death, myocardial infarction, or stroke, and net adverse clinical events, defined as major adverse cardiovascular events or Bleeding Academic Research Consortium (BARC) major bleeding unrelated to coronary artery bypass graft surgery. The analysis was by intention to treat. The two-sided α was prespecified at 0·025. The trial is registered at ClinicalTrials.gov, number NCT01433627. FINDINGS We randomly assigned 8404 patients with acute coronary syndrome, with or without ST-segment elevation, to radial (4197) or femoral (4207) access for coronary angiography and percutaneous coronary intervention. 369 (8·8%) patients with radial access had major adverse cardiovascular events, compared with 429 (10·3%) patients with femoral access (rate ratio [RR] 0·85, 95% CI 0·74-0·99; p=0·0307), non-significant at α of 0·025. 410 (9·8%) patients with radial access had net adverse clinical events compared with 486 (11·7%) patients with femoral access (0·83, 95% CI 0·73-0·96; p=0·0092). The difference was driven by BARC major bleeding unrelated to coronary artery bypass graft surgery (1·6% vs 2·3%, RR 0·67, 95% CI 0·49-0·92; p=0·013) and all-cause mortality (1·6% vs 2·2%, RR 0·72, 95% CI 0·53-0·99; p=0·045). INTERPRETATION In patients with acute coronary syndrome undergoing invasive management, radial as compared with femoral access reduces net adverse clinical events, through a reduction in major bleeding and all-cause mortality. FUNDING The Medicines Company and Terumo.
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Affiliation(s)
| | - Andrea Gagnor
- Cardiology Unit, Ospedali Riuniti di Rivoli, ASL Torino 3, Turin, Italy
| | - Paolo Calabró
- Division of Cardiology, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Enrico Frigoli
- Cardiology Unit, Ospedali Riuniti di Rivoli, ASL Torino 3, Turin, Italy; EUSTRATEGY Association, Forli', Italy
| | - Sergio Leonardi
- UOC Cardiologia, Dipartimento CardioToracoVascolare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Tiziana Zaro
- A.O. Ospedale Civile di Vimercate (MB), Vimercate, Italy
| | - Paolo Rubartelli
- Department of Cardiology, ASL3 Ospedale Villa Scassi, Genoa, Italy
| | | | - Giuseppe Andò
- Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", University of Messina, Messina, Italy
| | - Alessandra Repetto
- UOC Cardiologia, Dipartimento CardioToracoVascolare, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | | | | | | | | | | | | | | | - Gennaro Sardella
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic and Geriatric Sciences, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy
| | | | - Giovanni Esposito
- Division of Cardiology-Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | | | | | | | | | | | - Paolo Tosi
- Mater Salutis Hospital-Legnago, Verona, Italy
| | | | - Salvatore Brugaletta
- Hospital Clinic, University of Barcelona, Thorax Institute, Department of Cardiology, Barcelona, Spain
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, NC, USA
| | - Dik Heg
- Clinical Trials Unit, University of Bern, Bern, Switzerland; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium
| | - Peter Jüni
- Clinical Trials Unit, University of Bern, Bern, Switzerland; Institute of Primary Health Care, University of Bern, Bern, Switzerland
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42
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Howe MJ, Seth M, Riba A, Hanzel G, Zainea M, Gurm HS. Underutilization of Radial Access in Patients Undergoing Percutaneous Coronary Intervention for ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.114.002036. [DOI: 10.1161/circinterventions.114.002036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background—
The purpose of this study was to evaluate the frequency and temporal trends in use of transradial access (TRA) for percutaneous coronary intervention (PCI) in ST-segment–elevation myocardial infarction (STEMI). The use of TRA has been associated with less bleeding and improved clinical outcomes in patients undergoing PCI for STEMI.
Methods and Results—
The frequency of TRA compared with transfemoral access for patients undergoing PCI for STEMI or other indications (non–ST-segment–elevation myocardial infarction, unstable angina, and non–acute coronary syndrome) in The Blue Cross Blue Shield of Michigan Cardiovascular Consortium database between 2010 and 2013 was evaluated. Propensity matching was used to assess the relationship of TRA with in-hospital clinical end points of major bleeding, transfusion, and death. The TRA cohort of patients was stratified into deciles based on their predicted bleeding risk and compared with PCI indication. Of 122 728 PCI procedures, 17 912 (14.6%) were via TRA. Among patients with STEMI cases, 8.3% of the PCI cases were performed via TRA. The use of TRA increased over the study period although the growth was slower for STEMI than for other indications,
P
<0.001. The use of TRA for PCI in STEMI was associated with a lower rate of bleeding (11.7% versus 20.0%;
P
<0.001) and vascular complications (0.7% versus 2.6%;
P
=0.001), but no mortality difference (1.25% versus 2.33%;
P
=0.175). There was a strong negative association between the predicted risk of bleeding and the use of TRA (
P
<0.001).
Conclusions—
The use of radial access for PCI in STEMI is increasing but at a slower pace than for patients with other indications. TRA was associated with a reduction in bleeding and transfusion, but there is a strong negative correlation between the predicted risk of bleeding and actual use of TRA in STEMI.
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Affiliation(s)
- Michael J. Howe
- From the Division of Cardiovascular Medicine, Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor (M.J.H., M.S., H.S.G.); Division of Cardiovascular Medicine, Department of Medicine, Oakwood Healthcare System, Dearborn, MI (A.R.); Division of Cardiovascular Medicine, Department of Medicine, Beaumont Hospital, Royal Oak, MI (G.H.); and Division of Cardiovascular Medicine, Department of Medicine, McLaren Macomb, McLaren Healthcare, Mt. Clemens, MI (M.Z.)
| | - Milan Seth
- From the Division of Cardiovascular Medicine, Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor (M.J.H., M.S., H.S.G.); Division of Cardiovascular Medicine, Department of Medicine, Oakwood Healthcare System, Dearborn, MI (A.R.); Division of Cardiovascular Medicine, Department of Medicine, Beaumont Hospital, Royal Oak, MI (G.H.); and Division of Cardiovascular Medicine, Department of Medicine, McLaren Macomb, McLaren Healthcare, Mt. Clemens, MI (M.Z.)
| | - Arthur Riba
- From the Division of Cardiovascular Medicine, Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor (M.J.H., M.S., H.S.G.); Division of Cardiovascular Medicine, Department of Medicine, Oakwood Healthcare System, Dearborn, MI (A.R.); Division of Cardiovascular Medicine, Department of Medicine, Beaumont Hospital, Royal Oak, MI (G.H.); and Division of Cardiovascular Medicine, Department of Medicine, McLaren Macomb, McLaren Healthcare, Mt. Clemens, MI (M.Z.)
| | - George Hanzel
- From the Division of Cardiovascular Medicine, Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor (M.J.H., M.S., H.S.G.); Division of Cardiovascular Medicine, Department of Medicine, Oakwood Healthcare System, Dearborn, MI (A.R.); Division of Cardiovascular Medicine, Department of Medicine, Beaumont Hospital, Royal Oak, MI (G.H.); and Division of Cardiovascular Medicine, Department of Medicine, McLaren Macomb, McLaren Healthcare, Mt. Clemens, MI (M.Z.)
| | - Mark Zainea
- From the Division of Cardiovascular Medicine, Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor (M.J.H., M.S., H.S.G.); Division of Cardiovascular Medicine, Department of Medicine, Oakwood Healthcare System, Dearborn, MI (A.R.); Division of Cardiovascular Medicine, Department of Medicine, Beaumont Hospital, Royal Oak, MI (G.H.); and Division of Cardiovascular Medicine, Department of Medicine, McLaren Macomb, McLaren Healthcare, Mt. Clemens, MI (M.Z.)
| | - Hitinder S. Gurm
- From the Division of Cardiovascular Medicine, Department of Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor (M.J.H., M.S., H.S.G.); Division of Cardiovascular Medicine, Department of Medicine, Oakwood Healthcare System, Dearborn, MI (A.R.); Division of Cardiovascular Medicine, Department of Medicine, Beaumont Hospital, Royal Oak, MI (G.H.); and Division of Cardiovascular Medicine, Department of Medicine, McLaren Macomb, McLaren Healthcare, Mt. Clemens, MI (M.Z.)
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Vidovich MI, Khan AA, Xie H, Shroff AR. Radiation safety and vascular access: attitudes among cardiologists worldwide. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:109-15. [PMID: 25669957 DOI: 10.1016/j.carrev.2015.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 01/15/2015] [Accepted: 01/23/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To determine opinions and perceptions of interventional cardiologists on the topic of radiation and vascular access choice. BACKGROUND Transradial approach for cardiac catheterization has been increasing in popularity worldwide. There is evidence that transradial access (TRA) may be associated with increasing radiation doses compared to transfemoral access (TFA). METHODS We distributed a questionnaire to collect opinions of interventional cardiologists around the world. RESULTS Interventional cardiologists (n=5332) were contacted by email to complete an on-line survey from September to October 2013. The response rate was 20% (n=1084). TRA was used in 54% of percutaneous coronary interventions (PCIs). Most TRAs (80%) were performed with right radial access (RRA). Interventionalists perceived that TRA was associated with higher radiation exposure compared to TFA and that RRA was associated with higher radiation exposure that left radial access (LRA). Older interventionalists were more likely to use radiation protection equipment and those who underwent radiation safety training gave more importance to ALARA (as low as reasonably achievable). Nearly half the respondents stated they would perform more TRA if the radiation exposure was similar to TFA. While interventionalists in the United States placed less importance to certain radiation protective equipment, European operators were more concerned with physician and patient radiation. CONCLUSIONS Interventionalists worldwide reported higher perceived radiation doses with TRA compared to TFA and RRA compared to LRA. Efforts should be directed toward encouraging consistent radiation safety training. Major investment and application of novel radiation protection tools and radiation dose reduction strategies should be pursued.
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Affiliation(s)
- Mladen I Vidovich
- Department of Medicine, Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois.
| | - Asrar A Khan
- Department of Medicine, Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois
| | - Hui Xie
- Division of Epidemiology and Biostatistics and Cancer Center, University of Illinois at Chicago, Chicago, Illinois
| | - Adhir R Shroff
- Department of Medicine, Division of Cardiology, University of Illinois at Chicago, Chicago, Illinois
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