Radial Approach Expertise and Clinical Outcomes of Percutanous Coronary Interventions Performed Using Femoral Approach

Machine learning prediction of no reflow in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

No-reflow (NRF) phenomenon is a significant challenge in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). Accurate prediction of NRF may help improve clinical outcomes of patients. This retrospective study aimed at creating an optimal model based on machine learning (ML) to predict NRF in these patients, with the additional objective of guiding pre- and intra-operative decision-making to reduce NRF incidence.

Methods

Data were collected from 321 STEMI patients undergoing pPCI between January 2022 and May 2023, with the dataset being randomly divided into training and internal validation sets in a 7:3 ratio. Selected features included pre- and intra-operative demographic data, laboratory parameters, electrocardiogram, comorbidities, patients' clinical status, coronary angiographic data, and intraoperative interventions. Post comprehensive feature cleaning and engineering, three logistic regression (LR) models [LR-classic, LR-random forest (LR-RF), and LR-eXtreme Gradient Boosting (LR-XGB)], a RF model and an eXtreme Gradient Boosting (XGBoost) model were developed within the training set, followed by performance evaluation on the internal validation sets.

Results

Among the 261 patients who met the inclusion criteria, 212 were allocated to the normal flow group and 49 to the NRF group. The training group consisted of 183 patients, while the internal validation group included 78 patients. The LR-XGB model, with an area under the curve (AUC) of 0.829 [95% confidence interval (CI): 0.779-0.880], was selected as the representative model for logistic regression analyses. The LR model had an AUC slightly lower than XGBoost model (AUC 0.835, 95% CI: 0.781-0.889) but significantly higher than RF model (AUC 0.731, 95% CI: 0.660-0.802). Internal validation underscored the unique advantages of each model, with the LR model demonstrating the highest clinical net benefit at relevant thresholds, as determined by decision curve analysis. The LR model encompassed seven meaningful features, and notably, thrombolysis in myocardial infarction flow after initial balloon dilation (TFAID) was the most impactful predictor in all models. A web-based application based on the LR model, hosting these predictive models, is available at https://l7173o-wang-lyn.shinyapps.io/shiny-1/.

Conclusions

A LR model was successfully developed through ML to forecast NRF phenomena in STEMI patients undergoing pPCI. A web-based application derived from the LR model facilitates clinical implementation.

Influence of Previous Coronary Artery Bypass Grafting on Clinical Outcomes After Percutaneous Coronary Intervention: A Meta-Analysis of 250 684 Patients

Background

Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is the preferred strategy for treating obstructive coronary artery disease. Existing literature suggests the worsening of clinical outcomes in patients with previous coronary artery bypass grafting (CABG) history. In light of this, a comprehensive systematic review and meta-analysis was performed.

Methods

Databases including PubMed, Cochrane Library, and ScienceDirect were utilized for the inclusive systematic search dating from inception to September 01, 2023. The risk of bias assessment was performed using the Newcastle-Ottawa scale for cohort studies, and the Cochrane Risk of Bias Tool for randomized controlled trials.

Results

Ultimately, there were 16 eligible studies pooled together, involving a total of 250 684 patients, including 231 552 CABG-naïve patients, and 19 132 patients with a prior history of CABG. Overall, patients with CABG history were associated with significantly greater short-term mortality (P = .004), long-term mortality (P = .005), myocardial infarction (P < .00001), major adverse cardiovascular events (P = .0001), and procedural perforation (P < .00001). Contrastingly, CABG-naïve patients were associated with significantly greater risk of cardiac tamponade (P = .02) and repeat CABG (P = .03). No significant differences in stroke, bleeding, revascularization, or repeat PCI were observed.

Conclusion

Comparatively worsened clinical outcomes were observed, as patients with prior CABG history typically exhibit complex coronary anatomy, and have higher rates of comorbidities in comparison to their CABG-naïve counterparts. The refinement of current procedural and surgical techniques, in conjunction with continued research endeavors, are needed in order to effectively address this trend.

Aetiology and predictors of major bleeding events in patients with heart failure with reduced ejection fraction undergoing percutaneous coronary intervention

OBJECTIVES

We sought to determine the relationship between the degree of left ventricular ejection fraction (LVEF) impairment and the frequency and type of bleeding events after percutaneous coronary intervention (PCI).

