Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: an updated report from the national cardiovascular data registry (2007-2012)

Comparative Analysis of Transradial and Transfemoral Approaches in Transarterial Radioembolization for Liver Tumors: A Systematic Review and Meta-Analysis

PURPOSE

Transarterial radioembolization (TARE) is a minimally invasive therapy combining embolization and radiation for cancer treatment. This meta-analysis compares radiation exposure, quality of life, and safety of the transradial (TRA) versus transfemoral (TFA) approaches in TARE for liver tumors.

MATERIALS AND METHODS

We searched PubMed, SCOPUS, Cochrane, EMBASE, and Web of Science for studies comparing TRA versus TFA in TARE for liver tumors. Our primary outcomes focused on various measures of patient radiation exposure, including procedure time, fluoroscopy time, air kerma, and dose-area product (DAP). For secondary outcomes, we evaluated safety parameters, such as overall pain experienced during the procedure, pain in the recovery room post-procedure, the incidence of adverse events, and the impact on quality of life. Study quality was assessed using Cochrane's ROB 2 tool for RCTs and the Newcastle-Ottawa scale for observational studies. Data analysis was conducted with REVMAN 5.4.1 software.

RESULTS

Six studies, comprising one RCT and five cohort studies with 1,209 patients, underwent comprehensive analysis. The aggregated findings revealed a significant reduction in procedure duration associated with TRA (MD =- 6.30, 95% CI [- 9.88, - 2.73], P = 0.005). However, no statistically significant differences were found between TRA and TFA groups concerning fluoroscopy time, recovery time, air kerma, DAP, pain in the recovery room, overall pain during the procedure, quality of life measuring mental health and physical function or adverse events.

CONCLUSION

TRA and TFA showed comparable results in TARE for liver tumors, but TRA offered a shorter procedure time. Further RCTs with larger samples are needed to confirm these findings. Future studies should assess long-term efficacy for a more complete evaluation.

Safety and Efficacy of Radial Artery Access for Peripheral Vascular Intervention: A Single-Center Experience

Radial artery (RA) access has been increasingly utilized for coronary procedures because of lower rates of access-site complications and improved patient satisfaction. However, limited data are available for RA access for peripheral vascular intervention (PVI). We performed a retrospective review of 143 patients who underwent PVI through RA access from February 2020 to September 2022 at a single institution. Baseline characteristics and follow-up data were ascertained from a prospectively maintained institutional database. Of 491 PVI, 156 (31.8%) were performed through the RA. Anatomical locations for intervention were the femoral (44.8%), iliac (31.1%), popliteal (9.6%) peroneal (2.7%), tibial (9.9%), and subclavian (1.9%) arteries. Procedural access was obtained through the right RA (92.9%), left RA (4.5%), or right ulnar artery (2.6%) using the 6 French R2P Destination Slender sheath in 85, 105, and 119 cm lengths. Atherectomy was used in 34.7%. Mean contrast volume was 105.5 ml and the average fluoroscopy time was 18.5 minutes. Conversion to femoral access occurred in 3 cases (1.9%) because of arterial spasm and noncrossable lesions. Concomitant pedal access occurred in 2 cases (1.3%). Periprocedural complication rate was 3.84%, of which access-site hematoma was most common (3.2%); none required blood transfusion, surgical intervention, or additional hospital stay. There was 1 case (0.64%) of in-hospital stroke. The mortality rate at 30-day, 6-month, and 1-year was 1.4%, 2.8%, and 4.2%, respectively. In conclusion, RA access is feasible for diverse PVI, and future studies are needed to assess safety and benefit compared with femoral artery access.

Comparative Analysis of Right vs. Left Radial Access in Percutaneous Coronary Intervention: Impact on Silent Cerebral Ischemia

Background and Objectives: Silent cerebral ischemia (SCI) is defined as a condition that can be detected by biochemical markers or cranial imaging methods but does not produce clinical symptom. This study aims both to compare the frequency of SCI in PCIs performed with right transradial access and left transradial access and to evaluate the influencing factors. Materials and Methods: A prospective, single-center study included 197 patients undergoing PCI via transradial access between November 2020 and July 2022. The patients were categorized into right radial and left radial groups. Neuron-specific enolase (NSE) values were measured and recorded before and 18 h after the procedure. A post-procedure NSE level higher than 20 ng/dL was defined as SCI. Results: SCI occurred in 60 of the 197 patients. NSE elevation was observed in 37.4% (n = 37) of the right radial group and in 23.5% (n = 23) of the left radial group (p = 0.032). Patients with SCI had higher rates of smoking (p = 0.043), presence of subclavian tortuosity (p = 0.027), and HbA1c (p = 0.031). In the multivariate logistic regression analysis, the level of EF (ejection fraction) (OR: 0.958 95% CI 0.920-0.998, p = 0.039), right radial preference (OR: 2.104 95% CI 1.102-3.995 p = 0.023), and smoking (OR: 2.088 95% CI 1.105-3.944, p = 0.023) were observed as independent variables of NSE elevation. Conclusions: Our findings suggest that PCI via right radial access poses a greater risk of SCI compared to left radial access. Anatomical considerations and technical challenges associated with right radial procedures and factors such as smoking and low ejection fraction contribute to this elevated risk.

Sex and Racial Disparities in Proportionate Mortality of Premature Myocardial Infarction in the United States: 1999 to 2020

BACKGROUND

The incidence of premature myocardial infarction (PMI) in women (<65 years and men <55 years) is increasing. We investigated proportionate mortality trends in PMI stratified by sex, race, and ethnicity.

METHODS AND RESULTS

CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) was queried to identify PMI deaths within the United States between 1999 and 2020, and trends in proportionate mortality of PMI were calculated using the Joinpoint regression analysis. We identified 3 017 826 acute myocardial infarction deaths, with 373 317 PMI deaths corresponding to proportionate mortality of 12.5% (men 12%, women 14%). On trend analysis, proportionate mortality of PMI increased from 10.5% in 1999 to 13.2% in 2020 (average annual percent change of 1.0 [0.8-1.2, P <0.01]) with a significant increase in women from 10% in 1999 to 17% in 2020 (average annual percent change of 2.4 [1.8-3.0, P <0.01]) and no significant change in men, 11% in 1999 to 10% in 2020 (average annual percent change of -0.2 [-0.7 to 0.3, P=0.4]). There was a significant increase in proportionate mortality in both Black and White populations, with no difference among American Indian/Alaska Native, Asian/Pacific Islander, or Hispanic people. American Indian/Alaska Natives had the highest PMI mortality with no significant change over time.

CONCLUSIONS

Over the last 2 decades, there has been a significant increase in the proportionate mortality of PMI in women and the Black population, with persistently high PMI in American Indian/Alaska Natives, despite an overall downtrend in acute myocardial infarction-related mortality. Further research to determine the underlying cause of these differences in PMI mortality is required to improve the outcomes after acute myocardial infarction in these populations.

