Access Site Bleeding Complications Research Articles

Same-day discharge after large-bore access in percutaneous coronary intervention of chronic total coronary occlusions.

Same-day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) of a chronic total occlusion (CTO) is appealing because of the increased patient comfort. However, data on SDD following large-bore vascular access are scarce. We investigated the feasibility and safety of SDD in patients undergoing large-bore CTO PCI. Between 2013 and 2023, 948 patients were prospectively enrolled in a single-centre CTO registry and underwent CTO PCI. SDD was pursued in all patients. Large-bore access was defined as the use of ≥7 French (Fr) sheaths in ≥1 access site. A logistic regression analysis was used to identify predictors for non-SDD. Clinical follow-up was obtained at 30 days. SDD was observed in 62% of patients. Large-bore access was applied in 99% of the cohort. SDD patients were younger and more often male, with lower rates of renal insufficiency and prior coronary artery bypass grafting. Local access site bleeding (odds ratio [OR] 8.53, 95% confidence interval [CI]: 5.24-13.87) and vascular access complications (OR 7.23, 95% CI: 1.98-26.32) made hospitalisation more likely, with vascular access complications occurring in 3%. At 30 days, the hospital readmission rate was low in both SDD and non-SDD patients (5% vs 7%; p=non-significant). Finally, SDD was not a predictor for major adverse cardiovascular events (MACE) at follow-up. Same-day discharge can be achieved in the majority of patients undergoing CTO PCI with large-bore (≥7 Fr) access. Similar low hospital readmission and MACE rates between SDD and non-SDD patients at 30 days demonstrate the feasibility and safety of SDD.

A systematic algorithm for large-bore arterial access closure after TAVI: the TAVI-MultiCLOSE study.

Despite transcatheter aortic valve implantation (TAVI) having become a routine procedure, access site bleeding and vascular complications are still a concern which contribute to procedure-related morbidity and mortality. The TAVI-MultiCLOSE study aimed to assess the safety and efficacy of a new vascular closure algorithm for percutaneous large-bore arterial access closure following transfemoral (TF)-TAVI. All consecutive TF-TAVI cases in which the MultiCLOSE vascular closure algorithm was used were prospectively included in a multicentre, observational study. This stepwise algorithm entails the reinsertion of a 6-8 Fr sheath (primary access) following the initial preclosure with one or two suture-based vascular closure devices (VCDs). This provides the operator with the opportunity to perform a quick and easy angiographic control and tailor the final vascular closure with either an additional suture- or plug-based VCD, or neither of these. Among 630 patients who underwent TF-TAVI utilising the MultiCLOSE algorithm, complete arterial haemostasis was achieved in 616 patients (98%). VCD failure occurred in 14 patients (2%), treated with either balloon inflation (N=1), covered stent (N=12) or surgical repair (N=1). Overall, this vascular closure approach resulted in a minor and major vascular complication rate of 2.2% and 0.6%, respectively. At 30 days, only one new minor vascular complication (0.2%) was noted. In-hospital and 30-day all-cause mortality rates were 0.2% and 1.0%, respectively. Use of the MultiCLOSE vascular closure algorithm was demonstrated to contribute to an easy, safe, efficacious and durable vascular closure after TF-TAVI, resulting in a major vascular complication rate of less than 1%.

Transulnar artery approach in STEMI - Best alternative to radial?