DESIGN

This was an observational retrospective cohort analysis. Patients who underwent PCI from 2009 to 2017 were identified from our institutional National Cardiovascular Disease Registry (NCDR) CathPCI database. Patients were stratified by pre-PCI LVEF: preserved (≥50%), mildly reduced (41%-49%) and reduced (≤40%) LVEF.

PRIMARY OUTCOME MEASURES

The outcome was major bleeding, defined by NCDR criteria. Events were classified based on bleeding aetiology and analysed by multivariable logistic regression.

RESULTS

Among 13 537 PCIs, there were 817 bleeding events (6%). The rate of bleeding due to any cause, blood transfusion, gastrointestinal bleeding and coronary artery perforation or tamponade each increased in a stepwise fashion comparing preserved, mildly reduced and reduced LVEF reduction (p<0.05 for all comparisons). However, there were no differences in bleeding due to asymptomatic drops in haemoglobin, access site haematoma or retroperitoneal bleeding. After multivariable adjustment, mildly reduced and reduced LVEF remained independent predictors of bleeding events (OR 1.36, 95% CI 1.06 to 1.74, p<0.05 and OR 1.73, 95% CI 1.45 to 2.06, p<0.0001).

CONCLUSIONS

The degree of LV dysfunction is an independent predictor of post-PCI major bleeding events. Patients with mildly reduced or reduced LVEF are at greatest risk of post-PCI bleeding, driven by an increased need for blood transfusion, major GI bleeding events and coronary artery perforation or tamponade. Pre-PCI LV dysfunction does not predict asymptomatic declines in haemoglobin, access site haematoma or retroperitoneal bleeding.

The importance of ankel-brachial index in prediction vascular complications in transradial access procedures

OBJECTIVE

The study aimed to explore the predictors of vascular complications (VCs) associated with transradial access, as the occurrence and severity of these complications were found to be significantly lower compared to femoral access. However, it is important to note that the occurrence of these complications still has a negative impact on clinical outcomes. Nevertheless, there is limited available data on the predictors of complications specifically related to radial access.

METHODS

A retrospective case-control study was conducted on individuals who underwent percutaneous coronary diagnostic or therapeutic procedures at Daping Hospital, following the inclusion and exclusion criteria. The study compared demographic characteristics, VC types, ankle brachial index (ABI), and severity of coronary artery stenosis between the two groups.

RESULTS

We enrolled 300 subjects with VCs and 300 age- and sex-matched subjects without VCs as controls. There were no differences in the baseline characteristics or comorbidities between the groups. Compared to the control group, the VC group has a higher portion of left radial access (6.0%) and previous radial artery puncture history (29.7% vs. 18.3%, p<0.001). The ABI was significantly lower than the non-VC group (1.17  ±  0.17 vs. 1.23 ± 0.14, p<0.001). In the multivariate logistic regression analysis, several factors were found to be independently associated with the occurrence of VC. These factors include ABI (OR=0.060, 95% CI: 0.014-0.249, p<0.001), the procedure being performed by junior operators (OR=1.892, 95% CI: 1.314-2.745, p<0.001), and previous access on the same radial artery (OR=1.795, 95% CI: 1.190-2.707, p<0.01).

CONCLUSIONS

Patients who exhibit a lower ABI and have a history of prior radial access procedures may be at an increased risk of developing radial access VC. Therefore, it is recommended to routinely measure ABI prior to these procedures, as it may serve as a predictive tool for assessing the risk of VC.