Incidence and Prognostic Factors of Radial Artery Occlusion in Transradial Coronary Catheterization

Background/Objectives: Radial artery occlusion (RAO) is the most common complication of transradial coronary catheterization. In this study, we aimed to evaluate the incidence of RAO and identify the risk factors that predispose patients to it. Methods: We conducted an investigator-initiated, prospective, multicenter, open-label study involving 1357 patients who underwent cardiac catheterization via the transradial route for angiography and/or a percutaneous coronary intervention (PCI). Univariate and multivariate logistic regression analyses were performed to identify potential predictors of RAO occurrence. Additionally, a subgroup analysis only for patients undergoing PCIs was performed. Results: The incidence of RAO was 9.5% overall, 10.6% in the angiography-only group and 6.2% in the PCI group. Independent predictors of RAO were as follows: (i) the female gender (aOR = 1.72 (1.05-2.83)), (ii) access site cross-over (aOR = 4.33 (1.02-18.39)), (iii) increased total time of the sheath in the artery (aOR = 1.01 (1.00-1.02)), (iv) radial artery spasms (aOR = 2.47 (1.40-4.36)), (v) the presence of a hematoma (aOR = 2.28 (1.28-4.06)), (vi) post-catheterization dabigatran use (aOR = 5.15 (1.29-20.55)), (vii) manual hemostasis (aOR = 1.94 (1.01-3.72)) and (viii) numbness at radial artery ultrasound (aOR = 8.25 (1.70-40)). Contrariwise, two variables were independently associated with increased odds for radial artery patency (RAP): (i) PCI performance (aOR = 0.19 (0.06-0.63)), and (ii) a higher dosage of intravenous heparin per patient weight (aOR = 0.98 (0.96-0.99)), particularly, a dosage of >50 IU/kg (aOR = 0.56 (0.31-1.00)). In the PCI subgroup, independent predictors of RAO were as follows: (i) radial artery spasms (aOR = 4.48 (1.42-14.16)), (ii) the use of intra-arterial nitroglycerin as a vasodilator (aOR = 7.40 (1.67-32.79)) and (iii) the presence of symptoms at echo (aOR = 3.80 (1.46-9.87)), either pain (aOR = 2.93 (1.05-8.15)) or numbness (aOR = 4.66 (1.17-18.57)). On the other hand, the use of intra-arterial verapamil as a vasodilator (aOR = 0.17 (0.04-0.76)) was independently associated with a greater frequency of RAP. Conclusions: The incidence of RAO in an unselected, all-comers European population after transradial coronary catheterization for angiography and/or PCIs is similar to that reported in the international literature. Several RAO prognostic factors have been confirmed, and new ones are described. The female gender, radial artery trauma and manual hemostasis are the strongest predictors of RAO. Our results could help in the future identification of patients at higher risk of RAO, for whom less invasive diagnostic procedures maybe preferred, if possible.

Transradial access for cerebral angiography and neurointerventional procedures: A meta-analysis and systematic review

PURPOSE

Transradial access (TRA) for diagnostic and interventional neurointerventional procedures has recently gained traction over transfemoral access (TFA) in the neurointerventional community. This meta-analysis aims to assess and summarize the utility of TRA in cerebral angiography and neurointerventional procedures.

METHODS

A systematic literature review was performed utilizing Pubmed, Embase, and Scopus databases. Using PRISMA guidelines, records were extracted with the following search terms: transradial approach, transradial access, radial access, cerebral angiogram, cerebral angiography, neurointervention, and neuroendovascular. The primary outcomes assessed were case success rate, complication rate, and crossover rate from TRA to TFA. Secondary analysis was performed on procedure time, fluoroscopy time, fluoroscopy time per vessel (diagnostic procedures only), contrast dose, radial artery diameter, distal radial artery diameter, and patient preference for TRA over TFA.

RESULTS

Sixty-two full-text articles were analyzed for this meta-analysis, representing 12,927 diagnostic and interventional TRA access patients. Our analysis revealed a combined diagnostic and interventional case success rate of 95.9% and complication rate of 3.5%, with crossover to TFA occurring in 4.9% of cases.

CONCLUSION

This meta-analysis demonstrates that TRA access for diagnostic angiography and neurointerventional procedures is a safe and effective approach, though determining a true complication rate is challenging as the definition of TRA complications has changed in various publications over time.

Distal Versus Proximal Radial Artery Access for Cardiac Catheterization: 1-Year Outcomes

Proximal radial artery (PRA) access for cardiac catheterization is safe but can jeopardize subsequent use of the artery because of occlusion. Distal radial artery (DRA) access in the anatomical snuffbox preserves the RA but safety and potential detrimental effects on hand function are unknown. We aimed to assess hand function and complications after DRA and PRA. In this single-center trial, 300 patients were randomly allocated 1:1 to cardiac catheterization through DRA or PRA. The primary end point of change in hand function from baseline to 1 year was a composite of the Quick Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, hand grip test, and thumb-forefinger pinch test. The secondary end points included access feasibility and complications. Of 216 patients with 1-year completed follow-up, 112 were randomly allocated to DRA and 104 to PRA, with balanced demographics and procedural characteristics. Both groups had similar access site bleeding rates (DRA 0% vs PRA 1.4%, p = 0.25). Radial artery occlusion occurred in 1 PRA patient versus 2 in DRA. There was no significant difference in change of hand function, median (interquartile range) hand grip (DRA 0.7 [-3 to 4.5] vs PRA 1.3 [-2 to 4.3] kg, p = 0.57), pinch grip (DRA -0.1 [-1.1 to 1] vs PRA -0.3 [-1 to 0.7] kg, p = 0.66), and Quick DASH (DRA 0 [-6.6 to 2.3] vs PRA 0 [-4.6 to 2.9] points, p = 0.58). The composite of hand function was comparable between PRA and DRA. In conclusion, DRA is a safe strategy for cardiac catheterization, with a low complication rate. Compared with PRA, there is no increased risk of hand dysfunction or radial artery occlusion at 1 year.

Radial Artery Occlusion After Transradial Access for Coronary Interventions

Background Transradial access (TRA) is a medical procedure primarily used for percutaneous coronary interventions (PCI) and cardiac catheterization. Based on the recently published Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of AngioX (MATRIX) trial, TRA is being used more frequently than transfemoral access (TFA) since it has reduced rates of bleeding and fatality. A structural complication of TRA is radial artery occlusion (RAO), which may cause temporary pain to limit TRA in the future. Objective This study aimed to investigate the onset and risk factors of RAO following TRA for coronary interventions. Material and methods An observational study was conducted at Fauji Foundation Hospital in Peshawar, Pakistan. The study included 1,680 patients recruited between April 2021 to December 2023. Fifty-eight patients were lost to follow-up, while another 95 patients did not come for a visit within the study period. The final study, therefore, included 1,527 patients. Results The mean age of patients was 58.09 ± 8.07 years. Patients were divided into two age groups (greater or less than 60 years). Diagnostic angiograms were completed for 955 patients, while 572 also underwent PCI. The overall RAO onset was 81 (5.3%). There was a significantly higher RAO onset in patients over 60 years old (7.1 vs 3.8%, p = 0.003). Conclusion Overall, the risk of RAO is low following TRA. The risk of RAO is significantly higher in people aged over 60 years.

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

BACKGROUND

There are many percutaneous coronary approaches. The most commonly used one is the radial artery because of its lowest risk of adverse vascular events. However, it could not be an option in some situations as congenital radial artery hypoplasia and spasm. In these cases, the second most common access is the femoral artery. The current literature over the brachial artery access is controversial. Thus, the aim of this study was to verify the brachial artery approach's effectiveness and safety.

RESULTS

We studied 300 patients who underwent elective coronary angiography and angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients with brachial access and 150 with femoral access. Access, procedural and fluoroscopy times were recorded. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, P = 0.05), but no significant difference noted regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not significantly differ (P = 0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ± 1.1 vs. 3.4 ± 0.7 min, P = 0.05) and hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, P < 0.001). Regarding major and minor complications (especially hematomas), they were significantly less in the brachial arm (P = 0.04 and P = 0.05, respectively).

