Access Site Hematoma Research Articles

Upper Extremity Access Has Worse Outcomes in F/BEVAR Using the VQI Dataset

Physician-modified endografts and custom-manufactured devices use branched and fenestrated techniques (F/BEVAR) to repair complex aneurysms. Traditionally, many of these are deployed through a combination of upper and lower extremity access. However, with newer steerable sheaths, you can now simulate upper extremity (UEM) access from a transfemoral approach. Single-institution studies have demonstrated increased risks of access site complications and stroke when UEM access is used. This study compares outcomes after F/BEVAR in a national database between total transfemoral (TTF) access and mixed UEM access. This study is an analysis of the Vascular Quality Initiative for all patients who underwent F/BEVAR from 2014 to 2021. Patients were stratified based on a TTF delivery of all devices versus any UEM access for deployment of target vessel stents. Primary outcomes included stroke, myocardial infarction (MI), and perioperative death. Secondary outcomes included access site hematoma, occlusion or embolization, operative time, fluoroscopy time, and technical success. Multivariable linear and logistic regression analyses were performed. Three thousand one hundred forty six patients underwent an F/BEVAR: 2,309 (73.4%) TTF and 837 (26.6%) UEM. Logistic regression analysis indicated a two-fold increased risk of death and MI and a three-fold increased risk of stroke in the UEM group. Furthermore, there is decreased operative time (221 vs. 297min, P<0.001) and fluoroscopy time (62 vs. 80min, P<0.001) in the TTF group and no difference in technical success between groups (96% vs. 97%, P=0.159). Finally, there was a decrease in access site hematoma 2.54% vs. 4.31% (P=0.013), access site occlusion 0.61% vs. 1.91% (P=0.001), and extremity embolization 2.17% vs. 3.58% (P=0.026) in the TTF versus UEM group. This study using Vascular Quality Initiative data demonstrates that patients who undergo an F/BEVAR using UEM access have an increased risk of perioperative MI, death, and stroke compared to TTF access.

Effect of inferior vena cava filter placement position on device complications

BackgroundIndwelling inferior vena cava (IVC) filters can cause complications, including penetration into surrounding structures, migration, and thrombosis of the vena cava. Computational fluid dynamics suggests juxtarenal placement of IVC filters decreases the risk of thrombosis; however, this has not been explored clinically. The present study examines the effect of filter placement position on long-term device complications with an emphasis on IVC thrombosis. We hypothesized that IVC filters placed further caudal to the renal veins were more likely to develop long-term thrombosis. MethodsA retrospective review of the medical records of patients receiving IVC filters at a single tertiary center between 2008 and 2016 was performed. Patients missing follow-up or procedural imaging data were excluded. The placement procedure venograms were reviewed, and the distance from the filter apex to the more inferior renal vein was measured using reported IVC filter lengths for calibration. The patients were divided into three groups according to the tip position relative to the more inferior renal vein: at or superior (group A), 1 to 20 mm inferior (group B), and >20 mm inferior (group C). The patient and procedural characteristics and outcomes were compared between the three groups. The primary end points were IVC thrombosis and device-related mortality. ResultsOf 1497 eligible patients, 267 (17.8%) were excluded. The most common placement position was group B (64.0%). The mean age was lowest in group C, followed by groups A and B (age, 59.5 years, 64.6 years, and 62.2 years, respectively; P = .003). No statistically significant differences were found in the distribution of sex or the measured comorbidities. Group C was the most likely to receive jugular access (group C, 71.7%; group A, 48.3%; group B, 62.4%; P < .001) and received more first-generation filters (group C, 58.5%; group A, 46.6%; group B, 52.5%; P = .045). The short-term (<30-day) and long-term (≥30-day) outcomes, including access site hematoma, deep vein thrombosis, and pulmonary embolism, were uncommon, with no differences between the groups. Cases of symptomatic filter penetration, migration, and fracture were rare (one, one, and three cases, respectively). Although a pattern of increasing thrombosis with more inferior placement was found, the difference between groups was not statistically significant (group A, 1.5%; group B, 1.8%; group C, 2.5%; P = .638). No cases of device-related mortality occurred. All-cause mortality after a mean follow-up of 2.6 ± 2.3 years was 41.3% and did not vary significantly between the groups (P = .051). Multivariate logistic regression revealed that placement position did not predict for short- or long-term deep vein thrombosis, pulmonary embolism, IVC thrombosis, or all-cause mortality after adjustment for the baseline patient characteristics. ConclusionsIVC filters have low rates of short- and long-term complications, including IVC thrombosis. The placement position did not affect the occurrence of device complications in this study.