Abstract Background Transulnar artery approach is a valuable alternative wrist access site for percutaneous coronary interventions. Currently published data about using transulnar approach (TUA) in the STEMI setting are missing. Due to its similarities with transradial approach (TRA), TUA in STEMI (ST segment elevation myocardial infarction) procedures can help in decreasing access site bleeding and vascular complications without sacrificing procedural success. Purpose To assess the success and safety of Transulnar access in STEMI. Materials and Methods In the period from March 2011 until December 2021, 8013 consecutive STEMI patients underwent primary PCI (percutaneous coronary intervention) in our center. All consecutive patients with transulnar approach (TUA) were included in a single center prospective registry of effectiveness and safety. The primary outcome was procedural success through ulnar access. We also examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TUA. Results In this period, 172 STEMI patients (2.1%) underwent PPCI through transulnar approach. Mean age of patients was 60 ± 12 years with 27% females. All procedures were successfully performed through right TUA. There were no STEMI TUA cases with crossover to Transfemoral approach. In 150 patients (87%) TUA was the primary choice of puncture due to no palpable radial artery from previous radial artery occlusion. In 22 patients (12.7%) the reason for crossover from primary TRA to TUA were complex RA anomalies. Type 3 and 4 EASY Score hematoma was present in 4 patients (2.3%). 7% of patients had over 1 access site puncture. UA spasm was registered in 1.7%. Mean procedural time was 32±23 min and fluoroscopy time was 8.5±9.2 min. Ulnar artery anomalies were registered in 1% of patients. There were no ulnar artery occlusions detected at discharge. There were no clinical or ischemic hand complications seen during clinical follow up. Conclusion Transulnar approach is safe and feasible alternative wrist access in the STEMI setting and can further decrease TFA crossover.

Access Site, Antithrombotic Therapy and Major Bleeding Complications in Chronic Kidney Disease Patients Undergoing Percutaneous Coronary Intervention: Here We Go Again

Access Site, Antithrombotic Therapy and Major Bleeding Complications in Chronic Kidney Disease Patients Undergoing Percutaneous Coronary Intervention: Here We Go Again

Femoral Access-Site Complications with Tenecteplase versus Alteplase before Mechanical Thrombectomy for Large-Vessel-Occlusion Stroke.

IV thrombolysis with alteplase before mechanical thrombectomy for emergent large-vessel-occlusion stroke is associated with access-site bleeding complications. However, the incidence of femoral access-site complications with tenecteplase before mechanical thrombectomy requires exploration. Here, femoral access-site complications with tenecteplase versus alteplase before mechanical thrombectomy for large-vessel-occlusion stroke were compared. All patients receiving IV thrombolytics before mechanical thrombectomy for large-vessel-occlusion stroke who presented from January 2020 to August 2022 were reviewed. In May 2021, our health care system switched from alteplase to tenecteplase as the primary thrombolytic for all patients with stroke, facilitating the comparison of alteplase-versus-tenecteplase femoral access-site complication rates. Major (requiring surgery) and minor (managed conservatively) access-site complications were assessed. One hundred thirty-nine patients underwent transfemoral mechanical thrombectomy for large-vessel-occlusion stroke, of whom 46/139 (33.1%) received tenecteplase and 93/139 (66.9%) received alteplase. In all cases (n = 139), an 8F sheath was inserted without sonographic guidance, and vascular closure was obtained with an Angio-Seal. Baseline demographics, concomitant antithrombotic medications, and periprocedural coagulation lab findings were similar between groups. The incidence of conservatively managed groin hematomas (2.2% versus 4.3%), delayed access-site oozing requiring manual compression (6.5% versus 2.2%), and arterial occlusion requiring surgery (2.2% versus 1.1%) was similar between the tenecteplase and alteplase groups, respectively (P = not significant). No dissection, arteriovenous fistula, or retroperitoneal hematoma was observed. Tenecteplase compared with alteplase before mechanical thrombectomy for large-vessel-occlusion stroke is not associated with an alteration in femoral access-site complication rates.

Percutaneous coronary intervention with Impella support with and without intra-aortic balloon in cardiogenic shock patients