Sudden cardiac death in long-term follow-up in patients treated with primary percutaneous coronary intervention

Objective. Most studies analyzing predictors of sudden cardiac death (SCD) after acute myocardial infarction included only high-risk patients or index reperfusion had not been performed in all patients. The aim of our study was to analyze the incidence of SCD and determine the predictors of SCD occurrence during 6-year follow-up of unselected patients with ST-elevation myocardial infarction (STEMI), treated with primary percutaneous coronary intervention (pPCI). Method. we analysed 3114 STEMI patients included included in the University Clinical Center of Serbia STEMI Register. Patients presenting with cardiogenic schock were excluded. Echocardiographic examination was performed before hospital discharge. Results. During 6-year follow-up, lethal outcome was registered in 297 (9.5%) patients, of whom 95 (31.9%) had SCD. The highest incidence of SCD was recorded in the first year of follow-up, when SCD was registered in 25 patients, which is 26.3% of the total number of patients who had had SCD, i.e. 0.8% of the patients analyzed. The independent predictors for the occurrence of SCD during 6-year follow-up were EF < 45% (HR 3.07, 95% 1.87-5.02), post-procedural TIMI flow <3 (HR 2.59, 95%CI 1.37-5.14), reduced baseline kidney function (HR 1.87, 95%CI 1.12-2.93) and Killip class >1 at admission (HR 1.69, 95%CI 1.23-2.97). Conclusion. There is a low incidence of SCD in unselected STEMI patients treated with primary PCI. Predictors of SCD occurence during long-term follow-up in analyzed patients are clinical variables that are easily recorded during index hospitalization and include: EF ≤45%, post-procedural flow TIMI < 3, Killip class >1, and reduced baseline kidney function.

Assessment of silent brain injury in patients undergoing elective percutaneous coronary intervention due to chronic total occlusion

Objective: Silent brain infarcts (SBI) are thromboembolic complications associated with cardiac surgery, diagnostic angiography, and percutaneous interventions. Serum neuron-specific enolase (NSE) is the proven biomarker for measuring neuronal damage. This study aimed to evaluate the incidence of SBI, defined as elevated NSE after coronary chronic total occlusion (CTO) intervention and elective coronary stenting. Design: The study population consisted of two patient groups: the CTO group included consecutive patients with coronary CTO intervention, and the control group consisted of patients who underwent elective coronary intervention. NSE blood levels were measured before and 12-18 h after the procedure. NSE blood levels of >20 ng/mL were considered SBI. Results: A total of 108 patients were included in the study. Of these, 55 (50.9%) had SBI after the procedure. The SBI rate was 59.7% in the CTO group and 39.1% in the control group. Patients with SBI were more likely to have diabetes mellitus, hyperlipidemia, higher HbA1c, higher total stent length, and longer procedural time. Multivariate logistic regression analysis showed that CTO procedure (odds ratio [OR]: 3.129; 95% confidence interval [CI]: 1.246-7.858; p < 0.015) and diabetes mellitus (OR: 2.93; 95% CI: 1.185-7.291; p < 0.020) are independent predictors of SBI. Conclusion: Our data suggest that SBI occurs more frequently after CTO intervention than after non-CTO intervention. Intervention complexity and patient clinical characteristics may explain the increased incidence.

An Easy-to-Use Nomogram Based on SII and SIRI to Predict in-Hospital Mortality Risk in Elderly Patients with Acute Myocardial Infarction

Aim

Inflammatory response is closely associated with poor prognosis in elderly patients with acute myocardial infarction (AMI). The aim of this study was to develop an easy-to-use predictive model based on medical history data at admission, systemic immune inflammatory index (SII), and systemic inflammatory response index (SIRI) to predict the risk of in-hospital mortality in elderly patients with AMI.

Methods

We enrolled 1550 elderly AMI patients (aged ≥60 years) with complete medical history data and randomized them 5:5 to the training and validation cohorts. Univariate and multivariate logistic regression analyses were used to screen risk factors associated with outcome events (in-hospital death) and to establish a nomogram. The discrimination, calibration, and clinical application value of nomogram were evaluated based on receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA), respectively.

Results

The results of multivariate logistic regression showed that age, body mass index (BMI), previous stroke, diabetes, SII, and SIRI were associated with in-hospital death, and these indicators will be included in the final prediction model, which can be obtained by asking the patient's medical history and blood routine examination in the early stage of admission and can improve the utilization rate of the prediction model. The areas under the ROC curve for the training and validation cohorts nomogram were 0.824 (95% CI 0.796 to 0.851) and 0.809 (95% CI 0.780 to 0.836), respectively. Calibration curves and DCA showed that nomogram could better predict the risk of in-hospital mortality in elderly patients with AMI.

