Common Access Site Research Articles

Angiology in rhythmology: What should Iknow about vascular complications?

Both the performance of electrophysiological examinations and the implantation of cardiac devices (pacemakers, implantable cardioverter-defibrillator [ICDs], and cardiac resynchronization therapy defibrillator [CRT-D] systems) are associated with vascular punctures. This article provides an overview of possible vascular complications and their management from the perspective of angiology. The most common access site for invasive electrophysiological procedures is usually via the femoral veins and/or arteries. Puncture of the brachial vessels is apossible but rarely used alternative. For implantation of transvenous cardiac devices, access via the cephalic vein or axillary vein is used. The electrodes located in the venous vascular system represent aforeign material and increase the risk of thrombus formation in the affected vein. Punctures of the femoral vessels can lead to bleeding, thrombosis and the formation of arteriovenous fistulas or pseudoaneurysms (aneurysma spurium). Venous thromboses can occur postprocedurally. The correct puncture technique is essential to avoid complications. Ultrasound-guided puncture also significantly reduces the rate of vascular complications.

Sex differences in transradial access failure in ST segment elevation myocardial infarction.

Transradial access (TRA) is now the default access site for PPCI, but technically is a more challenging approach mostly due to anatomic challenges connected to the RA. To assess the differences according to sex in radial artery (RA) access site characteristics during primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI). All 5092 consecutive STEMI patients from our center in the period from March 2011 until December 2017 were examined. The right proximal radial was the "intention-to-treat" access in all patients. Preprocedural RA angiography was performed in all patients. Clinical and procedure characteristics, type of radial anatomy variants, need to use another arterial access sites (the primary endpoint for this study), and procedure time were analyzed by sex. Using logistic regression, we selected predictors of radial crossover. Access site bleeding complications and vascular complications were also recorded. The STEMI population in this period included 1326 females and 3766 male patients. Females were older (65 ± 11 years) than males (59 ± 11 years, p < 0.0001). Among standard risk factors, hypertension and diabetes mellitus were more common in women and smoking less common. RA anomalies were more frequent in the females (8.8% vs. 6.5%, p < 0.0001), with complex RA loop and tortuous RA twice as frequent in women. Failure of TRA access as the initially chosen site occurred in 4.6% (61) of females versus 2.5% (97) of male STEMI patients (p = 0.0003). The most common subsequent access site was right ulnar access in both groups (57 and 61% respectively). Access site bleeding complications were more common in women 4.4% versus 3.2%, mirrored in hematomas with EASY score III to V. Clinical RA spasm (RAS) was significantly more frequent in females (5.7% vs. 2.2%, p < 0.0001). Multiple regression analysis identified 5 independent predictors for TRA access crossover: previous TRA, anomalous RA, RAS, along with female sex and diabetes. Female sex is a significant predictor of more complex TRA in STEMI. Understanding sex differences and predictors for TRA crossover will strengthen the use of different procedural modalities that can help in preserving a successful wrist access in female STEMI patients.

320 Intraoperative Angiography in Neurosurgery: Temporal Trend, Access Site, and Operative Indication Considerations From a Six-year Institutional Experience

INTRODUCTION: Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiogram (IOA). However, in line with trends in cardiac interventional vascular access preferences, transradial approach (TRA) and transulnar approach (TUA) are gaining popularity due to favorable safety and patient satisfaction outcomes. METHODS: Between July 2016 and December 2022, 317 angiograms were included based on our case definition, comprising 59 TRA cases, 11 TUA cases, 243 TFA, and four transpopliteal cases. Fluoroscopy time, contrast dose, reference air kerma (RAK), and dose area products (DAP) per target vessel catheterized were the primary endpoints of interest. Univariate and multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure metrics. RESULTS: Contrast dose per vessel catheterized was significantly lower in TRA/TUA cases versus TFA cases (p = 0.001), but radiation exposure metrics did not differ between access site groups. TRA/TUA versus TFA does not significantly predict elevated levels of radiation exposure or contrast dose. Aneurysm cases were associated with significantly lower odds of elevated radiation exposure for all radiation metrics (p &lt; 0.05) whereas AVM cases had higher odds of elevated radiation exposure across all measures (p &lt; 0.01). There was a significant relationship between case number and operative indication over the study period (p &lt; 0.001) with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of AVF and AVM. CONCLUSIONS: TRA and TUA are safe and effective access site options for neurointerventional procedures and are increasingly employed. Cases using wrist access may be associated with a lower contrast dosing for patients.