ObjectiveTo assess the clinical characteristics and in-hospital bleeding complications and major adverse cardiac and cerebrovascular events (MACCE) associated with the use of Impella alone or the combination of an intra-aortic balloon pump (IABP) with Impella in cardiogenic shock (CS) patients undergoing percutaneous coronary intervention (PCI). MethodsAll CS patients who underwent PCI and were treated with an Impella mechanical circulatory support (MCS) device were identified. Patients were divided into two groups: having MCS support with Impella alone or with both, IABP and Impella simultaneously (dual MCS group). Bleeding complications were classified by a modified Bleeding Academic Research Consortium (BARC) classification. Major bleeding was defined as BARC≥3 bleeding. MACCE was the composite of in-hospital death, myocardial infarction, cerebrovascular events and major bleeding complications. ResultsBetween 2010 and 2018 a total of 101 patients were treated at six tertiary care New York hospitals with either Impella (n = 61) or dual MCS with Impella and IABP (n = 40). Clinical characteristics were similar for both groups. Dual MCS patients presented more often with a STEMI (77.5 % vs. 45.9 %, p = 0.002) and had left main coronary artery intervention (20.3 % vs. 8.6 %, p = 0.03). Major bleeding complications (69.4 % vs. 74.1 %, p = 0.62) and MACCE rates (80.6 % vs. 79.3 %, p = 0.88) were very high but similar in both groups, however access site bleeding complications were lower in patients treated with dual MCS. In-hospital mortality was 29.5 % for the Impella group and 25.0 % for the dual MCS group (p = 062). Access site bleeding complications were lower in in patients treated with dual MCS (5.0 % vs. 24.6 %, p = 0.01). ConclusionIn CS patients undergoing PCI with either the Impella device alone or with Impella and IABP, major bleeding complications and MACCE rates were high but not significantly different between the two groups. In hospital mortality was relatively low in both MCS groups despite the high-risk characteristics of these patients. Future studies should assess the risks and benefits of the simultaneous use of these two MCS in CS patients undergoing PCI.

Gender Differences in High-risk CAS through Radial Access

AIMS: Transradial (TR) carotid artery stenting (CAS) has been established as an acceptable alternative to carotid endarterectomy, especially in patients with a high risk for surgery. The purpose of this study was to evaluate the gender differences of radial access CAS in high-risk patients. MATERIALS AND METHODS: This was a prospective analysis which included 54 consecutive patients in the period from December 2020 to January 2022. According to the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy study for high-risk CAS, patients with at least one anatomic or comorbid factor associated with increased surgical risk were included in the study. Subjects were divided into two groups according to sex. Follow-up assessments included neurological exams, 12-lead electrocardiogram, and duplex ultrasound (DUS). The primary endpoint was 30-day composite rate of stroke, death, and myocardial infarction. Secondary endpoints included procedure success, access site complications according to Early Discharge after TR Stenting of Coronary Arteries (EASY) score classification, target lesion revascularization, and in-stent restenosis evaluated with DUS. RESULTS: The study population was predominantly male 37 (61.1%) and females were 17 (38.9%). Mean age in the women group was 64.4 ± 7.43 years, and in men, it was 69.1 ± 8.01 years (p = 0.0223). From risk factors for coronary artery disease, hypertension and smoking were more frequent in the male group and hyperlipidemia and diabetes in the female group. Most of the male patients were symptomatic compared to the female group (p = 0.0151). Procedural success was obtained in all cases. Transient vasospasm induced by the distal protection device was present in one male patient. No 30-day major adverse events were recorded between the two groups. Minor access site bleeding complications according to EASY score (Easy type 1) were recorded in 4 patients (3 males vs. 1 female). There were no cases of hand ischemia after procedure or follow-up. None of the patients had in-stent restenosis >70% on DUS during 1-year follow-up. CONCLUSION: Results from this study demonstrate no gender-related differences in radial access CAS for high-risk patients.

CRT-100.28 Access Site, Antithrombotic Therapy and Major Bleeding Complications in Chronic Kidney Disease Patients Undergoing Percutaneous Coronary Intervention: Here We Go Again

CRT-100.28 Access Site, Antithrombotic Therapy and Major Bleeding Complications in Chronic Kidney Disease Patients Undergoing Percutaneous Coronary Intervention: Here We Go Again

Safety and Feasibility of Retrograde Recanalization of Radial Artery Occlusion in Patients with Need for Repeated Wrist Procedures