Conclusion

The nomogram constructed by combining SII, SIRI, and partial medical history data (age, BMI, previous stroke, and diabetes) at admission has a good predictive effect on the risk of in-hospital death in elderly patients with AMI.

Association of Radial Artery Access with Reduced Incidence of Acute Kidney Injury

Objectives

To determine if radial artery (RA) access compared with femoral artery (FA) access for percutaneous coronary intervention (PCI) is associated with a lower incidence of acute kidney injury (AKI).

Background

AKI results in substantial morbidity and cost following PCI. Prior studies comparing the occurrence of AKI associated with radial artery (RA) versus femoral artery (FA) access have mixed results.

Methods

Using a large state-wide database, 14,077 patients (8,539 with RA and 5,538 patents with FA access) were retrospectively compared to assess the occurrence of AKI following PCI. To reduce selection bias and balance clinical data across the two groups, a novel machine learning method called a Generalized Boosted Model was conducted on the arterial access site generating a weighted propensity score for each variable. A logistic regression analysis was then performed on the occurrence of AKI following PCI using the weighted propensity scores from the Generalized Boosted Model.

Results

As shown in other studies, multiple variables were associated with an increase in AKI after PCI. Only RA access (OR 0.82; 95% CI 0.74-0.91) and male gender (OR 0.80; 95% CI 0.72-0.89) were associated with a lower occurrence of AKI. Based on the calculated Mehran scores, patients were stratified into groups with an increasing risk of AKI. RA access was consistently found to have a lower risk of AKI compared with FA access across these groups of increasing risk.

Conclusions

Compared with FA access, RA access is associated with an 18% lower rate of AKI following PCI. This effect was observed among different levels of risk for developing AKI. Although developed from a retrospective analysis, this study supports the use of RA access when technically possible in a diverse group of patients.

Development and Validation of a Prediction Rule for Major Adverse Cardiac and Cerebrovascular Events in High-Risk Myocardial Infarction Patients After Primary Percutaneous Coronary Intervention

Background and Aims

We aimed to develop a clinical prediction tool to improve the prognosis of major adverse cardiac and cerebrovascular events (MACCE) among high-risk myocardial infarction (MI) patients undergoing primary percutaneous coronary intervention (PCI).

Methods

The present study was a prospective and observational study. A total of 4151 consecutive MI patients who underwent primary PCI at Fuwai Hospital in Beijing, China (January 2010 and June 2017) were enrolled. Forty-eight patients without follow-up data were excluded from the study. The pre-specified criteria (Supplementary Information 1) were chosen to enroll MI patients at high risk for MACCE complications after PCI.

Results

The full model included seven variables, with a risk score of 160 points. Derivation and validation cohort models predicting MACCE had C-statistics of 0.695 and 0.673. The area under the curve (AUC) of the survival receiver operating characteristic curve (ROC) for predicting MACCE was 0.991 and 0.883 in the derivation and validation cohorts, respectively.

Conclusion

The predicted model was internally validated and calibrated in large cohorts of patients with high-risk MI receiving primary PCI to predict MACCE and showed modest accuracy in the derivation and validation cohorts.

Knowledge and Prevalence of Risk Factors for Coronary Artery Disease in Patients after Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

BACKGROUND

Percutaneous coronary intervention (PCI) is associated with a short hospital stay and fast recovery. However, it might be related to insufficient implementation of lifestyle changes after the procedure. Conversely, coronary artery bypass grafting (CABG) is a highly invasive technique that requires a prolonged hospital stay and long rehabilitation with more opportunities for education. This study aimed to evaluate the impact of CABG on adherence to lifestyle modifications and knowledge about coronary artery disease (CAD) in comparison with PCI. We also evaluated the level of education and tried to define groups of patients that might require targeted education.

METHODS

Data was collected using a self-designed 56-item questionnaire. Questions assessed the knowledge of CAD risk factors and the level of their control.