Emergency Placed Percutaneous Nephrostomy Catheter Provides Safe and Effective Access for Future Percutaneous Nephrolithotomy Operation

Objective: It was aimed to investigate the feasibility of the percutaneous nephrostomy (PCN) catheter placed in an emergency in the future percutaneous nephrolithotomy (PNL) operation. Material and Methods: Patients who underwent PCN catheter insertion by an interventional radiologist under emergency situations prior to PNL surgery between January 2013 and December 2018 were included in the study. Demographic characteristics, indication for PCN insertion, stone characteristics, pre- and post-operative laboratory values, intra-operative data, usability/non-usability of PCN catheter for renal access, post-operative data and complications were recorded. Results: A total of 32 patients were included in the study. (PCN usable: 21, unusable: 11). Indications for catheter insertion were obstruction in 26 (81.25%) patients and urinary tract infection in 6 (18.75%) patients. Renal access was achieved in 21 (65.62%) patients by using the PCN catheter tract during PNL. The most common PCN access was used in the inferior pole. In 11 (34.37 %) patients, the PCN tract was not usable for access. In patients in whom PCN was unusable due to an unsuitable calyx for access, the most common new access site was the inferior calyx in 6 patients, the superior calyx in 3 patients and the middle calyx in 2 patients. There was no statistically significant difference between the two groups in which the PCN catheter was usable and unusable for PNL access (p&amp;gt;0.05), except for the mean length of hospital stay (p=0.039). Conclusions: PCN catheters inserted prior to PNL surgery can be used effectively and safely for renal access during surgery. However, in emergency cases, it is important that the PCN catheter is inserted through the appropriate calyx in patients undergoing future surgery.

Transcatheter Aortic Valve Implantation Access Sites: Same Goals, Distinct Aspects, Various Merits and Demerits.

Transcatheter aortic valve implantation (TAVI) has been established as a safe and efficacious treatment for patients with severe symptomatic aortic stenosis (AS). Despite being initially developed and indicated for high-surgical-risk patients, it is now offered to low-risk populations based on the results of large randomized controlled trials. The most common access sites in the vast majority of patients undergoing TAVI are the common femoral arteries; however, 10-20% of the patients treated with TAVI require an alternative access route, mainly due to peripheral atherosclerotic disease or complex anatomy. Hence, to achieve successful delivery and implantation of the valve, several arterial approaches have been studied, including transcarotid (TCr), axillary/subclavian (A/Sc), transapical (TAp), transaortic (TAo), suprasternal-brachiocephalic (S-B), and transcaval (TCv). This review aims to concisely summarize the most recent literature data and current guidelines as well as evaluate the various access routes for TAVI, focusing on the indications, the various special patient groups, and the advantages and disadvantages of each technique, as well as their adverse events.

Transradial versus transfemoral approach in cerebral angiography: A meta-analysis.