SAFETY, EFFICACY AND FEASIBILITY OF TRANS RADIAL APPROACH IN COMPARISON WITH TRANSFEMORAL APPROACH IN PATIENTS UNDERGOING CORONARY CATHETERIZATION

Background:Percutaneous Coronary Intervention has been done traditionally through Transfemoral route. Trans Radial route is coming up in the practice. We compared Trans Radial with Transfemoral accesses for ease of operability, time of procedure, complications, and failure rates through a cross sectional study.&#x0D; Objectives:To assess the efficacy, feasibility, safety and procedural variables in Trans radial approach compared with the Transfemoral Approach in patients undergoing coronary artery catheterization.&#x0D; Patients and Methods:A total of 180 patients with both chronic and acute coronary syndromes were enrolled in this study, one hundred forty 140 cases with Radial, 28 of whom were crossed to Femoral access (hence 112 Radials with 108 Right Radial and 4 Left Radial) and 68 cases with Femoral access.&#x0D; Results:Procedural time between Trans Radial and Transfemoral accesses were similar (17.39±10.33 vs 19.68±16.62 minutes P-value 0.36) respectively while among Femoral crossover group was higher (33.50±20.30 minutes P-value 0.01). The Fluoroscopy time was (5.51±4.70 in Trans Radial Vs. 7.18 ±7.65 minutes in Transfemoral P-value 0.07) were similar in both groups. Post procedure access site complications seen in (9% in Trans Radial compared to 7.35% in Transfemoral, P-value 0.048), Access site Hematoma being the most common one (6.25% in Trans Radial vs 4.4% in Transfemoral), Non-flow limiting dissections occurred in (0.89% in Trans Radial VS 1.4% Transfemoral), Radial artery perforation occurred in 1.78%, 1.4% of patients in Femoral group had Femoral artery perforation and had major bleeding.&#x0D; Conclusion:The overall local complications were lower in Transfemoral access, except for major bleeding which is still a big concern. Both vascular Access techniques should not be considered opposite or mutually exclusive, but rather provide the Interventionist a wide spectrum of the therapeutic options.

Diagnostic Electrophysiology Study: The Auckland Regional Experience

Auckland City Hospital provides electrophysiology (EP) procedures for people residing in the Northern Region and is a national service for paediatric and congenital cardiac patients. Electrophysiology procedures are primarily therapeutic and typically undertaken with a view to ablation. When ablation is not delivered, these procedures are considered diagnostic. This retrospective study was undertaken to explore the clinical characteristics and outcomes of patients who underwent diagnostic EP study. The Auckland City Hospital Electrophysiology Registry was reviewed and patients who underwent an EP procedure without ablation from 1 June 2020 to 31 December 2021 were included. Patient characteristics, indications, procedure prioritisation, study indication, reason for no ablation, antiarrhythmic medications, procedure outcomes, and complications were reviewed. There were 912 procedures, 79 (8.7%) were diagnostic EP studies alone. Patients were aged 3–83 years (median, 41). Ethnicities included NZ European (54%) and Māori (18%). The indication in 56 patients was for an assessment of palpations. The most common reason for no ablation undertaken was no inducible tachycardia (n=36). Other reasons included no accessory pathway identified, high-risk procedure due to proximity to the AV node, and no ablation was intended (i.e., for VT stimulation). There were three reported complications: one moderate pericardial effusion that did not require intervention, one VT/VF arrest, and one access site haematoma. Diagnostic EP studies remain common with acceptable complication rates.

Transradial access for balloon-assisted maturation of arteriovenous fistulas.

Balloon-assisted maturation (BAM) of arteriovenous fistulas has conventionally been performed via direct fistula access. The transradial approach has not been well described for BAM, although its use has been reported throughout the cardiology literature. The purpose of the present study was to assess the outcomes of transradial access for its use with BAM. A retrospective review of 205 patients with transradial access for BAM was performed. One sheath was inserted into the radial artery distal to the anastomosis. We have described the procedural details, complications, and outcomes. The procedure was considered technically successful if transradial access had been established and the AVF had been ballooned with at least one balloon without major complications. The procedure was considered clinically successful if no further interventions had been required for AVF maturation. The average time for BAM via transradial access was 35± 20minutes, with 31± 17mL of contrast used. No access-related perioperative complications, including access site hematoma, symptomatic radial artery occlusion, or fistula thrombosis, had occurred. The technical success rate was 100%, and the rate of clinical success was 78%, with 45 patients requiring additional procedures to achieve maturation. Transradial access is an efficient alternative to trans-fistula access for BAM. It is technically easier and allows for better visualization of the anastomosis.