AIM: The purpose of the study was to present a new technique of retrograde recanalization of radial artery (RA) occlusion (RAO) in patients with need for repeated wrist access percutaneous angiographic procedures. MATERIALS AND METHODS: During a 10-year period from March 2011–May 2021, 53 000 patients were referred for percutaneous coronary intervention (PCI) in a high-volume transradial center. RAO on angiography was documented in 1165 patients. Retrograde recanalization of RAO was attempted in 70 patients. The selected patients were with multiple previous bilateral wrist interventions (n = 3–9). Ipsilateral ulnar artery was usually rudimented or occluded and contralateral wrist approach could not be used. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and procedural success of retrograde recanalization of RAO. Visual analog scale (VAS) score forearm pain assessment was performed after procedure. Technique: All patients had palpable pulse distal of previous puncture site due to collaterals from ipsilateral ulnar and interosseous artery. The RA was punctured with an inner metallic needle with a plastic cannula. Using retrograde radial angiography performed by injecting contrast through the plastic cannula, the occluded segment was visualized and crossed with different types of hydrophilic chronic total occlusion guide wires. After sheath insertion, balloon dilatation of the occluded RA segment, successful catheterization, and/or percutaneous coronary intervention was performed. Final RA angiography was performed on all patients. RESULTS: Successful retrograde opening of RAO was achieved in 65 out of 70 patients (92%). PCI was performed in 56% of patients through the opened RAO and 5 patients underwent CAS. Procedural success through opened RA was achieved in all 65 patients. Forearm pain during procedure was present in all cases (VAS score 3 ± 2.1). Access site bleeding EASY score 3 and 4 occurred in 6 patients (8.5%). One patient had discharge of embolic material up the arm without clinical consequences. In one patient, we observed dissection of the interosseous artery. Clinical and duplex long-term follow-up with a median of 4.1 years showed patent RA in only 20 patients. There were no registered cases of hand ischemia. About 61% of patients underwent subsequent PCIs, through other alternative access sites. CONCLUSION: Retrograde recanalization of RAO is successful and safe in patients with need of repeated coronary angiography procedures and inability to use other wrist access sites. Puncturing the collateral and performing retrograde radial angiography through the cannula is a key factor in successful opening of the RAO.

Anatomical, functional and pain hand assessment after transulnar artery access with ipsilateral RAO for percutaneous coronary interventions

Abstract Aims The purpose of our research comes from the increasing need for an alternative approach when the standard right radial is not accessible, most commonly due to the presence of RAO. The use of this approach is still controversial in the interventional community, due to lack of published studies. Our purpose was to prove its' safety and success. Material and methods In the period from September 2019 until April 2021, 103 consecutive patients underwent PCI through primarily chosen TUA with ipsilateral RAO. These patients were included in a prospective single center study of effectiveness and safety. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TUA. Anatomical, functional and pain assessment of the punctured arm was performed at baseline and after the procedure and at follow-up. Using pre-procedural UA angiography, we measured the diameter of the UA and the collateral circulation for the occluded RA by QCA (Quantitative angiography). Values of UA diameter were compared with previous angiographies before RAO. Additional functional assessment of the arm was performed using JAMAR dynamometer for hand strength and self-assessment with QUICK DASH questionnaire. VAS score was used for pain assessment. Clinical and duplex ultrasound evaluation for ulnar patency were examined. Results Mean age of patients was 62.9±9 years with 30% females. Previous TRA was present in all patients, 32% of patients had multiple previous TRA (>3), with 10 being the largest number. Procedural success through primary chosen TUA with ipsilateral RAO was 96.2%. In 4 (3.8%) patients we had an inability to puncture the right UA and were transferred to left TRA. Procedural success after UA puncture was 100%. Number of punctures of the UA was 1.6±0.9 (1–6 punctures). Access site bleeding complications were detected in 4% (EASY score >2). On duplex ultrasound follow up, there wasn't a single case of UAO detected. There were no clinical or ischemic hand complications seen during long-term follow up. Local bleeding complications were found to be related to larger number of punctures, time of puncture and longer procedural time (p<0.0001). QCA assessment showed an increasing of UA diameter after RAO of 0.28±0.35 mm (p<0.0001). Dynamometer values of arm strength showed a small decrease in values 12 hours after procedure (72.6±23 vs. 71.9p, p=0.029), but without changes in initial strength on 1, 6 and up to 1 year after procedure. QUICK DASH self-assessment showed no significant changes in the follow-up period. Conclusion Transulnar approach with ipsilateral RAO is safe and successful for PCI. The existence of appropriate collateral support for the occluded RA, allows for a safe TUA with ipsilateral RAO. Anatomical, functional and pain assessment of the punctured arm affirmed the safe use of this approach as the best alternative for right TRA and preservation of wrist access benefits. Funding Acknowledgement Type of funding sources: None.