RESULTS

The study group consisted of 155 consecutive patients admitted to the Cardiology Department. Patients with a history of PCI (68%) (at least 8 weeks before) were included in the prior-PCI group, and patients with previous surgical revascularization (also at least 8 weeks before) were assigned to the prior-CABG group (32%). The knowledge score was higher in the prior-CABG group. The median (IQR) results in the prior-PCI vs. prior-CABG group were, respectively: 20 (12-24) vs. 22 (19-25) [points, per 31 max.]; p = 0.01. Similar results were obtained in the level of risk control (prior-PCI vs. prior-CABG, respectively: 6 (4-7) vs. 7 (6-8) [points, per 15 max.]; p = 0.002).

CONCLUSIONS

The method of treatment of CAD might impact the implementation of lifestyle modifications after the procedure. More effort is required to improve secondary prevention, especially in PCI patients.

Outcomes of Nonagenarians with Acute Myocardial Infarction with or without Coronary Intervention

Percutaneous coronary intervention (PCI) is the mainstay treatment of acute myocardial infarction (AMI); however, many clinicians are reluctant to perform PCI in the elderly population. This study aimed to compare the clinical outcomes of PCI versus medical therapy in nonagenarian Korean patients with AMI. We compared the clinical outcomes of nonagenarian patients with AMI with or without PCI. From the pooled data, based on a series of Korean AMI registries during 2005−2020, 467 consecutive patients were selected and categorized into two groups: the PCI and no-PCI groups. The primary endpoint was 1-year major adverse cardiac event (MACE), a composite of all-cause death, non-fatal myocardial infarction, and any revascularization. Among the 467 participants, 68.5% received PCI. The PCI group had lower proportions of Killip classes III-IV, previous heart failure, and left ventricular ejection fraction <40%, but had higher proportions of all prescribed medications and STEMI diagnosis. The 1-year MACE and all-cause death were higher in the no-PCI group, although partially attenuated post-IPTW. Our study showed that nonagenarian patients with AMI undergoing PCI had better clinical outcomes than those without PCI. Nonetheless, further investigation is needed in the future to elucidate whether PCI is beneficial for this population.

Development of a Clinical Risk Score for Prediction of Life-Threatening Arrhythmia Events in Patients with ST Elevated Acute Coronary Syndrome after Primary Percutaneous Coronary Intervention

ST-elevated acute coronary syndrome (STEACS) is a serious condition requiring timely treatment. Reperfusion with primary percutaneous coronary intervention (pPCI) is recommended and preferred over fibrinolysis. Despite its efficacy, lethal complications, such as life-threatening arrhythmia (LTA), are common in post-PCI patients. Although various risk assessment tools were developed, only a few focus on LTA prediction. This study aimed to develop a risk score to predict LTA events after pPCI. A risk score was developed using a retrospective cohort of consecutive patients with STEACS who underwent pPCI at Chiangrai Prachanukroh Hospital from January 2012 to December 2016. LTA is defined as the occurrence of malignant arrhythmia that requires advanced cardiovascular life support (ACLS) within 72 h after pPCI. Logistic regression was used for model derivation. Among 273 patients, 43 (15.8%) developed LTA events. Seven independent predictors were identified: female sex, hemoglobin < 12 gm/dL, pre- and intra-procedural events (i.e., respiratory failure and pulseless arrest), IABP insertion, intervention duration > 60 min, and desaturation after pPCI. The LTA score showed an AuROC of 0.93 (95%CI 0.90, 0.97). The score was categorized into three risk categories: low (<2.5), moderate (2.5–4), and high risk (>4) for LTA events. The LTA score demonstrated high predictive performance and potential clinical utility for predicting LTA events after pPCI.

Predictors of Adverse Events Among Chronic Total Occlusion Patients Undergoing Successful Percutaneous Coronary Intervention and Medical Therapy

Objective

Limited data are available on the predictors of major adverse cardiac events (MACE) after a successful coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) and medical therapy. This study aimed to identify predictors of MACE in CTO patients undergoing successful recanalization and medical therapy.

Methods

A total of 2015 patients with CTOs were enrolled. About 718 patients underwent successful CTO recanalization, and 1297 patients received medical therapy. The primary outcome was the frequency of MACE, defined as a composite of cardiac death, myocardial infarction, and target-vessel revascularization. Multivariate models were used to determine predictors of MACE.