Single-center Experience with JETi Hydrodynamic Thrombectomy System for Arterial Occlusions of the Extremities

Percutaneous aspiration thrombectomy is a new modality for treating patients with acute limb ischemia (ALI). We report our experience and outcomes using the JETi hydrodynamic thrombectomy system (Abbott Vascular, Abbott Park, IL) to treat acute arterial occlusions of the extremities. This a single-center retrospective review of patients with acute occlusions of peripheral arteries or grafts treated with the JETi from September 2020 to December 2022. JETi was used either as primary intervention or as an adjunct to treat distal vessel thrombus after proximal open thrombectomy. The primary outcome for success was defined as >50% luminal opening post-intervention. Indications, limb salvage, and major adverse events were reviewed. The JETi was used in 59 procedures (56 acute lower extremity ischemia [ALEI], three acute upper extremity ischemia [AUEI]) to treat 124 arteries in 57 patients. Mean age was 62 years (range, 29-95 years), and 49% were male. The mean duration of symptoms before hospitalization was 4.8 days (range, 0 hours to 21 days) for ALEI. The primary outcome was achieved in 102 of 124 (83%) arteries by JETi alone. Additional modalities including open thrombectomy, angioplasty, and stenting were used in five arteries to achieve the primary outcome. Seventeen arteries failed to achieve primary outcome with JETi with or without an adjunct. Reasons for failure were attributed to small artery size and chronic nature of the clot. Complete luminal patency with JETi thrombectomy alone was achieved in 52 arteries (42%). Additionally, 55 arteries underwent additional procedures (angioplasty and stenting) to restore complete luminal patency, which was successfully achieved in 49 vessels (89%) (Table). Average estimated blood loss in JETi-only procedures was 335 mL and 384 mL in those who underwent adjunctive procedures to achieve the primary outcome. Complications included distal embolization (5), access site hematoma (3), and acute kidney injury (AKI) (8). Two AKIs were attributed to rhabdomyolysis with creatine phosphokinas >10,000 IU/L; none of whom needed dialysis. There was a single 30-day mortality. Six patients required major limb amputations within 30 days – two after unsuccessful recanalization and one each for severe gangrene despite restoration of in-line flow, reocclusion of a distal bypass graft, recurrent ALEI postoperative day 15 with non-viable muscle on exploration, and a delayed compartment syndrome diagnosis. Success of the JETi to remove the targeted clot was 83%. The JETi system is an efficacious and safe tool for use in the treatment of acute artery occlusion.TableJETi thromboembolectomy technical success outcomes by vessel/graft intervened uponName of artery/graftNo. of each vesselJETi >50%JETi + adjunctive >50%JETi 100%JETI + adjunctive 100%JETI 4- adjunctive 50% <X <100%Aorta000000Common iliac660150External iliac642150Common femoral440310Superficial femoralI8170313IProfunda iroris220100Popliteal20I80882Anterior tibial16111840Tibioperoneal trunk13110821Peroneal artery13100910Posterior tibial1382631Femoral-anterior tibial bypass330030Femoral-popliteal bypass55004lAxillary femoral bvpass110100Axillary200000Subclavian110100Brachial110100124101552496 Open table in a new tab

C-25 | Radial and Ulnar Artery Access for Peripheral Vascular Intervention: A Single Center Experience

Radial artery access has been increasingly utilized for coronary procedures due to lower rates of access complications, improved patient satisfaction, and shorter length of hospital stay. However, limited data are available for peripheral vascular intervention (PVI) with a reported percentage of 2% as per most report. A retrospective review of consecutive patients who underwent PVI via radial or ulnar artery access from February 2020 to September 2022 at a single institution was performed. Baseline patient, procedural, and follow-up data were ascertained from a prospectively maintained institutional database. Among 153 patients, 165 procedures were performed, 94.54% (156/165) for therapeutic purposes and 5.45% (9/165) for diagnostic purposes. Patient and procedural characteristics and outcomes are summarized in Table 1. Procedural access was obtained through the right radial artery (157/165; 95.15%), left radial artery (4/165; 2.42%), and right ulnar artery (4/165; 2.42%) using an R2P Destination Slender sheath. Conversion to femoral access occurred in 8 cases (4.84%) due to arterial spasm, arm pain, and non-crossable lesions. There were no perioperative deaths, post-operative bleeding events requiring transfusion, or pseudoaneurysms, but there were 7 access-site hematomas, which did not require blood transfusion, surgical intervention, and did not prolong hospital stay. Peripheral vascular intervention performed via radial artery access is safe and feasible and allows for simultaneous bilateral and multilevel intervention.

Comparing the Efficacy and Success Rate of Radial Artery Approach under Ultrasound Guidance and Palpation Technique for Coronary Intervention at Central Chest Institute of Thailand