Access site bleeding complications comparing oral anticoagulation therapy with NOACs and VKAs in patients with atrial fibrillation undergoing cardiac implantable device intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation is frequent in patients undergoing cardiac implantable electronic device (CIED) intervention. Such population require oral anticoagulation therapy, which increases risk of procedure related bleeding. There is a lack on data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) vs vitamin K antagonist anticoagulants (VKAs) in patients with AF undergoing CIED intervention. Study purpose Aim of the present stud was to evaluate whether NOACs have a safety benefit compared to VKAs in terms of fewer hemorrhagic complications at the site of CIED implant. Methods Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, monocentric investigation. Primary endpoint was the incidence of post-intervention clinically significant pocket hematoma. Multivariate analysis was performed to investigate the association between covariates and the primary endpoint. Results A total of 311 patients were enrolled, 146 on NOACs and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC vs 13.3% in the VKA group (p=0.002) (Figure 1). Primary outcome-free survival at 30-days was 96.6 % in patients on NOACs and 86.0% in those on VKAs (p=0.019) (Figure 2). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs vs VKAs (HR 0.35, 95% CI 0.13-0.96, p=0.042). Such NOACs benefit was confirmed vs patients on VKAs without peri-procedural bridging with low-molecular weight heparin (HR 0.34, 95% CI 0.11-0.99, p=0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups. Conclusion Among patients with AF undergoing implantable cardiac defibrillator or pace-maker intervention, the use of NOACs vs VKAs is associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low molecular-weight heparin in the VKA group.

Access Site Bleeding Complications with NOACs versus VKAs in Patients with Atrial Fibrillation Undergoing Cardiac Implantable Device Intervention.

There are no data on procedure-related bleeding outcome with non-vitamin K antagonist anticoagulants (NOACs) versus vitamin K antagonist anticoagulants (VKAs) in patients with atrial fibrillation (AF) undergoing cardiac implantable electronic device (CIED) intervention. Our aim was to evaluate whether NOACs have a safety benefit even in terms of fewer hemorrhagic complications at the site of CIED implant. Consecutive AF patients receiving NOACs or VKAs at the time of CIED procedure were included in this observational, retrospective, and monocentric investigation. Primary endpoint was the incidence of post-intervention pocket hematoma. A total of 311 patients were enrolled, 146 on NOACs, and 165 on VKAs. The incidence of pocket hematoma was 3.4% in the NOAC versus 13.3% in the VKA group (p = 0.002). Primary outcome-free survival at 30-days was 96.6% in patients on NOACs and 86.0% in those on VKAs (p = 0.019). Multivariate analysis, adjusted by propensity-score calculation of inverse-probability-weighting, showed a significantly lower occurrence of pocket hematoma in patients receiving NOACs versus VKAs (HR 0.35, 95% CI 0.13–0.96, p = 0.042). Such NOACs benefit was confirmed versus patients on VKAs without peri-procedural bridging with low-molecular-weight heparin (HR 0.34, 95% CI 0.11–0.99, p = 0.048). The incidence of pocket infection, surgical pocket evacuation, ischemic events, and major bleeding complications at 30 days (secondary endpoints) was similar in the two groups. In conclusion, our data suggest that, among patients with AF undergoing implantable cardiac defibrillator or pacemaker intervention, the use of NOACs versus VKAs may be associated with significant reduction of post-procedural pocket hematoma, regardless of bridging with low-molecular-weight heparin in the VKA group. These results are hypothesis generating and need to be confirmed in a specific randomized study.