CONCLUSIONS

Brachial access is a safe, efficient and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

Distal Versus Proximal Radial Artery Access for Cardiac Catheterization: 30-Day Outcomes of the DIPRA Study

Background Proximal radial artery (pRA) access for cardiac catheterization is safe but can jeopardize subsequent use of the artery because of occlusion. Distal radial artery (dRA) access in the anatomical snuffbox preserves the radial artery, but safety and potential detrimental effects on hand function are unknown. Methods and Results In the DIPRA (Distal Versus Proximal Radial Artery Access for Cardiac Catheterization and Intervention) study, a single-center trial, 300 patients were randomized 1:1 to cardiac catheterization through dRA or pRA. The primary end point of change in hand function from baseline to 30 days was a composite of the QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) questionnaire, hand-grip test, and thumb forefinger pinch test. Secondary end points included access feasibility and complications; 254 of 300 patients completed follow-up at 30 days; of these, 128 were randomized to dRA and 126 to pRA with balanced demographic and procedural characteristics. Both groups had similar rates of access site bleeding (dRA 0% versus pRA 1.4%; P=0.25). Six patients with dRA failed access compared with 2 patients with pRA. Radial artery occlusion occurred in 2 pRA versus none in dRA. There were no significant differences in change in hand function, median hand-grip (dRA 0 [-3.2, 3.3] versus pRA 0.7 [-2.3, 3.3] kg; P=0.21), pinch-grip (dRA -0.3 [-1.2, 0.5] versus pRA 0 [-0.9, 0.9] kg; P=0.09), and QuickDASH (dRA 0 [-4.6, 2.3] versus pRA 0 [-4.6, 2.3] points, P=0.96). There was no significant difference in the composite of hand function between pRA and dRA. Conclusions dRA is a safe strategy for cardiac catheterization with a low complication rate. Compared with pRA, there is no increased risk of hand dysfunction at 30 days. Registration URL: https://www.ClinicalTrials.gov. Unique identifier: NCT04318990.

Transradial Access for Transarterial Radioembolization (TARE) in Patients with Hepatocellular Carcinoma: Comparison with Transfemoral Access

PURPOSE

To compare safety, efficacy, radiation exposure and patients comfort in patients of transradial access (TRA) in patients undergoing TARE compared with transfemoral access (TFA) including patient radiation exposure and patient comfort.

METHODS

A total of 222 patients undergoing technetium-99 m macro-aggregated albumin and TARE were retrospectively reviewed from 2017 to 2022. We analyzed procedure-related pain, quality of life, recovery time, procedure time, fluoroscopy time (FT), air kerma product and air kerma (AK) to compare the two access for intervention for HCC.

RESULTS

A total of 222 [(TFA (n = 147) and TRA (n = 75)] patients who underwent TARE for hepatocellular carcinoma (HCC) were included. No significant difference was found regarding FT and DAP in comparison of TRA and TFA. (p = 0.385, p = 0.842). While the mean AK was 892.7 mGy in TFA patients, it was 545.2 mGy in TRA patients and there was statistically significant difference (p = 0.017). Patients who underwent TRA had significantly shorter hospital stays, and recovery times compared to those who underwent TFA (p = 0.001, p = 0.001). In terms of both mental health and physical function, TRA versus TFA has been observed to produce more favorable outcomes (p = 0.044, p = 0.032).

CONCLUSION

TRA access for TARE procedures significantly enhances patient comfort and satisfaction. The total radiation dose exposed to the patients who underwent TRA access was found to be significantly lower than the patients who underwent TFA access.

Outcomes of same-day discharge following percutaneous coronary intervention in a rural population

BACKGROUND

Same-day discharge (SDD) following percutaneous coronary intervention (PCI) is safe, yet the nationwide rate of SDD remains low. The impact that residing in a rural area has on the safety of SDD is unknown.

OBJECTIVE

To investigate the safety of SDD compared to next-day discharge (NDD) among PCI patients living in a largely rural area.

METHODS

There were 3502 outpatient elective PCIs at a tertiary care center between January 1, 2011 and December 31, 2017. Data from the National Cardiovascular Data Registry CathPCI Registry® and the electronic medical records were obtained for patient demographics, procedural characteristics, and procedural outcomes. Data from the initial PCI in each 365-day period were included in the analysis for each patient. Rural-Urban Commuting Area codes 4-10 were used to define rural status.

RESULTS

A total of 2099 (59.9%) PCIs met the inclusion criteria (63% rural). The overall rate of SDD increased over time (4.7% in 2011 to 39.6% in 2017) as radial access increased (14.2% in 2011 to 59.9% in 2017). In this population, a total of 329 PCIs had SDD (15.7%; median (interquartile range) age 66.0 (14.0) years, 20.1% female, 52.3% rural status). Compared to NDD, SDD patients had less hyperlipidemia, atrial fibrillation, congestive heart failure, history of coronary artery bypass graft, and more radial access. SDD was noninferior to NDD for 30-day readmission but had a decreased 1-year (adjusted odds ratio [aOR]: 0.20, 95% confidence interval [CI]: 0.05-0.81, p = 0.024) and 5-year (aOR: 0.43, 95% CI: 0.28-0.66, p < 0.001) all-cause mortality compared to NDD. Rural status did not predict outcomes.

CONCLUSIONS

SDD in patients in rural areas does not have a significantly higher rate of 30-day readmission. SDD patients had lower odds of 1- and 5-year mortality when compared to NDD. Future studies prospectively evaluating the safety of SDD in this population are warranted.

Predictors of radial to femoral artery crossover during primary percutaneous coronary intervention in ST-elevation myocardial infarction: A systematic review and meta-analysis

BACKGROUND

In contrast to traditional femoral artery access, radial artery access for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding but has higher crossover rates. Therefore, factors associated with crossover warrant exploration as crossover due to technical challenges associated with the radial route may be mitigated.

OBJECTIVE

The objective of this study was to identify predictors of radial access failure or crossover to femoral access in PPCI.

METHODS

A systematic review and meta-analysis was undertaken according to the Joanna Briggs Institute Systematic Reviews Checklist with searches conducted in Medline, EMBASE, CINAHL, and SCOPUS databases. Inclusion criteria for this study included patients with STEMI; PPCI; and primary research identifying predictors of radial access failures and/or crossovers, published in English, and after 2010. This study was registered with PROSPERO (CRD42020167122). Statistical analysis was performed using IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, NY) and RevMan version 5.4 (Cochrane Collaboration, London, United Kingdom) with meta-analysis conducted by using the DerSimonian and Laird random-effects method. The National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was utilised for quality and risk of bias assessment, with EndNote software used for citations.

RESULTS

Eight observational studies met inclusion criteria, comprising 12,621 patients. Risk of bias of these studies was assessed using the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The mean age was 61.2 ± 12.0 years, and 75.3% were male. Crossover from transradial to transfemoral artery occurred in 529 (4.2%) patients. Reasons for radial access failure included failed puncture (35.3%), peripheral occlusion or tortuosity (24.5%), and radial artery spasm (20.1%). Predictors of crossover included older age (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.44-2.65; p < 0.001), female sex (OR, 2.10; 95% Cl, 1.58-2.80; p < 0.001), weight ≤65 kg (OR, 2.95; 95% CI, 1.95-4.46; p < 0.001), and previous percutaneous coronary intervention (OR, 2.80; 95% Cl, 1.74-4.52; p < 0.001).

CONCLUSION

Older age, female sex, weight ≤65 kg, and previous percutaneous coronary intervention were predictors of crossover or failure from the radial to femoral artery. As these predictors are known to be associated with high bleeding and mortality, they should not preclude attempting a radial-first approach in all patients with STEMI. However, as these results were unadjusted, this study warrants further research to thoroughly investigate predictors of radial artery crossover.

Feasibility and safety of Post-Urgent PCI Same-DaY discharge (PUSDY Trial) in China: protocol for a multicentre randomised controlled trial

INTRODUCTION

In the Chinese healthcare system, where there is overcrowding in hospitals, especially in tertiary care centres, adoption of same-day discharge (SDD) post-percutaneous coronary intervention (PCI) could potentially lead to significant savings of healthcare resources and costs. This study is a non-inferiority trial examining whether post-PCI SDD is feasible in China. The primary hypothesis is that patient outcomes in post-urgent PCI SDD patients are non-inferior to regular discharge patients.