Background: Previous studies of ultrasound guidance for transradial artery access during coronary angiography or interventional procedures demonstrate improving success rate, number of attempts, and short-time access in radial artery cannulation. Objective: To compare the benefit of ultrasound guidance radial artery access during coronary angiography (CAG) or percutaneous coronary intervention (PCI) with palpation technique in experienced and inexperienced operators. Materials and Methods: A randomized prospective study was performed between October 2021 and April 2022. One hundred sixty-four patients were randomized into three groups. The first group, group I (55 cases), underwent radial artery puncture with ultrasound guidance by an experienced interventionist. The second group, group II (56 cases), underwent radial artery puncture using the palpation technique by another experienced interventionist. The third group, group III (53 cases), was also assigned to radial artery puncture with the palpation technique, however, performed by three interventional cardiology fellows. Results: The success rate of radial cannulation was 55 (100%) in group I, 52 (92.9%) in group II, and 48 (90.6%) in group III (p=0.060). Firstattempt success rates in the three groups were 83.6%, 75%, and 69.8%, respectively (p=0.233). The median number of attempts was not significantly different (p=0.208). Time to access the radial artery in group I was reduced significantly compared to the palpation technique in group II and group III (p&lt;0.001). There were no significant differences in complications such as difficult access, access site crossover, radial spasm, and hematoma/ bleeding complication (p=0.135, 0.367, 0.132, and 0.700, respectively). Conclusion: In experienced operators, an ultrasound-guided technique has been shown to have beneficial advantages in reducing the time to access radial artery cannulation compared to experienced and inexperienced operators using the palpation technique. Keywords: Transradial catheterization; Ultrasound guide

Abstract No. 589 Reconstruction of Upper Extremity and Thoracic Central Veins Using Dedicated Venous Stents: Deployment of 75 Stents in 46 Patients

Dedicated bare-metal venous stents, including Abre (Medtronic; Dublin, Ireland), Venovo (Becton, Dickinson, and Company; Franklin Lakes, NJ), Vici (Boston Scientific; Marlborough, MA), and Zilver Vena (Cook Medical; Bloomington, IN), are approved for treatment of iliofemoral venous occlusive diseases. This study describes the use of these stents in the upper extremity and thoracic central veins. Forty-six patients (24 females and 22 males; mean age 52.8 ± 15.5 years) underwent reconstruction of the upper extremity and thoracic central veins using dedicated venous stents from 10/17/2019 to 08/15/2022. All patients presented with swelling, 21 with pain, three with dysphagia, and one with dyspnea. Stent placement parameters (type, location, diameter, length), technical success (stent deployment resulting in patent in-line flow), adverse events, clinical success (resolution of presenting symptoms), and revision parameters were recorded. Seventy-five stents were deployed during 52 procedures. Venous stents used included 43 Abre, 21 Venovo, seven Vici, and four Zilver Vena. Reconstructed veins included: superior vena cava (SVC)-to-bilateral brachiocephalic veins (BCVs) (n = 12), unilateral BCV (n = 12), SVC-to-unilateral BCV (n = 9), SVC only (n = 8), SVC-to-unilateral subclavian vein (SCV) (n = 6), and unilateral BCV-to-SCV (n = 5). Overall mean stent diameter was 13.7 ± 2.0-mm. Mean stent diameters of Abre, Venovo, Vici, and Zilver Vena were 13.2 ± 1.8-mm, 15.2 ± 1.8-mm, 12.3 ± 0.8-mm, and 14 ± 0-mm, respectively. Technical success was achieved in all procedures. One Venovo stent malexpansion occurred which responded to angioplasty. One patient experienced an access site hematoma at the left brachial vein which resolved without intervention. Clinical success was achieved in all patients. No stent fractures or migrations occurred. Six patients required stent revisions at mean of 124.3 ± 82.1 days after the initial procedures. The use of dedicated venous stents in the upper extremity and thoracic central veins yielded excellent technical and clinical success rates without immediate adverse events.

Outcomes of Catheter-Based Pulmonary Artery Embolectomy in Patients With Sub-Massive to Massive Pulmonary Embolism.

Background Pulmonary embolism (PE) is the third leading cause of cardiovascular death after myocardial infarction and stroke. The ideal therapeutic approach for these patients remains undetermined. We report our single-center outcome data for using a catheter-based pulmonary artery thrombectomy using the FlowTriever (Inari Medical, Irvine, CA) device asmanagement for patients with submassive PE. Methods We retrospectively collected data from a single center of patients who underwent thrombectomy using INARI FlowTriever device. The data on baseline characteristics, procedural and clinical outcomes was collected and analysed Results A total of 38 patients with PE treated endovascularly with the FlowTriever device were identified: 33 with submassive PE and five with massive PE. The mean age was 65.9 years (95% CI 61.9 - 69.8), and most patients were male (73.7%). All patients had right heart strain as the main indication for thrombectomy. Four patients (10.53%) required pressor support before the procedure. In 31 patients, pre- and post-thrombectomy average mean pulmonary artery pressure (mPAP) was improved significantly by 22% (p < 0.01). Two patients had significant adverse events at 48 hours (5.26%). One patient experienced procedure-related access site hematoma and life-threatening bleeding, while another developed intraprocedural-related massive hemoptysis and cardiopulmonary arrest. Overall post-procedural length of stay was 7.7 ± 5.6 days; 52.63% of patients (n = 20) required intensive care. Three patients (7.89%) required pressor support before the procedure, and 78.9% of patients (n = 30 of 38) survived hospital discharge. Thirty patients who survived were discharged with oral anticoagulation. There were no device-related complications. Conclusion Randomized trials of interventional devices for submassive PE are warranted to either support or alert the medical community of the safety and efficacy of their use for patients with submassive and massive PE. In time, pulmonary embolismresponse team (PERT)may generate outcome data that better inform treatment decisions.