Balloon-assisted injection of fibrin sealant for the treatment of postintervention access-site bleeding complications.

This study sought to evaluate a new method that uses injection of fibrin sealant under simultaneous balloon occlusion for the treatment of postinterventional access site bleeding complications.With the rising complexity of interventional procedures, iatrogenic false aneurysms and active bleeding has become more common. In general, these complications are associated with increased morbidity and mortality, especially if surgical repair is required. Although high success rates are reported for ultrasound-guided compression and ultrasound-guided thrombin injection, these methods are not always feasible.All procedures of fibrin sealant injection under simultaneous balloon occlusion for the treatment of postinterventional access site bleeding complications or pseudoaneurysm were prospectively collected. Additional data were retrospectively obtained and analyzed for all patients treated by this new method.In total, 53 patients were included from 2018 to 2021. Most of the access site complications were related to transcatheter aortic valve replacement (40%) or percutaneous coronary intervention (21%), but also to a wide variety of other procedures. Of the 53 patients, 30 had to be treated for false aneurysms and 23 for active bleeding. A high primary success rate of 94% was achieved. Recurrences of false aneurysms occurred in six patients, of which only one needed open surgical repair. Regarding complications, twoperipheral embolisms, thereof one requiring additional stent implantation occurred.Balloon-assisted thrombin injection seems to be feasible and safe. It provides a new alternative to prevent surgery for patients where common techniques are unavailable or have failed.

Sex differences in transradial access site characteristics and crossover in STEMI

Abstract Objective To assess the differences according to sex in radial artery access site characteristics and crossover and it's influence on the success of ST segment elevation myocardial infarction (STEMI) procedures with primary chosen transradial access site in a large series of patients. Background Transradial angiography (TRA) is now the default access site for PPCI, but technically is a more challenging approach mostly due to anatomic challenges connected to the radial artery. Methods All 5092 consecutive STEMI patients from our center, in the period from March 2011 until December 2017 were examined. Patient were divided in two groups according to sex. Preprocedural radial artery angiography was performed in all patients. Clinical and procedure characteristics, type of radial anatomy variants, transfer to other access sites, transfer direction and procedure time were analyzed. Access site bleeding complications and in-hospital mortality were also recorded. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another access site to finish the procedure. Results From the STEMI population in this period the female group had 1326 PPCI treated patients and the male group 3766 patients. The female group of patients was older 65±11 than the male group 59±11 (p<0,0001). BMI was 27 vs. 30 in the male group (p=0.0003). Most common risk factors in both groups were hypertension, smoking and diabetes, with the latter being more frequent in the female group p<0,0001. Radial artery anomalies were more frequent in the female group 8,8% vs 6,5% (p<0,0001), with complex RA loop and tortuous RA having double percentage than in their male counterparts. Primary chosen TRA access site failure occurred in 4.6% (61) vs. 3.5% (97) of STEMI patients (p<0.0001). Most common access site crossover site was right ulnar access in both groups with 57 and 61% accordingly. Access site bleeding complications, were more common in the female group with 4.4% vs. 3.2%, also this difference persisted in EASY score hematoma 3 to 5. Clinical radial artery spasm was significantly more frequent in female patients 5,7% vs. 2.2% (p<0.0001). In-hospital mortality rate was similar in the two group of patients. Conclusion Female sex is a significant risk factor for TRA failure in STEMI usually connected to smaller size of RA and the more common finding of radial artery anomalies and spasm. Funding Acknowledgement Type of funding sources: None.

Ultrasound- Versus Fluoroscopy-Guided Strategy for Transfemoral Transcatheter Aortic Valve Replacement Access: A Systematic Review and Meta-Analysis.