METHODS AND ANALYSIS

Post-Urgent PCI Same-DaY is an investigator-initiated multicentre randomised unblinded clinical non-inferiority trial, with 1:1 centralised randomisation to the SDD or usual care (UC) group. Based on sample size calculations, 1296 patients from at least three hospitals, with mild to moderate myocardial infarction, will be included, and acute coronary syndrome patients will be excluded. All patients will receive UC while patients assigned to the SDD group will be discharged on the same day or within 12 hours post-PCI. The primary outcome is major adverse cardiovascular and cerebrovascular events 30 days after discharge. The secondary outcomes are all-cause mortality, bleeding and access site complications. The outcome rates will be compared between groups with the absolute risk difference with a 95% CI.

ETHICS AND DISSEMINATION

The study protocol V.2.0 has been approved on 21 January 2022 by the Ethics Committee of Beijing Anzhen Hospital, Capital Medical University (approval number: 2021 KLSD No. 23). The outcomes of this study will be disseminated through a peer-reviewed journal and presented at international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR 2200057065; China Clinical Trial Registration.

Distal radial artery access is a safe and feasible technique in the anatomical snuffbox for visceral intervention

Regarding the site of arterial access during the intervention, transracial intervention can reduce the risk of bleeding and vessel-related complications as well as improve patient comfort. Importantly, the distal radial artery (DRA) approach may reduce the incidence of radial artery occlusion and digital ischemia, but the feasibility and safety of DRA in performing subdiaphragmatic vascular interventions remain unclear. From January 2018 to December 2019, 106 patients were admitted to our department for visceral angiography and intervention by left distal radial artery accessing in an anatomical snuffbox. In total, 152 times of vascular interventions were performed during this period. Patients demographics, procedure details, technical success, and access site-related complications were recorded and evaluated. The mean age was 58.9 (range 22-86) years. Males accounted for 80.2%. Thirty-five patients (33%) had 2 or more procedures via the DRA approach. Technical success was achieved for 96.1% of procedures (146 cases) and 3.9% of cases failed to perform the intended procedure via the DRA approach (6 cases). The 4-Fr sheath was used in 86.8% of cases, and the 5 Fr sheath was used in the rest of the 13.2% of procedures. The rate of asymptomatic radial artery occlusion was 5.7% (6 of 106 patients). No patient suffered from distal limb ischemia after a long-time follow-up. Eight patients suffered postoperative local pain, transient numbness, or local bruised in the anatomical snuffbox without major complications. Patients with postoperative complications recovered quickly by using nonsteroidal anti-inflammatory drugs or without further treatment. Left distal radial artery access is safe and feasible as a new technique for visceral angiography and intervention.

Clinical and Radiographic Predictors of Successful Coronary Angiography Through Right Radial Artery Access

Background: One of the limitations of the right radial access approach is complex vessel anatomy, such as subclavian tortuosity. Several clinical predictors have been proposed for tortuosities, such as older age, female sex and hypertension. In this study, we hypothesised that chest radiography would add predictive value to the traditional predictors. Methods: This prospective blinded study included patients who underwent transradial access coronary angiography. They were classified into four groups according to difficulty: Group I, Group II, Group III and Group IV. Different groups were compared according to clinical and radiographic characteristics. Results: The study included 108 patients (54, 27, 17 and 10 patients in Groups I, II, III and IV, respectively). The rate of crossover to transfemoral access was 9.26%. Age, hypertension and female sex were associated with a greater difficulty and failure rates. Regarding radiographic parameters, a higher failure rate was associated with a higher diameter of the aortic knuckle (Group IV, 4.09 ± 1.32 cm versus Groups I, II and III combined, 3.26 ± 0.98 cm; p=0.015) and the width of the mediastinum (Group IV, 8.96 ± 2.88 cm versus Groups I, II and III combined, 7.28 ± 1.78 cm; p=0.009). The cut-off value for prominent aortic knuckle was 3.55 cm (sensitivity 70% and specificity 67.35%) and the width of mediastinum was 6.59 cm (sensitivity 90% and specificity 42.86%). Conclusion: Radiographic prominent aortic knuckle and wide mediastinum are valuable clinical parameters and useful predictors for transradial access failure caused by tortuosity of the right subclavian/brachiocephalic arteries or aorta.

Rates of the Trans-radial Approach in Elective and Emergency Coronary Angiography in Iraq: A Cross-Sectional Study

Background and aims The trans-radial access is becoming the default approach in many cardiac centers worldwide. Data from the Middle East, including Iraq, on the trends and rates of the use of trans-radial access are scarce. The aim of this study is to determine the rates of trans-radial approach (TRA) versus transfemoral approach (TFA) in patients with coronary artery syndromes undergoing coronary angiography and/or percutaneous coronary intervention (PCI) in Iraq. Methods In this multicenter prospective study, we collected 885 cases of coronary artery disease undergoing coronary angiography/PCI from three main cities of the Kurdistan Region in Iraq from 2022 to 2023. Results Of the total sample, 57.2% were diagnostic coronary angiography and 42.8% were PCI, 57.1% of all cases were TFA and 42.9% were TRA, and 64.3% of PCI cases were performed through TFA. Eghty-two percent of total emergency PCI included (primary PCI) cases underwent the procedure through the TFA, and only 18% of such cases were through the TRA. The overall crossover rate between both approaches happened in 14 (3.6%) cases. Conclusions Despite its main benefits, the radial access use in the Cath lab is yet underused in our region. Further steps in training programs are indicated to popularize the use of radial access among interventional cardiologists in addition to transfemoral access.

PRECISE-DAPT and ARC-HBR Predict in-Hospital Outcomes in Patients Who Underwent Percutaneous Coronary Intervention

Bleeding events result in morbidity and mortality in patients who underwent percutaneous coronary intervention (PCI). There are limited data on the predicting bleeding complications in patients who underwent stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) and Academic Research Consortium for High Bleeding Risk (ARC-HBR) scores' ability to predict in-hospital outcomes in patients who underwent PCI. Consecutive patients who underwent PCI at tertiary centers from January 2016 to March 2018 were identified and the bleeding risk scores were calculated. The primary end point was the National Cardiovascular Data Registry-defined in-hospital bleeding stratified by low versus high predicted bleeding risk. The major and net adverse cardiovascular events were also examined. The discriminatory ability of the risk models was determined using receiver operating characteristic curves. Among 3,659 patients studied, the in-hospital major bleeding was 3.3% (n = 121). The patients characterized as high bleeding risk by either criterion had significantly higher bleeding rates than those meeting the low-risk criteria (ARC-HBR 5.4% vs 3.3%, p <0.001; PRECISE-DAPT 5.8% vs 2.4%, p <0.001), and higher major adverse cardiovascular events and net adverse clinical events. These risk estimates showed moderate and similar predictive ability (ARC-HBR high-risk area under the receiver operating characteristic curve [AUC] 0.62, PRECISE-DAPT ≥25 AUC 0.61, p = 0.49), with no incremental benefit to adding the estimates (AUC 0.60). The subgroup analysis revealed that women had higher bleeding rates than men (5.53% vs 2.39%, p <0.001); however, the predictive ability of the criteria were similar in women and men. The patients identified as having a high bleeding risk by the PRECISE-DAPT and the ARC-HBR criteria before PCI are at high risk for in-hospital bleeding and adverse outcomes independent of gender. The 2 scores have moderate predictive ability for bleeds. Further study is needed to determine strategies to reduce risk in this population.

Radial arterial access is a safe alternative to brachial artery and femoral artery access for endovascular lower extremity peripheral arterial disease

OBJECTIVE

Radial artery access is a well-described technique that has proven to be safe and efficacious in percutaneous cardiac intervention. This technique has been used with increased frequency in the treatment of lower extremity peripheral arterial disease (LE-PAD); however, the overall safety has not yet been well described in the vascular surgery literature. We sought to evaluate the safety of this technique compared with retrograde femoral artery access and brachial artery access (BA) in the treatment of PAD.

METHODS

The Vascular Quality Initiative database was used to identify all patients who underwent single site percutaneous access (retrograde femoral access [FA], BA, radial access [RA]) for treatment of LE-PAD from September 2016 through September 2019. Patients who underwent multiple access sites for intervention were excluded. Primary outcome was significant access site complications (ASCs), defined as those requiring treatment (blood transfusion, interventional treatment, or surgical treatment). Minor ASCs were also reported.