Optimal Hemostatic Band Duration After Transradial Angiography or Intervention: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials.

The optimal duration of hemostatic compression post transradial access is controversial. Longer duration increases the risk of radial artery occlusion (RAO) while shorter duration increases the risk of access site bleeding or hematoma. As such, a target of 2 hours is typically used. Whether a shorter or longer duration is better is not known. A PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized clinical trials of different duration (<90 minutes, 90 minutes, 2 hours, and 2-4 hours) of hemostasis banding. The efficacy outcome was RAO, primary safety outcome was access site hematoma, and secondary safety outcome was access site rebleeding. Primary analysis compared the effect of various duration in reference to the 2 hours duration using a mixed treatment comparison meta-analysis. Of the 10 randomized clinical trials included with 4911 patients, when compared to the 2-hour reference duration, there was a significantly higher risk of access site hematoma with 90 minutes (odds ratio, 2.39 [95% CI, 1.40-4.06]) and <90 minutes (odds ratio, 3.61 [95% CI, 1.79-7.29]) but not with the 2 to 4 hours duration. When compared with the 2-hour reference, there was no significant difference in access site rebleeding or RAO with shorter or longer duration but the point estimates favored longer duration for access site rebleeding and shorter duration for RAO. Duration of <90 minutes and 90 minutes ranked 1 and duration of 2 hours ranked 2 as the most efficacious duration whereas duration of 2 hours ranked 1 and 2 to 4 hours ranked 2 as the safest duration. In patients undergoing transradial access for coronary angiography or intervention, a hemostasis duration of 2 hours offers the best balance for efficacy (prevention of RAO) and safety (prevention of access site hematoma/rebleeding).

A Double-Blinded Randomized Controlled Trial Comparing Eptifibatide Bolus Only Versus Bolus Plus Infusion In Patients Undergoing Primary Percutaneous Coronary Intervention For ST-Elevation Myocardial Infarction

BackgroundsThe use of eptifibatide combined with heparin during percutaneous coronary intervention (PCI) in patients presenting with ST-elevation myocardial infarction (STEMI) is recommended to be followed by continuous infusion. Recently, there are some suggestions that using bolus only may be sufficient and cost-effective but randomized trials are lacking. AimsThe goal of this study was to evaluate these two approaches in a double-blinded randomized control trial. MethodsThe primary PCI patients who received bolus eptifibatide were randomized to 75 mg IV eptifibatide infusion or placebo blindly. The patients were followed up for the primary outcome of vascular or bleeding complications and secondary outcome of ischemic complications. Results330 patients (165 from each group) completed the study. The mean age was 57.67 ± 11.53 years and 77.3 % were male. Major bleeding was seen in 1 patient in each group. Hematoma occurred in 8.5 %. The relative risk of hematoma and ecchymosis in bolus plus infusion group to bolus only group were 0.988 (95 % CI: 0.486–2.006) and 1.032 (95 % CI: 0.729–1.459). Multivariate analysis confirmed no significant differences in the bleeding event. Furthermore, there was no significant difference in in-hospital death or any ischemic events. (Cath lab death: 1.4 % in bolus only vs zero % in the control group, p = 0.217, stent thrombosis was seen in one patient in each group). ConclusionThere were no differences in the risk of access site ecchymosis, hematoma or major bleeding. Ischemic events and stent thrombosis rates were also similar. Our study suggests that using eptifibatide bolus only during PCI of patients with STEMI is safe and can be cost-saving.

Percutaneous mechanical thrombectomy using the Rotarex®S device for the treatment of acute lower limb artery embolism: A retrospective single-center, single-arm study.

Acute limb embolism (ALE) is a challenging, highly morbid, and frequently fatal vascular emergency. Percutaneous mechanical thrombectomy (PMT) devices are an alternative treatment to restore perfusion by removing emboli in the limb arterial system. We evaluated the outcomes of treatment of ALE patients using PMT devices in our center. A retrospective review of ALE patients treated with Rotarex S (Straub Medical) at a single institution from 2018 to 2022 was performed. The primary outcome was technical success, defined as complete recanalization of the occluded segment with satisfactory outflow and good capillary filling of the distal parts of the foot without any major or obstructing residual emboli or thrombi either in the treated segment or in the outflow tract without the need for additional catheter-directed thrombolysis (CDT) or conversion to open surgery. Embolized segments treated, treatment outcomes, and perioperative complications were reviewed. A total of 17 ALE patients (29% men, 71% women; mean age, 73 years) underwent PMT procedures. The femoral arteries and popliteal arteries are the most commonly treated vessels, with both present in 59% of the patients. The technical success rate was 100%, but the majority of cases (82%) had concurrent percutaneous transluminal angioplasty or stent grafting, and two patients were treated with urokinase during the operation. There was one thrombotic recurrence that required amputation. There were no 30-day deaths. Complications included extravasation after PMT (two), intraoperative embolization of the outflow tract (one), access site hematoma (one), target artery thrombosis (one), and acute kidney injury (one). There were no severe bleeding complications. The Rotarex S device has a satisfactory success rate, although complementary use of various adjunctive techniques is frequently required. It seems to be a moderately effective tool for treating ALE to avoid CDT or open surgery. The device appears safe, with low risks of amputation and mortality rates, but special attention should be given to the potential for extravasation and distal embolism.