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Minimal Individual Haemostasis (Mih) - Feasibility in Conventional and Distal Trans-Radial Approach

Abstract There is a growing use of trans-radial catheterisation for angiography and percutaneous interventions. The advantages of trans-radial over traditional femoral access include a decrease in the incidence of access site bleeding complications and improved patient comfort and recovery. Ensuring short haemostasis, which controls arterial bleeding after transracial interventions, but at the same time maintains radial arterial flow, appears to be the most important factor in reducing peri-procedural complications, especially radial artery occlusion (RAO). We evaluated the technical feasibility of our gradual deflation haemostasis method in a population of patients treated by both conventional and distal trans-radial approach, within 1 month period. A feasibility assessment was performed for 101 patients to assess whether our hemostasis technique could be performed safely. We concluded that our technique is feasible after trans-radial approach, in both categories of access, conventional or distal. The rate of peri-procedural complications was low and related to the type of approach used, with more positive results on the distal trans-radial approach.

Ipsilateral transulnar artery approach catheterizations after failure of the radial approach-Are two sheaths in the same arm safe?

To assess the safety and feasibility of ipsilateral transulnar access (TUA) after failure of radial access (TRA), with two sheaths placed in the radial and ulnar arteries (RA and UA) in the same arm. All consecutive patients with TUA due to inability to cross from ipsilateral TRA in the period from March 2011 until September 2020 were included in the study. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TRA. Patients were assessed by duplex ultrasound post-procedure (at an average of 56 ± 31 months) and followed clinically (functional and pain assessment). In this period, out of 51,866 patients 112 (0.2%) had a transulnar artery approach due to inability to cross from ipsilateral radial approach. Mean age of patients was 65 ± 11 years with 44% females. Cause for crossover to ipsilateral TUA was inability to cross a RA anomaly in 107 (95%) patients, mostly due to the presence of a "360°" RA loop in 88 patients. Type 3 and 4 EASY Score hematoma was present in 3 patients (2.6%). Six (5.3%) of the patients had new ipsilateral radial artery occlusion noted on duplex on follow up. There were no ulnar artery occlusions detected. There were no clinical or ischemic hand complications seen during a median 4.3 years of follow up. Ipsilateral transulnar artery access following failed radial artery access crossing is safe and successful for coronary angiography and intervention with low rates of complications.

Abstract No. 53 Initial experience with Venovo venous stents in iliocaval and iliofemoral occlusions

To present early single-center, single-operator experience using the Bard Venovo venous stents in the treatment of patients with chronic iliocaval and iliofemoral venous occlusions and post-thrombotic syndrome A total of 19 patients (9 women) with a mean age of 56.1 years (range 8-80) presented between August 2019 and August 2020 with post-thrombotic syndrome and iliocaval or iliofemoral occlusion. Nine of the 19 patients were evaluated pre-procedurally with Villalta scores with an average of 16.1 (range 13-22) consistent with severe post-thrombotic syndrome. Ten Iliocaval and 9 iliofemoral venous reconstructions were performed using exclusively Venovo stents. Six of the iliocaval recanalizations were performed for occlusion of a filter-bearing IVC and one for thrombosis related to malignant compression. Three of the procedures required sharp recanalization techniques. All patients were discharged on anticoagulation and antiplatelet regimens with the exception of one patient for whom antiplatelet therapy was contraindicated. Clinical follow-up was available in all patients and 7 patients had in person follow up visits within the first 3 months after the procedure at which Villalta scores were calculated with an average of 4.3 (range 1-9). 18 of 19 patients (95%) demonstrated short-term primary stent patency. One patient had iliac stent thrombosis within 2 months but remained symptomatically improved and no additional intervention was performed. One stent maldeployment occurred requiring an additional stent placement. There were four complications including one spontaneous retroperitoneal hematoma, two access site bleeding complications prompting ER visits but treated conservatively and one episode of epistaxis requiring adjustment of the initial antiplatelet regimen. Initial experience with the Venovo venous stents in chronic iliocaval and iliofemoral venous occlusions has demonstrated good technical success, initial patency and relief of post-thrombotic syndrome symptoms as evidenced by early clinical follow up. Continued follow up will be needed to determine the durability of these results.