Results

In successful CTO recanalization group, MACE occurred in 123 (17.1%) patients. In multivariate analysis, heart failure (hazard ratio [HR] 1.77, 95% confidence interval [CI]: 1.04–3.04, p = 0.036) was identified as independent predictors for MACE in successful CTO recanalization. Additionally, in medical therapy group, the significant predictors of MACE were male gender (HR 1.53, 95% CI: 1.13–2.05, p = 0.005), diabetes mellitus (HR 1.39, 95% CI: 1.11–1.74, p = 0.003), heart failure (HR 1.44, 95% CI: 1.10–1.87, p = 0.007), J-CTO score (HR 1.17, 95% CI: 1.07–1.28, p = 0.001) and multivessel disease (HR 2.20, 95% CI: 1.42–3.39, p < 0.001).

Conclusion

Heart failure was predictor for composite cardiovascular events in patients with CTO after successful recanalization. Male gender, diabetes mellitus, heart failure, J-CTO score and multivessel disease were predictors of MACE in CTO patients with medical therapy.

Length of Stay and Short-Term Outcomes in Patients with ST-Segment Elevation Myocardial Infarction After Primary Percutaneous Coronary Intervention: Insights from the China Acute Myocardial Infarction Registry

BACKGROUND

Length of stay (LOS) in patients with ST-segment elevation myocardial infarction (STEMI) is directly associated with financial pressure and medical efficiency. This study aimed to determine impact of LOS on short-term outcomes and associated factors of LOS in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PPCI).

METHODS

A total of 3615 patients with STEMI after PPCI in the China Acute Myocardial Infarction registry were included in the analysis. Predictors of prolonged LOS were analyzed by multivariate logistic regression model with generalized estimating equation. The impact of LOS on 30-day clinical outcomes was assessed.

RESULTS

The median LOS was 9 (7, 12) days. Patients with a longer LOS (>7 days) were older, more often in lower-level hospitals, had more periprocedural complications and hospitalization expense. Fourteen variables, such as weekend admission and lower-level hospitals, were identified as independent associated factors of prolonged LOS. There were no significant difference in 30-day major adverse cardiac and cerebrovascular events (MACCE), readmission, and functional status between patients with LOS≤7d and LOS>7d after multivariate adjustment and propensity score matching. However, patients who discharged over one week had better medication adherence (adjusted odds ratio: 0.817, 95% confidence interval: 0.687-0.971, P=0.022). Significant interaction was observed in medication use between gender and LOS (Pinteraction=0.038).

CONCLUSION

Patients with STEMI undergoing PPCI experienced a relatively long LOS in China, which resulted in more medical expenses but no improvement on 30-day MACCE, readmission, and functional recovery. Poor 30-day medication adherence with short LOS reflects unsatisfying transition of management from hospital to community. More efforts are needed to reduce LOS safely and improve the efficiency of medical care.

Treatment Delay and Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction during the COVID-19 Pandemic

Pandemic-specific protocols require additional time to prepare medical staff and catheterization laboratories. Thus, we sought to investigate treatment delay and clinical outcomes in COVID-19 positive and negative patients with ST-segment elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI) during on- and off-hours. All consecutive patients with STEMI treated with PCI between 1 March and 31 December 2020 were enrolled in the analysis. A propensity score match was used to compare COVID-19 positive and negative patients for on- and off-hours. The study group was comprised of 877 paired patients treated during regular hours (every day 7:00 a.m. to 16:59 p.m.) and 418 matched pairs with PCI performed during off-hours (every day 17:00 p.m. to 06:59 a.m.) (ORPKI Polish National Registry). No difference in periprocedural mortality was observed between the two groups (on-hours: COVID-19 negative vs. COVID-19 positive: 17 (1.9%) vs. 11 (1.3%); p = 0.3; off-hours: COVID-19 negative vs. COVID-19 positive: 4 (1.0%) vs. 7 (1.7%); p = 0.5). Additionally, a similar rate of periprocedural complications was reported. Patients diagnosed with COVID-19 were exposed to longer time from first medical contact to angiography (on-hours: 133.8 (±137.1) vs. 117.1 (±135.8) (min); p = 0.001) (off-hours: 148.1 (±201.6) vs. 112.2 (±138.7) (min); p = 0.003). However, there was no influence of COVID-19 diagnosis on mortality and the prevalence of other periprocedural complications irrespective of time of intervention.