Endovascular treatment of multilevel brachiocephalic artery lesions in asymptomatic patients: a case series

Objective: To evaluate the outcomes of complete endovascular carotid revascularization in asymptomatic patients with tandem lesions of common carotid arteries (CCA) and internal carotid arteries (ICA) and to demonstrate the endovascular technique.Methods: Endovascular treatment of two-level brachiocephalic artery lesions was performed in 23 patients at the Almazov National Medical Research Centre from 2017 to 2022. The mean age of the patients was 71.3 years. The lesions were localized in the left CCA and ICA in 11 patients, in the right CCA and ICA in 7 patients, and in the brachiocephalic trunk and right ICA in 5 patients. All patients were asymptomatic on the affected side. Results: Completed with successful stent implantation, all the procedures were effective, with no complications at the access site (hematoma, dissection, bleeding) and no perioperative mortality or residual stenoses. Postoperative neurological disorders developed in two patients including ipsilateral neurological symptoms (NIHSS score 4, Rankin score 1) in one of them and moderate aphasia and dysarthria NIHSS score 2, Rankin score 1) in the other. Brain MSCT showed signs of ischemic stroke that did not require any additional surgical treatment in the second patient. Following the rehabilitation, the neurological symptoms regressed. The mean hospital stay was 4 days. Two years after the intervention two patients required reintervention, i.e. repeat angioplasty of the ICA stent, due to in-stent restenosis.Conclusion: The outcomes in a series of patients with tandem brachiocephalic artery lesions indicate the efficacy of complete endovascular intervention with good short-term results. Received 23 June 2022. Revised 31 July 2022. Accepted 23 August 2022 Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interests: Authors declare no conflict of interest. Contribution of the authorsLiterature review: A.V. Soboleva, V.A. SolovievDrafting the article: A.G. Vanyurkin, Yu.K. BelovaCritical revision of the article: M.A. ChernyavskiySurgical treatment: M.A. Chernyavskiy, A.G. Vanyurkin, N.V. SusaninFinal approval of the version to be published: A.G. Vanyurkin, A.V. Soboleva, N.V. Susanin, Yu.K. Belova, V.A. Soloviev, M.A. Chernyavskiy

Gender Differences in Clinical Outcomes After Percutaneous Coronary Intervention—Analysis of 15,106 Patients from the Cardiac Registry of Pakistan Database

There is a scarcity of data on gender differences in outcomes during and after percutaneous coronary intervention (PCI) in the South Asian population. We assessed the gender differences in in-hospital mortality and complications in patients who underwent PCI. We conducted a cross-sectional study of 15,106 patients from the CROP (Cardiac Registry of Pakistan) CathPCI database. Logistic regression was used to determine factors associated with in-hospital mortality (primary outcome), access site hematoma, and bleeding complications. Approximately 19.6% were women. Women were older (mean age = 57.3 vs 54.4 years) and had a higher prevalence of diabetes (49.3% vs 32.6%), hypertension (72.8% vs 56.4%), peripheral arterial disease (1.5% vs 1%), and cerebrovascular accident (1.2% vs 0.8%) than men (p <0.05).Unadjusted in-hospital mortality was higher in women than in men (odds ratio [OR]: 1.6, 95% confidence interval [CI] 1.1 to 2.2); however, after adjusting for age, hypertension, diabetes, history of cerebrovascular accident, and ST-elevation myocardial infarction at presentation in the multiple logistic regression model, in-hospital mortality was comparable between men and women (adjusted OR [AOR] 1.2, 95% CI 0.8 to 1.7). The results remained consistent after propensity score matching of 5,904 patients (2,952 in each group, OR 1.3, 95% CI 0.9 to 2.0 for in-hospital mortality). Bleeding complications (1.2% vs 0.4%, AOR 2.6, 95% CI 1.4 to 4.5) and access site hematoma (2% vs 0.6%, AOR 2.8, 95% CI 1.8 to 4.5) were higher in women than in men. In conclusion, the incidence of in-hospital mortality was higher for women versus men, but adjusted risks were similar, likely driven by a greater co-morbidity burden among women.