RESULTS

The cohort comprised 61,203 patients (270 RA, 1210 BA, and 59,723 FA) with an average age of 68 years and who were 59.6% male. The RA and BA groups had higher rates of prior endarterectomy or bypass compared with the FA group (66.7% RA; 86.0% BA; 50.2% FA; P < .001). RA was more often used for single-segment treatments (82% vs 74% [P < .020] and more aortoiliac arterial segments (59.6% vs 21.0% [P < .001]). ASC occurred in 1329 patients (2.7%), including minor ASC (996 [1.6%]) and significant ASC (333 [0.54%]). Significant ASC were less common after FA and RA compared with BA (RA, 1 [0.37%]; FA, 307 [0.51%]; BA, 25 [2.1%]; P < .001). On multivariate analysis, BA was the strongest predictor of significant ASC (odds ratio, 2.75; 95% confidence interval, 1.73-4.36; P < .001). Significant ASC was no different after RA compared with FA (odds ratio, 0.60; 95% confidence interval, 0.08-4.33; P = .616). Other factors independently associated with significant ASC were sex, age, diabetes, chronic obstructive pulmonary disease, dialysis, and closure device use.

CONCLUSIONS

RA as the primary access vessel for endovascular treatment of LE-PAD is safe when compared with other traditional access sites. When FA is not possible or desirable, the radial approach may provide suitable access to treatment with a better safety profile than BA.

Transradial Mechanical Thrombectomy Using a Radial-specific Neurointerventional Guiding Sheath for Anterior Circulation Large-Vessel Occlusions: Preliminary Experience and Literature Review

BACKGROUND

Transradial mechanical thrombectomy (MT) is increasingly used because it is associated with a low incidence of vascular access site complications. However, transradial carotid cannulation can be technically challenging to perform in patients with an unfavorable supra-aortic takeoff. In this study, the feasibility and safety of a new transradial MT system with a radial-specific neurointerventional guiding sheath-6F Simmons guiding sheath was evaluated-in patients with anterior circulation large-vessel occlusions. Additionally, a literature review was performed.

METHODS

We retrospectively analyzed data from our institutional database about consecutive patients who underwent transradial MT for anterior circulation large-vessel occlusion. After the 6F Simmons guiding sheath was engaged into the target common carotid artery, a triaxial system (Simmons guiding sheath/aspiration catheter/microcatheter), was established. MT using the continuous aspiration prior to intracranial vascular embolectomy technique was performed. Then, procedural success rate, successful revascularization, and procedure-related complications were assessed.

RESULTS

A total of 13 patients who had transradial MT were included in the analysis. All 13 patients underwent successful thrombectomy without catheter kinking or system instability, and 12 of them achieved successful revascularization (modified Thrombolysis in Cerebral Infarction score of ≥2b). No complications occurred.

CONCLUSIONS

To the best of our knowledge, this is the first case series on transradial MT using a radial-specific neurointerventional system for anterior circulation large-vessel occlusions. This method may increase the success rate of transradial MT. Based on our initial experience, transradial MT, using this system, was feasible and safe for anterior circulation large-vessel occlusions.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Clinical predictors and management for radial artery spasm: an Australian cross-sectional study

INTRODUCTION

The transradial approach for coronary artery catheterisation has increased in popularity compared to the transfemoral approach for patients undergoing percutaneous coronary interventions. However, radial artery spasm continues to be a major complication of the procedure. Current management strategies vary concerning radial artery spasm and there is limited evidence of practice in the Australian context.

AIM

To identify the predictors of radial artery spasm and the medications used for its prevention and management.

METHODS

A descriptive cross-sectional study was carried out over a three-month period in two tertiary hospitals in NSW, Australia. A self-administered pre-procedural survey was completed by patients undergoing coronary artery catheterisation. This survey collected socio-demographic data and assessed anxiety using the Spielberger State-Trait Anxiety Inventory. Procedural data, including length of procedure, equipment used, occurrence of radial artery spasm, and medications given, were collected post-procedure by the interventionalist.

RESULTS

Of the 169 participants, over half were male (59.8%) and aged 66 years or older (56.8%). Radial artery spasm was reported in 24 (14.2%) participants. Rates of spasm were significantly higher among females (66.6%, p = 0.004), those aged under 65 years (62.5%, p = 0.001) and those who reported a medical history of anxiety (33.3%, p = 0.0004). There were no significant differences in State and Trait anxiety scores among those who had RAS and those who did not. Logistic regression identified younger age as the only statistically significant predictor of RAS (OR 0.536; 95% CI 0.171-1.684; p = 0.005). To prevent radial artery spasm most patients received midazolam (n = 158; 93.5%), nitrates (n = 133; 78.7%) and/or fentanyl (n = 124; 73.4%) prophylactically. Nitrates were the most frequently administered medication to treat radial artery spasm (78.7%).

CONCLUSION

This study highlights that there is a need to develop a clearer understanding of the predictors of RAS, as identifying patients at risk can ensure prophylactic measures are implemented. This study identified nitrates as the preferred vasodilator as a preventative measure along with the use of sedation.

Comparison of radiation exposure associated with transradial and transfemoral access: An updated meta-analysis

OBJECTIVES

To assess differences in radiation exposure between transradial access (TRA) and transfemoral access (TFA) for coronary procedures.

BACKGROUND

TRA is associated with increased radiation exposure as compared to TFA. We compared radiation exposure between the two access sites.

METHODS

Databases were searched from June 2014 to August 2021 for randomized controlled trials (RCTs) reporting coprimary outcomes of fluoroscopy time (FT) and/or dose area product (DAP) comparing TRA with TFA. Meta-regression was performed to assess the behavior of weighted mean difference (WMD) in FT from 1995 to 2021. Observational study data was used for corroborative evidence.

RESULTS

Data from 8 RCTs (11,611 patients) showed the WMD of FT was 0.62 min (37 s) (95% confidence interval [CI]: [0.08-1.17], p = 0.023) in favor of TFA, WMD in DAP (9169 patients) was 1.94 Gy.cm² (95% CI: [-2.1 to 5.9], p = 0.35) showing no significant difference. Pooled data from OBS and RCTs (83,990 patients) showed a similar trend. Studies from outside US between 1995 and 2021 showed WMD of FT between TRA and TFA of 0.88 min (52 s) (95% CI: [0.67-1.09], p = 0.005) versus 2.1 min (126 s) (95% CI: [1.38-2.8], p = 0.005) for US in favor of TFA. Meta-regression showed a declining WMD of FT between TRA and TFA from 1.6 min (96 s) in 1996 to 0.5 min (30 s) in 2020 with the lower limit of CI crossing the zero line in 2019.

CONCLUSION

Radiation exposure between TRA and TFA continues to decrease overtime and is becoming clinically nonsignificant.

Enhanced external counterpulsation improves dysfunction of forearm muscle caused by radial artery occlusion

Objective

This study aimed to investigate the therapeutic effect of enhanced external counterpulsation (EECP) on radial artery occlusion (RAO) through the oscillatory shear (OS) and pulsatile shear (PS) models of human umbilical vein endothelial cells (HUVECs) and RAO dog models.

Methods

We used high-throughput sequencing data GSE92506 in GEO database to conduct time-series analysis of functional molecules on OS intervened HUVECs, and then compared the different molecules and their functions between PS and OS. Additionally, we studied the effect of EECP on the radial artery hemodynamics in Labrador dogs through multi-channel physiological monitor. Finally, we studied the therapeutic effect of EECP on RAO at the histological level through Hematoxylin-Eosin staining, Masson staining, ATPase staining and immunofluorescence in nine Labrador dogs.

Results

With the extension of OS intervention, the cell cycle decreased, blood vessel endothelial cell proliferation and angiogenesis responses of HUVECs were down-regulated. By contrast, the inflammation and oxidative stress responses and the related pathways of anaerobic metabolism of HUVECs were up-regulated. Additionally, we found that compared with OS, PS can significantly up-regulate muscle synthesis, angiogenesis, and NO production related molecules. Meanwhile, PS can significantly down-regulate inflammation and oxidative stress related molecules. The invasive arterial pressure monitoring showed that 30Kpa EECP treatment could significantly increase the radial artery peak pressure (p = 0.030, 95%CI, 7.236-82.524). Masson staining showed that RAO significantly increased muscle interstitial fibrosis (p = 0.002, 95%CI, 0.748-2.128), and EECP treatment can reduce this change (p = 0.011, 95%CI, -1.676 to -0.296). ATPase staining showed that RAO significantly increased the area of type II muscle fibers (p = 0.004, 95%CI, 7.181-25.326), and EECP treatment could reduce this change (p = 0.001, 95%CI, -29.213 to -11.069). In addition, immunofluorescence showed that EECP increased angiogenesis in muscle tissue (p = 0.035, 95%CI, 0.024-0.528).

Conclusion

EECP improves interstitial fibrosis and hypoxia, and increases angiogenesis of muscle tissue around radial artery induced by RAO.

Access Site Selection and Outcomes for Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the VA CART Program

Background

There has been increasing use of transradial access (TRA) for non-chronic total occlusion (CTO) percutaneous coronary intervention (PCI). There are limited data on TRA for CTO PCI. The objectives of this study were to assess the temporal trends in the use of TRA versus transfemoral access (TFA), identify procedural and lesion characteristics associated with the use of TRA and TFA, and evaluate the association of access site with procedural complications and technical success among veterans undergoing attempted CTO PCI.

Methods

We performed a retrospective analysis of veteran patients who underwent attempted CTO PCI to compare outcomes between TRA and TFA. Patients who had undergone attempted PCI of at least 1 CTO were included. Propensity score matching was used to evaluate the composite primary outcome of major procedural complications, in-hospital bleeding, or 30-day mortality and the secondary outcome of procedural success.

Results

In total, 4609 patients underwent attempted CTO PCI during 2010-2017. Rates of TRA for CTO PCI increased significantly, from 7% in 2010 to 38% in 2017 (P trend < .01). A greater percentage of CTO lesions in the TFA group was calcified and >20.0 mm in length. TRA was not associated with a reduction in the composite primary outcome (TRA 3.3% vs TFA 4.0%, P = .47) or procedural success (TRA 66.6% vs TFA 65.7%, P = .74) compared with TFA.

Conclusions

In this retrospective analysis of patients who underwent attempted CTO PCI, the proportion of TRA for CTO PCI has increased over time but was not associated with a greater safety or procedural success than TFA.

Relation of Operator Volume and Access Site to Short-Term Mortality in Radial Versus Femoral Access for Primary Percutaneous Coronary Intervention

The relation between operator volume and mortality of primary percutaneous coronary intervention (PPCI) procedures for ST-elevation myocardial infarction has not been studied comprehensively. This study included patients who underwent PPCI between 2010 and 2017 in all nonfederal hospitals approved to perform PCI in New York State. We compared risk-adjusted in-hospital/30-day mortality for radial access (RA) and femoral access (FA) and the relation between risk-adjusted mortality and procedure volume for each access site. In 44,540 patients in the study period, the use of RA rose from 8% in 2,010% to 43% in 2017 (p <0.0001). There was no significant change in PPCI risk-adjusted mortality during the period (p=0.27 for trend). RA was associated with lower mortality when imposing operator exclusion criteria used in recent trials. There was a significant operator inverse volume-mortality relation for FA procedures but not for RA procedures. FA procedures performed by lower volume FA operators (lowest quartile) were associated with higher risk-adjusted mortality compared with RA procedures (3.71% vs 3.06%, p = 0.01) or compared with FA procedures performed by higher volume FA operators (3.71% vs 3.16%, p = 0.01). In conclusion, in patients with ST-elevation myocardial infarction referred for primary PCI in New York State, there was a significant uptake in the use of RA along with relatively constant in-hospital/30-day mortality. There was a significant inverse operator volume-mortality relation for FA procedures accompanied by higher mortality for FA procedures performed by low volume FA operators than for all other primary PCI procedures. In conclusion, this information underscores the need for operators to remain vigilant in maintaining FA skills and monitoring FA outcomes.

Mechanical Thrombectomy via Transradial Approach for Posterior Circulation Stroke: A Systematic Review and Meta-Analysis

Mechanical thrombectomy for acute ischemic stroke (AIS) is traditionally performed via transfemoral access. While the majority of AISs are due to anterior circulation large vessel occlusions (AC-LVO), we performed a systematic review and meta-analysis to examine the feasibility of and outcomes following a transradial artery access for posterior circulation large vessel occlusion (PC-LVO) strokes. A systematic literature review of the English language literature was conducted using PubMed, MEDLINE, and Embase as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes of interest included 90-day modified Rankin scale (mRS) 0-2, puncture to recanalization time, and thrombolysis in cerebral infarction (TICI) scores 2b/3 and 3. We calculated pooled event rates and their corresponding 95% confidence intervals (CI) for all outcomes. We included seven studies with 68 patients in our analysis. All patients underwent mechanical thrombectomy via transradial artery access for AIS due to PC-LVO. The pooled meantime of puncture to recanalization was 29.19 (95% CI=24.05 to 35.42) minutes. Successful recanalization (TICI2b/3) was achieved in 98.69% (95% CI=93.50 to 100) of patients and complete recanalization (TICI 3) in 52.16% (95% CI=34.18 to 79.60) of the patients. Overall, 56.84% (95% CI=41.26 to 78.30) of patients achieved mRS 0-2. Transradial artery access for mechanical thrombectomy for PC-LVO stroke displays early promise and feasibility, particularly regarding very high rates of successful recanalization and low puncture to recanalization time.

The relationship between radial artery spasm and adropin levels in patients undergoing transradial coronary angiography

Introduction: Transradial coronary angiography (TRA) is associated with a lower incidence of bleeding rate and access site complications and is associated with better outcomes compared to transfemoral angiography. However, radial artery spasm (RAS) is an important limitation of TRA procedures. Little is known regarding the relationship of serum vasodilator and inflammatory markers with RAS. Therefore, the present study aimed to investigate the association between serum adropin level and RAS in patients undergoing TRA. Methods: From February 2020 to January 2021, 39 consecutive patients who underwent elective daiagnostic TRA and experienced RAS during the procedure, and 42 age and sex matched controls who did not experience RAS were prospectively included into the study. The groups were compared regarding serum adropin levels and inflammatory markers. Results: Although adropin levels were found to be lower in the RAS group, this difference was not statistically significant between the the patients with RAS and controls (14.9 vs. 16.1, P=0.105). However, inflammatory parameters monocyte count and MHR (monocyte/HDL cholesterol ratio) were found to be statistically significantly higher in the RAS group compared to controls (P=0.001 and P=0.010, respectively). Moreover, a significant positive correlation was found between the monocyte count and RAS (r:0.360, P<0.001), and between MHR and RAS (r:0.288, P=0.009). Furthermore, multivariate analysis demonstrated that monocyte count (OR:1.671, 95%CI:1.312-2.094, P=0.001) and MHR (OR:1.116, 95%CI:1.054-1.448, P=0.022) were found to be independent predictors of RAS. Conclusion: Serum vasodilator and inflammatory markers may be useful in the prediction of RAS in patients undergoing TRA procedures.

Prevention of radial artery occlusion by simultaneous ulnar and radial compression (PRO-SURC). A randomized duplex ultrasound follow-up study

BACKGROUND

There might be a beneficial effect of transient ulnar artery compression in prevention of radial artery occlusion (RAO) after trans-radial catheterization.