Transradial Interventions at the Forefront of Innovation

Interventional cardiology has witnessed tremendous changes over the years from a mainly diagnostic approach in an elective population to therapeutic strategies in critically ill patients. Currently, we can treat a broad spectrum of coronary artery, peripheral artery, and structural heart diseases with less invasive, percutaneous approaches that we did not anticipate to be possible just a decade ago. It is certain that the interventional techniques will see further development and we will be able to treat by percutaneous methods more conditions previously thought beyond our reach. Regardless of the advances in catheter-based diagnostic and therapeutic techniques, one thing remains constant. They all require vascular access. And, vascular access is the first technical part of any percutaneous cardiovascular procedure that can determine its overall success. High-quality data together with the availability of training courses for interventional cardiologists and fellows-in-training ensure systematic use of the transradial approach (TRA) which has demonstrated a considerable benefit compared to transfemoral approach both in chronic and acute coronary syndromes. Constant improvement of TRA techniques will further facilitate transradial endovascular and structural interventions, and the growing use for high-risk and complex percutaneous coronary interventions. A continuously growing body of evidence is focused on surpassing current TRA limitations (specifically radial artery occlusion) and expanding alternative vascular accesses such as transulnar approach or distal TRA ("snuff-box" technique). Should this downsizing trend continue, we could see a further paradigm shift toward using the snuff-box technique.

Rota-Lithotripsy-A Novel Bail-Out Strategy for Calcified Coronary Lesions in Acute Coronary Syndrome. The First-in-Man Experience

Heavy calcification remains one of the greatest challenges in the treatment of coronary artery disease (CAD), especially in subjects with an acute coronary syndrome (ACS). In the present case series study of high-risk patients with ACS, including both STEMI and NSTEMI, we performed a rota-lithotripsy-a combination of rotational atherectomy with subsequent intravascular lithotripsy-as a novel bail-out strategy to facilitate stent delivery in a tortuous calcified coronary artery.

Adoption of the Transradial Approach for Neurointerventions: A National Survey of Current Practitioners

OBJECTIVES

The transradial approach (TRA) is technically feasible for both diagnostic and therapeutic neurointerventions. It improves patient comfort and is not associated with increased procedural complications when compared to the transfemoral approach (TFA). To date, no studies have looked at barriers to adoption of TRA in the neurointerventionalist community. This study aims to obtain neurointerventionalist perspectives on their adoption of TRA.

MATERIALS AND METHODS

Online survey distributed to neurointerventionalists.

RESULTS

A total of 55 neurointerventionalists, 52 of whom utilized TRA, responded to our survey. Overall, participants were not concerned about TRA's technical feasibility for diagnostic or therapeutic neurointerventions or about procedural complications. Most of our cohort adopted TRA due to its increased patient comfort and to reduce access site complications. In-institution interventionalists were strongly perceived to be the most effective method of teaching TRA when compared to other methods. Catheters and equipment issues were reported by about 30% of our cohort as a barrier to TRA adoption.

CONCLUSIONS

The neurointerventionalist community largely perceives TRA to be technically feasible and was not concerned about its procedural complications. In-person institutionalists are strongly perceived to be the most effective method of teaching the approach. A significant barrier to adoption seems to be related to catheters and equipment issues.

Comparison of safety and effectiveness between the right and left radial artery approach in percutaneous coronary intervention

INTRODUCTION AND OBJECTIVES

There is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in "real-world" patients with either stable angina or acute coronary syndrome (ACS).

METHODS

To overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry).

RESULTS

The rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0±947.1 mGy vs 1007.4±983.5 mGy, P=.001; ACS: 1212.7±1005.5 mGy vs 1053.5±1029.7 mGy, P=.001). More contrast was used in LRA procedures but only in ACS patients (174.2±75.4mL vs 167.2±72.1mL, P=.001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P=.008), no-reflow phenomenon (0.65% vs 0.49%, P=.005), and puncture site bleeding (0.09% vs 0.05%, P=.04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P=.90).

CONCLUSIONS

Our finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients.