Comparison of short- and medium-term clinical outcomes between transradial approach and transfemoral approach in a high-volume PCI heart center in China

Percutaneous coronary intervention for chronic total occlusion of the left circumflex branch in mirror dextrocardia: a case report

BACKGROUND

Mirror dextrocardia (MDC) is a condition in which the heart is located in a mirror-image position on the right side of the chest compared to the normal position in individuals with physiological variations. Patients with MDC and chronic total occlusion (CTO) of the left circumflex branch (LCX) are extremely rare in clinical practice. The treatment of MDC-CTO-LCX differs significantly from patients without mirror dextrocardia and the same condition in terms of instrument selection and procedural techniques. In this article, we report a successful case of interventional treatment in a patient with MDC-CTO-LCX. We summarize the anatomical and electrocardiographic variations in patients with MDC-CTO-LCX, and discuss the selection of interventional instruments and techniques that can be useful for interventionists as well as the diagnostic and therapeutic considerations that can be helpful for clinical physicians.

CASE PRESENTATION

A male Han Chinese patient, 51, was admitted, presenting recurrent chest pain for a year and recent onset of exertional fatigue over the past week.He reported episodes of chest pain following physical activities over the past year, lasting between 5 and 20 min.Despite these symptoms, the patient did not seek immediate medical attention, and the occurrence of his chest pain has progressively lessened within the year.A week prior, the patient developed exertional dyspnea after brief walks, though without any episodes of nocturnal paroxysmal dyspnea.Upon arrival at our hospital for evaluation, he was initially diagnosed with chronic coronary syndrome, previous inferior myocardial infarction, atrial arrhythmia, and classified under the New York Heart Association functional class III.Following his admission, a chest X-ray and coronary angiography were conducted.The results indicated mirror dextrocardia and total occlusion of the left circumflex branch. Percutaneous coronary intervention (PCI) was performed on the left circumflex branch. Subsequent angiography demonstrated optimal stent positioning without evidence of hematoma or dissection.Following the procedure, the patient's symptoms of chest pain and exertional dyspnea were resolved, which led to his subsequent discharge.A follow-up electrocardiogram, 10 months post-procedure, displayed a slow and regular atrial rhythm.

CONCLUSIONS

The incidence of dextrocardia is very low, and it may appear normal on an electrocardiogram; however, careful diagnosis is required when there is an abnormal direction of the P wave in limb leads. During the operation for chronic occlusive lesions of the right-sided coronary artery, the anomalous anatomical structure necessitates specific requirements for instrument selection and operative techniques. After revascularization of chronic occlusive vessels in dextrocardia, routine electrocardiographic examination may show false normalization, requiring caution in interpretation.

Stroke risk in radial versus femoral approach in coronary intervention: an updated systematic review and meta-analysis

AIM

Peri-cardiac catheterization (CC) stroke is associated with increased morbidity and mortality. Little is known about any potential difference in stroke risk between transradial (TR) and transfemoral (TF) approaches. We explored this question through a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, and PubMed were searched from 1980 to June 2022. Randomized trials and observational studies comparing radial versus femoral access CC or intervention that reported stroke events were included. A random-effects model was used for analysis.

RESULTS

The total population in our 41 pooled studies comprised 1 112 136 patients - average age 65 years, women averaging 27% in TR and 31% in TF approaches. Primary analysis of 18 randomized-controlled trials (RCTs) that included a total of 45 844 patients showed that there was no statistical significance in stroke outcomes between the TR approach and the TF approach [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.48-1.06, P -value = 0.013, I2 = 47.7%]. Furthermore, meta-regression analysis of RCTs including procedural duration between those two access sites showed no significance in stroke outcomes (OR 1.08, 95% CI 0.86-1.34, P -value = 0.921, I2 = 0.0%).

CONCLUSIONS

There was no significant difference in stroke outcomes between the TR approach and the TF approach.

Short-term risk of periprocedural stroke relative to radial vs. femoral access: systematic review, meta-analysis, study sequential analysis and meta-regression of 2,188,047 real-world cardiac catheterizations

OBJECTIVES

To verify whether transradial (TRA) compared to transfemoral (TFA) cardiac catheterization reduces the risk of periprocedural stroke (PS).

METHODS

We reviewed (CRD42021277918) published real-world cohorts reporting the incidence of PS within 3 days following diagnostic or interventional catheterization. Meta-analyses and meta-regressions of odds ratios (OR) performed using the DerSimonian and Laird method were checked for publication bias (Egger test) and adjusted for false-positive results (study sequential analysis SSA).

RESULTS

The pooled incidence of PS from 2,188,047 catheterizations (14 cohorts), was 193 (105 to 355) per 100,000. Meta-analyses of adjusted estimates (OR = 0.66 (0.49 to 0.89); p = 0.007; I² = 90%), unadjusted estimates (OR = 0.63 (0.51 to 0.77; I² = 74%; p = 0.000)), and a sub-group of prospective cohorts (OR = 0.67 (0.48 to 0.94; p = 0.022; I² = 16%)) had a lower risk of PS in TRA (without indication of publication bias). SSA confirmed the pooled sample size was sufficient to support these conclusions. Meta-regression decreased the unexplained heterogeneity but did not identify any independent predictor of PS nor any effect modifier.

CONCLUSION

Periprocedural stroke remains a rare and hard-to-predict adverse event associated with cardiac catheterization. TRA is associated with a 20% to 30% lower risk of PS in real-world/common practice settings. Future studies are unlikely to change our conclusion.

Influence of access site choice for cardiac catheterization on risk of adverse neurological events: A systematic review and meta-analysis

BACKGROUND

Stroke is a rare but potentially catastrophic complication of cardiac catheterization. Although some procedural aspects are known to influence stroke risk, the impact of radial versus femoral access site use is unclear. Early observational studies and limited randomized trial data suggested more frequent embolic events with radial access. Subsequently, larger pooled analyses have shown no clear differences in stroke risk but were limited by low event rates. Recent publication of relevant new data prompted our reevaluation of this concern. Therefore, we conducted a systematic review and meta-analysis to evaluate stroke complicating cardiac catheterization with use of transradial versus transfemoral access.

METHODS AND RESULTS

A search of MEDLINE and EMBASE was undertaken using OVID SP with appropriate search terms. RevMan 5.3.5 was used to conduct a random-effects meta-analysis using the inverse variance method for pooling risk ratios (RRs) or the Mantel-Haenszel method for pooling dichotomous data. Pooled data from >24,000 patients in randomized controlled trials and >475,000 patients from observational studies were used. The risk ratio (RR) for (any) stroke, using randomized controlled trial data, was not significant (RR 0.87, 95% CI 0.58-1.29). Using observational data, a significant difference favoring radial access was seen (RR 0.71, 95% CI 0.52-0.98).

CONCLUSIONS

Radial access site utilization for cardiac catheterization is not associated with an increased risk of stroke events. These data provide reassurance and should remove another potential barrier to conversion to a "default" radial practice among those who are currently predominantly femoral operators.