Periprocedural management of anticoagulation therapy and in-hospital outcomes in patients with warfarin indication undergoing percutaneous coronary intervention. Data from the WAR-STENT registry

In patients with an indication for oral anticoagulation (OAC) with warfarin, the management of OAC peri-procedure of percutaneous coronary intervention (PCI) is still not fully defined. To investigate clinical practice and outcomes associated with continuation vs interruption of OAC, with or without bridging with low-molecular-weight heparin (LMWH), we examined the database of the observational, prospective, multicenter Italian WAR-STENT registry. The WAR-STENT registry was conducted in 2008-2010 in 37 Italian centers and included 411 consecutive patients in 157 of whom the peri-procedural international normalized ratio (INR) value was available. In relation to the continuation vs interruption of OAC, patients were divided into group 1 (n = 106) and group 2 (n = 51) respectively, and compared. The basal characteristics of the two groups were similar. The most frequent indication for OAC was atrial fibrillation and for PCI acute coronary syndromes, respectively. The pre-procedural mean value of INR was significantly different in group 1 vs group 2 (2.3 ± 0.4 vs 1.5 ± 0.2; p <0.001), while the use of antithrombotic drugs did not differ, except for LMWH which, albeit limited to only 14% of cases, was used significantly more frequently in group 2 (14% vs 2%; p=0.006). The radial approach was used significantly more often in group 1 vs group 2 (72% vs 45%; p=0.002). The in-hospital incidence of major bleeding complications was similar in groups 1 and 2 (4% vs 8%; p=0.27), as well as the occurrence of major adverse cardio-cerebrovascular events, including cardiovascular death, non-fatal myocardial infarction, re-revascularization of the treated vessel, stent thrombosis, stroke and venous thromboembolism (6% vs 6%; p=0.95). There was a tendency towards a higher incidence of minor access-site bleeding complications in group 1 patients treated by the femoral route. In unselected patients with an indication for OAC with warfarin and undergoing PCI, the continuation vs interruption of OAC (essentially without LMWH bridging) strategies appears similar in terms of efficacy and safety. In consideration of the superior convenience, peri-procedural continuation of OAC should therefore generally be preferred, with the possible exception of patients in whom the femoral approach is required for the procedure.

Transulnar Aproach for PCI after failed ipilateral TRA: 2 sheaths in same arm, is it safe?

Abstract Aims To assess the feasibility and safety of transulnar access (TUA) after failure to cross through ipsilateral radial access (TRA), with two sheaths placed in same arm (RA and UA). Methods and results All consecutive patients, with TUA due to inability to cross from ipsilateral TRA in the period from March 2011 until December 2017 were included in the study. Pre-procedural wrist artery angiography was performed in all patients through radial and afterwards ipsilateral ulnar artery. We examined clinical and procedure characteristics, access site complications and cause of failure of primary chosen TRA. Patients were followed up with a median of 4 years. From March 2011 untill December 2017, 104 patients had a transulnar artery approach due to inability to cross from ipsilateral radial approach. Mean age of patients was 64±11 years with 48% females. 15% of patients had a PPCI intervention due to STEMI. Cause for crossover to ipsilateral TUA was due to: inability to cross an RA anomaly in 94 patients, inability to cross high degree RA spasm in 8 and in 2 patients due to dissection of the RA. Most common anomaly of the RA that caused inability to cross was full 360 degree RA loop in 53 (56%) patients. 49 Patients (47%) underwent percutaneous coronary intervention, 5 (4,8%) patients carotid artery stenting and 50 (48%) diagnostic coronary angiography through ipsilateral TUA. Procedure duration was 35±16 minutes, contrast volume 120±35 ml and fluoroscopy time was 8±6 minutes. Access site bleeding complications were present in 7 (6.7%) patients after procedure with Type 4 EASY Score hemathoma present in 3 patients (2.8%) without further consequences. 5.7% of patients had ipsilateral RAO noted on duplex on follow up. There were no ischemic hand complications after intervention and follow up with median of 4 years. Conclusion Transulnar artery access due to failed ipsilateral radial access crossing is safe and feasible for angiography and PCI with low rate of complications on long term follow up. TUA after failed TRA (2 sheaths) Funding Acknowledgement Type of funding source: None