OBJECTIVE

The objective of this study was to assess, by Duplex ultrasound, the efficacy of simultaneous ulnar and radial artery compression (SURC), in prevention of RAO, compared to conventional and patent hemostasis techniques.

PATIENTS AND METHODS

Four hundred and fifty consecutive patients undergoing elective trans-radial catheterization were enrolled. Patients were randomized in 1:1:1 fashion into 3 groups; conventional hemostasis (Group A, n = 150 patients), patent hemostasis (Group B, n = 150 patients), and SURC technique (Group C, n = 150 patients). RAO was assessed by duplex ultrasound at 1-h post TR band removal (primary endpoint), and at 1-month.

RESULTS

The primary endpoint, RAO 1-h post TR-band removal, was significantly lower among patients of group C as compared to those of group A and B (1.3%, 6.7%, and 7.3%, respectively -p = 0.03). This was still consistent at 1-month (0.7%, 8%, and 6%, respectively -p = 0.03). Multiple regression analyses revealed that lower radial artery diameter (RAD) after flow-mediated dilatation (FMD) independently predicted RAO at 1-h, while RAD at 1-h post-TR band removal was the only independent predictor of RAO at 1-month. Receiver operator characteristic (ROC) analysis showed that RAD at 1-h post-TR band removal at cut-off ≤1.75 mm could predict RAO at 1-month with high accuracy (AUC = 0.9, CI = 0.8-1.0, p < 0.001-86% sensitivity, and 95% specificity).

CONCLUSION

A technique of SURC is associated with less incidence of early and late RAO compared to conventional hemostasis techniques.

Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018

BACKGROUND

Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox.

METHODS

In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test.

RESULTS

Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P<0.01)) and PCI procedures (14.0%-51.8%; P<0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P=0.02) but not PCI (3.4%-2.5%, P=0.20). Femoral access patients had a higher predicted risk for bleeding.

CONCLUSIONS

A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.

Clinical Characteristics and Long-Term Outcomes of Patients With Differing Haemoglobin Levels Undergoing Semi-Urgent and Elective Percutaneous Coronary Intervention in an Asian Population

Introduction

This study aimed to investigate the impact of anaemia on long-term clinical outcomes in patients who underwent semi-urgent and elective percutaneous coronary intervention (PCI) in an Asian population. Although the effects of anaemia on outcomes in Asian patients are well studied for acute coronary syndrome, its impact on Asian patients undergoing semi-urgent and elective PCI is unclear.

Methods

This was a retrospective cohort study of patients who underwent semi-urgent and elective PCI from January 1, 2014, to December 31, 2015, at a tertiary academic centre. A total of 1,685 patients were included. They were stratified into three groups: normal (≥12 g/dL), intermediate (10–11.9 g/dL), and low (<10 g/dL) haemoglobin levels. Demographics, risk factors, and end-points including the 5-point major adverse cardiac and cerebrovascular events (MACCE) (all-cause death, subsequent stroke, myocardial infarction, congestive cardiac failure, and target lesion revascularisation), cardiovascular death, and bleeding events were analysed.

Results

Patients in intermediate and low haemoglobin level groups were older with more comorbidities. Compared to the normal haemoglobin level group, low haemoglobin level group patients were associated with an increased risk of composite endpoints of all-cause death, subsequent stroke, myocardial infarction, congestive cardiac failure, and target lesion revascularisation [adjusted hazard ratio (aHR) 1.89, 95% confidence interval (CI):1.22, 2.92; p = 0.004]. This was driven by the increased risk of target lesions revascularisation observed in the low haemoglobin level group compared to the normal haemoglobin level group (aHR 17.74, 95% CI: 1.74, 180.80; p = 0.015). The patients in the low haemoglobin level group were also associated with a higher risk of bleeding events compared to the normal haemoglobin level group (aHR 7.18, 95% CI: 1.13, 45.40; p = 0.036).

Conclusion

In our Asian cohort, patients with anaemia undergoing PCI were associated with a higher comorbid burden. Despite adjustments for comorbidities, these patients had higher mortality and worse cardiovascular outcomes following contemporary PCI.

Radial Artery Access for Acute Coronary Syndromes: a Review of Current Evidence

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.

Safety and efficacy of coronary angiography and percutaneous coronary intervention via distal transradial artery access in the anatomical snuffbox: a single-centre prospective cohort study using a propensity score method

BACKGROUND

This study investigated the safety and efficacy of coronary angiography (CAG) and percutaneous coronary intervention (PCI) via distal transradial artery access (d-TRA).

METHODS

For this single-centre prospective cohort study, a total of 1066 patients who underwent CAG or PCI procedures from September 2019 to November 2020 were included. Patients were divided into two groups: the d-TRA group (346) and the conventional transradial artery access (c-TRA) group (720) based on access site. A total of 342 pairs of patients were successfully matched using propensity score matching (PSM) for subsequent analysis.

RESULTS

No significant differences in puncture success rate, procedural method, procedural time, sheath size, contrast dosage or fluoroscopy time were noted between the two groups. The puncture time in the d-TRA group was longer than that in the c-TRA group (P < 0.01), and the procedure success rate was lower than that in the c-TRA group (90.94% vs. 96.49%, P = 0.01). The haemostasis time in the d-TRA group was shorter than that in the c-TRA group (P < 0.01), and the visual analogue scale (VAS) was lower than that in the c-TRA group (P < 0.01). In addition, the prevalence of bleeding and haematoma in the d-TRA group was lower than that in the c-TRA group (1.75% vs. 7.31%, P < 0.01; 0.58% vs. 3.22%, P = 0.01, respectively). No significant difference in the incidence of numbness was noted between the two groups. No other complications were found in two groups.

CONCLUSION

d-TRA is as safe and effective as c-TRA for CAG and PCI. It has the advantages of improved comfort and fewer complications. Trail registration Chinese Clinical Trial Registry, ChiCTR1900026519.

Initial Experience with Left Transradial Neurointerventions for Cerebral Aneurysms Using the 6-French Simmons Guiding Sheath

OBJECTIVE

The use of a transradial approach utilizing a Simmons-shaped catheter for neurointervention has been steadily increasing. Although the right radial artery is commonly used, in interventional cardiology, the left transradial approach offers clear clinical benefits for right-handed patients. To the best of our knowledge, no previous studies have examined intracranial aneurysm embolization with the routine use of the left transradial approach. The aim of this study was to evaluate the technical feasibility of left transradial intracranial aneurysm embolization.

METHODS

We conducted a retrospective review of a prospective database of consecutive patients who had undergone left transradial intracranial aneurysm coiling using a 6-French Simmons guiding sheath between January and August 2021. The following outcome variables were then analyzed: whether the catheterization was successful, the angiographical results, and the presence of any procedure-related complications.

RESULTS

In total, 25 patients underwent left transradial coiling for 15 anterior and 10 posterior circulation aneurysms. The Simmons guiding sheath could be successfully shaped and cannulated into the targeted vessel in all patients. All aneurysms were completely embolized without any complications. Immediate postoperative angiograms showed Raymond 1 in 10 aneurysms (40.0%), Raymond 2 in 12 (48.0%), and Raymond 3a in 3 (12.0%). None of the patients required crossover to the right radial or femoral arteries, and no radial artery spasms or occlusions were observed.

CONCLUSION

The results of this study suggest that the left transradial approach for intracranial aneurysm coiling is not only safe, effective, and technically feasible, but also provides improved comfort to right-handed patients.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.

Meta-Analysis Comparing Gender-Based Cardiovascular Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention

Transradial (TR) access for percutaneous coronary intervention (PCI) improves outcomes and reduces the risk of major bleeding compared with transfemoral (TF) access. However, data on gender-stratified outcomes based on vascular access are limited. Databases were queried to find relevant articles. Primary outcomes, including major bleeding complications, mortality, and secondary outcome including major adverse cardiovascular events (MACEs), myocardial infarction, and cerebrovascular accidents, were analyzed using a random-effect model to calculate unadjusted odds ratio (OR) of TR-PCI and TF-PCI between the genders. A total of 9 studies comprising 3,889,257 patients (389,580 in the TR arm and 3,499,677 in the TF arm) were included. Males comprised 73% and 67% of the TR and TF arms, respectively. TR-PCI was associated with lower major bleeding (pooled OR 0.51, 95% CI 0.40 to 0.64, p = 0.00; female OR 0.49, 95% CI 0.34 to 0.71, p = 0.00; male OR 0.54, 95% CI 0.40 to 0.73, p = 0.00) and mortality (pooled OR 0.54, 95% CI 0.45 to 0.66, p = 0.00; female OR 0.56, 95% CI 0.44 to 0.71, p = 0.27; male OR 0.54, 95% CI 0.39 to 0.75, p = 0.00) regardless of gender as compared with TF-PCI. Furthermore, TR-PCI also showed lower MACE (pooled OR 0.74, 95% CI 0.66 to 0.84, p = 0.00; female OR 0.64, 95% CI 0.59 to 0.70, p = 0.00; male OR 0.81, 95% CI 0.66 to 0.98, p = 0.00) as compared with TF-PCI in both genders. On analysis of interaction magnitude of the difference of favor of female and male for TR-PCI showed no statistically significant measurable difference. Periprocedural myocardial infarction and cerebrovascular accidents were not statistically different in TR and TF-PCI and were not different based on gender. In conclusion, TR-PCI was associated with a lower risk of major bleeding, mortality, and MACE irrespective of gender. In conclusion, TR-PCI should be the default access.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.

Cost-Effectiveness and Safety of Same-Day Discharge after Elective Percutaneous Coronary Intervention

Objectives: We sought to investigate the rates of same-day discharge (SDD) post elective percutaneous coronary intervention (PCI) at our institution and review its safety by examining clinical outcomes. We also performed an economic analysis evaluating our hospital’s cost data for SDD following PCI. Methods: Patients undergoing elective PCI at St George Hospital, Australia, from January 2017 to December 2019 were evaluated. Primary outcomes included 7-day major adverse cardiovascular endpoints (MACEs) and readmission to hospital within 30 days. Results: Among 502 patients who underwent elective PCI, 421 patients (83.8%) were managed with SDD. There was one case of acute stent thrombosis and one case of coronary wire-induced perforation requiring a pericardial drain that occurred following elective PCI with SDD (0.54%). Unplanned cardiac re-hospitalisation at 30 days following elective PCI was 5.2%. SDD after elective PCI was associated with a healthcare cost saving of AUD 4817 per case. Conclusion: SDD following elective PCI was demonstrated to be a safe and effective strategy that was also associated with significant cost savings. SDD following elective PCI warrants more widespread use as it lowers healthcare costs, has equivalent patient outcomes and improves patient satisfaction.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered.

STRUCTURE

Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.

Impact of sex on outcomes of percutaneous coronary intervention for chronic total occlusion: A meta-analysis

BACKGROUND

Women are underrepresented in chronic total occlusion (CTO) trials and little is known about sex differences in the outcomes of CTO percutaneous coronary intervention (PCI). This meta-analysis aims to compare the outcomes of CTO PCI in males and females.

METHODS

A comprehensive search of PubMed, EMBASE, Cochrane, Web of Science, and Google Scholar was performed for studies comparing outcomes of CTO PCI in females versus males from inception to January 26, 2021. The current statistical analysis was performed using STATA version 15.1 software (Stata Corporation, TX); P < 0.05 indicated statistical significance.

RESULTS

Fourteen observational studies were included in the analysis with 75% males and 25% females. The mean age was 64.47 ± 10.5 years and 68.98 ± 9.5 years for males and females, respectively. The median follow-up duration was 2.4 years. Males had a higher Japanese-CTO (J-CTO) score compared with females (MD = -0.17; 95% CI: -0.25 to -0.10). Females had statistically higher success rates of CTO PCI (RR = 1.03; 95% CI: 1.01 to1.05), required less contrast volume (MD = -18.64: 95% CI: -30.89 to -6.39) and fluoroscopy time (MD = -9.12; 95% CI: -16.90 to -1.34) compared with males. There was no statistical difference in in-hospital (RR = 1.50; 95% CI: 0.73 to 3.09) or longer term (≥6 months) all-cause mortality (RR = 1.10; 95% CI: 0.86 to 1.42) between the two groups.

CONCLUSIONS

CTO PCI is feasible and safe in female patients with comparable outcomes in female versus male patients.

Vascular dysfunction and its recovery after transradial coronary angioplasty- A serial observational study

OBJECTIVE

To serially evaluate the effect of trans-radial coronary angioplasty (TRA) on the vascular function of radial artery (RA) and upstream brachial artery (BA) and to find out the relative contribution of endothelial dependent flow-mediated vasodilatation (FMD) and endothelial independent nitrate mediated dilatation (NMD).

METHODS

Forty patients of chronic stable angina with successful TRA were studied. FMD and NMD of bilateral RA and BA were measured with high-resolution ultrasound, before and at 24 h and at 3 months, after catheterization.

RESULTS

FMD as well as NMD were significantly decreased in right RA (16.3 ± 3.6% to 5.7 ± 1.8%; p = 0.001, and 24.1 ± 5.3% to 9.7 ± 2.8%; p = 0.001, respectively) as well as in upstream BA (17.0 ± 1.6% to 9.4 ± 0.5%; p = 0.001,and 26.5 ± 6.8% to 20.5 ± 3.7%; p = 0.001, respectively) at 24 h. FMD/NMD ratio was also decreased in RA (70 ± 10% to 60 ± 10%; p = 0.04) and as well as in BA (70 ± 20% to 50 ± 10%; p = 0.03). The endothelial dysfunctions returned to normal at 3 months. Control arm did not show any change in vascular function at any point of time. Radial artery diameter/sheath ratio <1 and catheter exchanges >2 were the independent predictors for >50% decrease in FMD.

CONCLUSIONS

TRA results in reversible depression in FMD as well as NMD in the radial artery as well as upstream brachial artery. These vascular dysfunctions are limited to the catheterized arm only and return to normal after 3 months.

Cost analysis of a coaching intervention to increase use of transradial percutaneous coronary intervention

BACKGROUND

The transradial approach (TRA) to cardiac catheterization is safer than the traditional transfemoral approach (TFA), with similar clinical effectiveness. However, adoption of TRA remains low, representing less than 50% of catheterization procedures in 2015. Peer coaching is one approach to facilitate implementation; however, the costs of this strategy for cardiac procedures such as TRA are unclear.

METHODS

We conducted an activity-based costing analysis (ABC) of a multi-center, hybrid type III implementation trial of a coaching intervention designed to increase the use of TRA. We identified the key activities of the intervention and determined the personnel, resources, and time needed to complete each activity. The personnel cost per hour and the activity duration were then used to estimate the cost of each activity and the total variable cost of the implementation. Fixed costs related to designing and running the implementation were calculated separately. All costs are reported in 2019 constant US dollars.

RESULTS

The total cost of the coaching intervention implementation was $374,863. Of the total cost, $367,752 were variable costs due to travel, preparatory work, in-person coaching, post-intervention evaluation, and administrative time. We estimated fixed costs of $7112. The mean marginal cost of implementing the intervention at only one additional medical center was $52,536.

CONCLUSIONS

We provide granular cost estimates of a conceptually rooted implementation strategy designed to increase the uptake of TRA for cardiac catheterization. We estimate that implementation costs stemming from the coaching approach would be offset after the conversion of approximately 409 to 1363 catheterizations from TFA to TRA. Our estimates provide benchmarks of the expected costs of implementing evidence-based, but expertise-intensive, cardiac procedures.

TRIAL REGISTRATION

ISRCTN, ISRCTN66341299 . Registered 7 July 2020-retrospectively registered.