Intracoronary versus intraarterial heparin administration during coronary angiography and percutaneous intervention: A three-year experience from Hospital Universiti Sains Malaysia

Vascular access site hematoma is one of the common vascular complications for percutaneous coronary intervention (PCI). We conduct a study for site specific unfractionated heparin (UFH) administration of intracoronary versus intraarterial in relation to vascular access site hematoma.

Multi-institutional patterns of clopidogrel response among patients undergoing transcarotid artery revascularization.

Current guidelines recommend dual antiplatelet therapy (DAPT) in patients undergoing carotid artery stenting. The most common DAPT regimen is aspirin and clopidogrel, a P2Y12 receptor antagonist; however, the prevalence of clopidogrel resistance (CR) in patients undergoing percutaneous coronary interventions may exceed 60%. Few studies have investigated the prevalence and impact of CR in patients undergoing extracranial carotid artery stenting, particularly transcarotid artery revascularization (TCAR). Consecutive high-risk patients ≥ 18years who underwent TCAR for high grade (≥70%) and/or symptomatic (≥50%) carotid stenosis with preoperative P2Y12 testing between August 2019 and December 2021 were identified across five institutions. Preoperative platelet reactivity was measured with the VerifyNow P2Y12 Reaction Unit (PRU) Test (Instrumentation Laboratory, Bedford, MA), with CR defined as PRU ≥ 194 and hyper-response as PRU <70. Patients without preoperative P2Y12 testing within 30days prior to TCAR or those on a non-clopidogrel P2Y12 inhibitor preoperatively were excluded. The primary outcome of interest was prevalence of CR. Secondary outcomes of interest included the incidence of ischemic and hemorrhagic complications. Of 92 patients identified, the majority were male (59%) and Caucasian (75%) with a mean age of 75years (±8, range 56-92). Preoperatively, 93% of patients were on aspirin, 100% on clopidogrel, and 13% on therapeutic anticoagulation. At presentation, 36% were symptomatic. The mean preoperative P2Y12 was 156 PRU (±76, range 6-349). In total, 30 (33%) patients met criteria for CR (mean PRU 240 ± 37; range 197-349), and 15 (16%) met criteria for hyper-responder (mean PRU 38 ± 20; range 6-68). There was no significant difference by clopidogrel response phenotype in terms of sex (p = 0.246), race (p = 0.384), or symptomatic presentation (p = 0.956). Postoperatively, the cumulative incidence of stroke and MI was 2.1%, with no statistically significant difference in the incidence of in-hospital stroke (PRU 238, p = 0.489) or MI (PRU 168, p = 1) between clopidogrel phenotypes. Three (3.3%) patients, one CR (PRU 240) and two responders (PRU 119 and PRU 189), experienced postoperative access site hematomas that required no subsequent intervention. No other index hospitalization hemorrhagic complications occurred. Using preoperative P2Y12 testing with a threshold PRU ≥ 194 to define CR, we identified a high prevalence of CR in patients undergoing TCAR similar to that in the pre-existing coronary literature. We found no significant differences in postoperative ischemic or hemorrhagic complications by clopidogrel response phenotype, although complication rates in the overall study cohort were low. CR may be a spectrum from responder to partial responder to complete non-responder, and this may account for the differences in our CR cohort compared to the ROADSTER 2 protocol deviation cohort. Further investigation is warranted to determine if a quantitative assessment of CR is sufficient to identify patients at risk of developing secondary cerebrovascular ischemic events in this patient population.

Complications and Adverse Events of Gonadal Vein Embolization with Coils.

Background: The efficacy and safety of gonadal vein embolization (GVE) with coils in the treatment of pelvic venous disease (PeVD) has not been fully investigated, and the outcomes after GVE do not always meet expectations of both doctors and patients. The study was aimed at assessing the incidence and causes of the complications after GVE with coils in patients with PeVD. Methods: This retrospective cohort study included 150 female patients with PeVD who underwent GVE with coils in 2000-2020. A total of 4975 patients with chronic pelvic pain (CPP) were examined, of which 1107 patients had the PeVD-related CPP and 305 underwent surgical or endovascular interventions on the gonadal veins. Complication rates were evaluated 30 days after GVE and classified according to the Society for Interventional Radiology (SIR) adverse event classification system. The pain severity before and after GVE was assessed using a visual analogue scale (VAS). All patients underwent duplex ultrasound after GVE, while patients with persisting pain syndrome and suspected perforation of the gonadal vein were also evaluated using computed tomographic venography. Results: At 30 days after GVE, the CPP was decreased in 109 (72.6%) patients (from 8.2 ± 1.5 at baseline to 1.7 ± 0.8 scores, p = 0.0001) and persisted in 41 (27.4%) patients (mean change from 8.1 ± 0.7 at baseline to 7.8 ± 0.4 scores; p = 0.71). Post-embolic syndrome (PES) occurred in 22% of patients and was completely resolved in 1 month after GVE. The efficacy of GVE in the CPP relief after resolving PES was 94.6%. The GVE complications were identified in 52 (34.6%) patients. Minor complications included access-site hematoma (4%) and allergic reactions (1.3%), and major complications included protrusion of coils (5.3%), thrombosis of the parametrial/uterine veins (21.3%) and deep veins of the calf (2.7%). Conclusions: Gonadal vein embolization with coils in the treatment of PeVD is associated with the development of specific complications and adverse events. The most common complication was pelvic vein thrombosis. Post-embolization syndrome should be considered as an adverse event of this procedure.

Outcomes of carotid stenting in patients with fibromuscular dysplasia

ObjectiveFibromuscular dysplasia (FMD) is a noninflammatory arterial disease that affects the extracranial carotid arteries in young patients. The ideal treatment of FMD has continued to be debated, and the role of carotid artery stenting (CAS) is controversial. The aim of the present study was to assess the feasibility and outcomes of CAS for patients with FMD. MethodsA retrospective analysis of patients who had undergone CAS was performed using the Vascular Quality Initiative database from December 2012 to May 2021. Patients who had undergone CAS for atherosclerosis and FMD were included and matched 1:1 by age, gender, and clinical presentation. The demographics, clinical parameters, and procedural data were analyzed. The end points included postoperative stroke and transient ischemic attack (TIA), and adverse events (perioperative and 1-year mortality, neurologic changes, access site complications, hematoma or bleeding, infection, congestive heart failure, arrhythmia, myocardial infarction, reperfusion symptoms), and hospital length of stay. ResultsAfter matching, 55 patients had undergone CAS for FMD (mean age, 58.7 ± 14 years; 62% women; 69% White; mean body mass index, 28 ± 6 kg/m2). Most of these procedures (69%) were elective. The FMD group had had a lower rate of hypertension (55% vs 82%; P = .002), smoking (35% vs 80%; P < .001), diabetes (13% vs 45%; P < .001), and coronary artery disease (9% vs 45%; P < .001) compared with the non-FMD group. In the FMD group, prior TIA and stroke was identified in 39 (71%) and 31 (57%) patients, respectively. The mean interval from a prior stroke or TIA to the index surgery was 160 days. Additionally, 23 patients (42%) had had anatomically high lesions above the level of the second cervical vertebra. In the FMD group, the transfemoral approach was used for 43 patients (78%), with distal embolic protection used for 40 patients (93%). Flow reversal was used for nine patients (23%). Most cases were performed with local anesthesia (58%). Three patients (6%) in the FMD group had had access site complications that were managed nonoperatively. No differences were found between the FMD and non-FMD groups in perioperative stroke, TIA, or 30-day mortality. The length of stay was similar between the two groups, and the 1-year survival was 100% for both groups. All the patients in the FMD group were discharged without neurologic complications, and 50 patients (91%) were receiving dual antiplatelet therapy. The median follow-up was 328 days (interquartile range, 1-732 days) with no mortality or reinterventions during follow-up. ConclusionsCAS for FMD is a feasible and safe procedure with favorable technical success, a low incidence of neurologic complications, and good clinical outcomes at 1 year of follow-up.

Guide Extension Catheter-assisted Interventions - A Single-Centre Experience

Objective: To evaluate the technical and procedural success and safety of guide extension catheter-assisted percutaneous coronary intervention (PCI) in challenging and complex coronary lesions. Methods: A physician-initiated, observational study conducted at a tertiary care centre in India between July 2021 and July 2022. The patients who underwent guide extension catheter-assisted PCI with the indication of facilitating stent delivery and deployment were consecutively enrolled in the study. Complete medical records including history, demographics and clinical characteristics, and angiographic data of patients who underwent guide extension catheter-assisted PCI were reviewed and noted. Results: Total 19 patients were included in the study of which 18 underwent guide extension catheter-assisted PCI, and one patient internal carotid artery angioplasty. The mean of patients was 62.74±10.38 years ranging from 42 years to 82 years. Total 9 (47.3%) patients were presented with chronic stable angina, 8 (42.1%) with unstable angina and only one patient represented acute myocardial infarction. The right coronary artery (RCA) was the most common target vessel involved in (63.2%). Total 31.6% lesions were distally located, 57.9% were heavily calcified, and 10.5% lesions were chronic totally occluded. A 100% procedural success was noted with the use of guide extension catheter. No case of stent disruption, vessel dissection or ventricular arrythmias and in-hospital death or myocardial infarction were noted during hospital-stay. Only one case of small access site hematoma was reported. Conclusion: The study concluded that the use of guide extension catheter facilitates easy advancement of stents or other devices through tortuous, heavily calcified, distal, bifurcations and CTOs coronary as well as carotid lesions. However, larger studies on wide range of patient population are required to validate our findings. Keywords: percutaneous coronary intervention, coronary artery, carotid artery, guide catheters