Cerebral angiography has two common access sites: Transradial approach and transfemoral approach. However, there's no definitive answer to which one is superior. Compare transradial approach and transfemoral approach for a cerebral angiography procedure. A systematic review of the literature of studies reporting both transradial approach and transfemoral approach results was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed, Cochrane Library, and Embase were queried. The meta-analysis examined 18 studies comprising 9388 patients undergoing cerebral angiography. Among the patients, 4598 underwent transradial approach (48.9%) and 4790 underwent transfemoral approach (51.1%). Our results revealed no statistical differences between the approaches regarding procedure success, crossover to transfemoral approach, procedure and fluoroscopy time between both approaches in cerebral angiography. Total, major, and minor complications comparisons were more favorable to transradial approach for this procedure. These findings suggest, despite the ultimate decision regarding the choice of access method might be influenced by the physician's experience and personal preference, the data distinctly lean toward transradial approach as the preferable option for cerebral angiography. The advantages of transradial approach, highlighted by its lower complication rates, especially major complications, suggest that its adoption could contribute to enhanced patient safety and procedural outcomes.

Intraoperative angiography in neurosurgery: temporal trend, access site, and operative indication considerations from a 6-year institutional experience.

Historically, the transfemoral approach (TFA) has been the most common access site for cerebral intraoperative angiography (IOA). However, in line with trends in cardiac interventional vascular access preferences, the transradial approach (TRA) and transulnar approach (TUA) have been gaining popularity owing to favorable safety and patient satisfaction outcomes. To compare the efficacy and safety of TRA/TUA and TFA for cerebral and spinal IOA at an institutional level over a 6-year period. Between July 2016 and December 2022, 317 angiograms were included in our analysis, comprising 60 TRA, 10 TUA, 243 TFA, and 4 transpopliteal approach cases. Fluoroscopy time, contrast dose, reference air kerma, and dose-area products per target vessel catheterized were primary endpoints. Multivariate regression analyses were conducted to evaluate predictors of elevated contrast dose and radiation exposure and to assess time trends in access site selection. Contrast dose and radiation exposure metrics per vessel catheterized were not significantly different between access site groups when controlling for patient position, operative region, 3D rotational angiography use, and different operators. Access site was not a significant independent predictor of elevated radiation exposure or contrast dose. There was a significant relationship between case number and operative indication over the study period (P<0.001), with a decrease in the proportion of cases for aneurysm treatment offset by increases in total cases for the management of arteriovenous malformation, AVF, and moyamoya disease. TRA and TUA are safe and effective access site options for neurointerventional procedures that are increasingly used for IOA.

Transradial versus transfemoral access in carotid artery stenting: A meta-analysis.

The carotid artery stenting (CAS) has two common access sites: transradial access (TRA) and transfemoral access (TFA). However, there's no definitive answer to which one is superior. Compare TRA and TFA for the CAS. A systematic review of the literature of studies reporting both TRA and TFA results was conducted following the PRISMA guidelines. PubMed, Cochrane Library, Web of Science and Embase were queried. The meta-analysis examined nine studies comprising 7513 patients who underwent CAS. Of these, 6750 patients had TFA (90%), while 763 had TRA (10%). There was no significant difference in procedure success rates between TRA and TFA, with a risk ratio (RR) of 0.99 (6/9; 95% CI 0.98 to 1.00; I² = 9%, fixed effects). However, cross-over to TFA was more frequent in TRA (odds ratio (OR) 10.37 (6/9; 95% CI 5.18 to 20.77; I² = 17%, fixed effects)). There were no significant differences in terms of major access complications (RR = 0.88 (7/9; 95% CI: 0.29 to 2.63; I² = 0, fixed effects)), total access complications (RR = 1.10 (6/9; 95% CI: 0.56 to 2.15; I² = 7%, fixed effects)), and mean difference in length of stay (Mean difference of -0.08 (3/9; 95% CI -0.18 to 0.02; I² = 0%, fixed effects)). There were no significant differences between TFA and TRA in terms of procedure success rates, time, complications, and length of stay, although cross-over to TFA was more common in TRA cases.

Feasibility of Ultrasound-Guided, Peripherally Inserted Central Catheter Placement at the Bedside in a Communicable-Disease Isolation Unit.

Previous studies have investigated the safety of peripherally inserted central catheters (PICCs) in the intensive care unit (ICU). However, it remains uncertain whether PICC placement can be successfully carried out in settings with limited resources and a challenging environment for procedures, such as communicable-disease isolation units (CDIUs). This study investigated the safety of PICCs in patients admitted to CDIUs. These researchers used a handheld portable ultrasound device (PUD) to guide venous access and confirmed catheter-tip location with electrocardiography (ECG) or portable chest radiography. Among 74 patients, the basilic vein and the right arm were the most common access site and location, respectively. The incidence of malposition was significantly higher with chest radiography compared to ECG (52.4% vs. 2.0%, p < 0.001). Using a handheld PUD to place PICCs at the bedside and confirming the tip location with ECG is a feasible option for CDIU patients.

Treatment of iatrogenic pseudo-aneurysms with ultrasonography-guided percutaneous thrombin injection and compression

Background/Aim: Recently, endovascular interventional procedures have become prevalent. Thus, complications due to arterial catheterization are frequent. The most common access site complications are pseudo-aneurysms (PSAs). The present study aimed to treat iatrogenic pseudo-aneurysm (PSA) with ultrasonography (US)-guided compression and percutaneous thrombin injection and to report these methods’ effectiveness and short-term outcomes. Methods: The study was designed as a retrospective cohort study. Two treatment techniques were performed. Forty-eight of 54 patients were included in the study. Forty patients were treated with US-guided percutaneous thrombin injection, and eight were treated with US-guided compression. Six of the 54 patients were excluded from the study. Two of these patients needed further surgical treatment. The other four patients needed no further intervention due to spontaneous thrombosis of PSA. The patient demographics, history of AC/AA drug use, indication for performing arterial catheterization, localization and size of PSAs, treatment method applied, the effectiveness of treatment, early outcomes, and the treatment complications were evaluated. Results: In eight patients treated with US-guided compression, recurrent filling was not observed at the 24-h and first-month post-treatment follow-ups, and 100% success was achieved. Among the 40 patients treated with percutaneous thrombin injection for whom a second session was applied, recurrent filling was observed in six PSAs at the 24-h post-treatment follow-up. While the treatment success rate was 85% in the first session, it increased to 97.5% after the second session. A first-month follow-up could be made in 84.6% of the treated patients, and recurrence was observed in no patients. Conclusion: US-guided thrombin injection for PSAs has a high success rate. It is practical, relatively rapid to perform, has low complication rates, and may be selected as the first treatment choice for PSA.

Safety and efficiency of femoral artery access closure using QuikClot Combat Gauze in patients with severe arterial calcification of access sites

In order to achieve better hemostasis of puncture holes in the femoral artery (FA) after an endovascular procedure, this study evaluated the effect and safety of manual compression (MC) with QuikClot Combat Gauze (QIC) and with mechanical compression (using a C-clamp) of the common access site, the FA, in patients with peripheral arterial occlusive disease (PAOD) combined with anterior femoral artery calcification (AFAC). We prospectively reviewed 100 patients receiving either MC with QIC or mechanical compression (control group) after endovascular intervention for PAOD plus AFAC from February 2014 to September 2018 in a single unit, which was assessed using computerized tomography angiography (CTA). The mean time to completion of hemostasis was 30±0 minutes in the control group and 18±2.20 minutes in the QIC group (P<0.001). The time to ambulation of the QIC and control groups was 4.38±0.46 and 4.86±0.30 hours (P<0.001), respectively. Eight (16%) patients in the control group had hematoma, as compared with one patient (2%) in the QIC group (P=0.031), while sixteen (32%) patients in the control group had ecchymosis, as compared with four (8%) in the QIC group (P=0.005). Use of QIC and coronary artery disease (CAD) were identified as independent factors correlated with an increased risk of minor complications. QIC facilitated effective and safe hemostasis in patients with PAOD and AFAC.

Con: General Anesthesia Should No Longer Routinely Be Used for Transfemoral Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) procedures were introduced in the early 2000s as an alternative to surgical aortic valve replacement (SAVR) in high-risk patients who were not surgical candidates. 1 Bourantas CV Serruys PW. Evolution of transcatheter aortic valve replacement. Circ Res. 2014; 114: 1037-1051 Crossref PubMed Scopus (54) Google Scholar The safety of the procedure improved over time as the procedure became more widespread and new deployment devices, valves, and percutaneous access were refined. 1 Bourantas CV Serruys PW. Evolution of transcatheter aortic valve replacement. Circ Res. 2014; 114: 1037-1051 Crossref PubMed Scopus (54) Google Scholar Encouraging outcomes, such as a decreased hospital length of stay and improved morbidity, have expanded access to TAVRs to populations deemed intermediate and low-risk for SAVR. 2 Carroll JD Mack MJ Vemulapalli S et al. STS-ACC TVT Registry of transcatheter aortic valve replacement. J Am Coll Cardiol. 2020; 76: 2492-2516 Crossref PubMed Scopus (294) Google Scholar According to the Society of Thoracic Surgery-American College of Cardiology Transcatheter Valve Therapy Registry, >70,000 TAVRs were performed in the United States in 2019, surpassing the number of SAVRs that year. 2 Carroll JD Mack MJ Vemulapalli S et al. STS-ACC TVT Registry of transcatheter aortic valve replacement. J Am Coll Cardiol. 2020; 76: 2492-2516 Crossref PubMed Scopus (294) Google Scholar The most common access site is increasingly transfemoral (95% in 2019), and the need for conversion to open cardiac surgery with the use of cardiopulmonary bypass has significantly decreased from 4% to 0.4% since the introduction of TAVRs. 2 Carroll JD Mack MJ Vemulapalli S et al. STS-ACC TVT Registry of transcatheter aortic valve replacement. J Am Coll Cardiol. 2020; 76: 2492-2516 Crossref PubMed Scopus (294) Google Scholar The focus of care surrounding TAVRs is now shifting to a minimally invasive approach with shorter procedure time, shorter hospital length of stay, and reduced costs. 3 Sawan MA Calhoun AE Grubb KJ et al. Update on minimalist TAVR care pathways: Approaches to care in 2022. Curr Cardiol Rep. 2022; 24: 1179-1187 Crossref PubMed Scopus (2) Google Scholar Although both conscious sedation and general anesthesia techniques can be used for TAVR procedures, the authors assert that conscious sedation is superior as it helps achieve these goals with potentially less risk.

Initial experience of using a large-bore (0.096″ inner diameter) access catheter in neurovascular interventions.

The purpose of this study was to report our initial experience of using a large-bore (0.096″ inner diameter) access catheter in neurovascular interventions. Data were retrospectively collected from 5 sites in the US for neurovascular procedures performed using a large-bore access catheter. The effectiveness outcome was technical success, defined as the access catheter's successfully reaching its target vessel without conversion to direct carotid puncture or to a smaller-bore access catheter and successfully completing the intended neurointervention. One hundred and thirteen procedures performed in 112 patients were included in this study. The mean age of the patients was 67.5 years (SD 16.2), and about half (49.1%) were female. The most common primary access sites were the femoral (64.6%) or radial (32.7%) artery. Challenging anatomic variations included severe vessel tortuosity (26/81, 32.1%), type II aortic arch (17/88, 19.3%), type III aortic arch (14/88, 15.9%), bovine arch (16/104, 15.4%), severe angle (<30°) between the subclavian and target vessel (11/74, 14.9%), and subclavian loop (7/79, 8.9%). The median access time to branch view was 18 min (IQR 11-28, N = 75). The technical success rate was 94.7%. Two dissections (1.8%) were related to the large-bore access catheter. Access site complications occurred in 2 patients (1.8%). Four additional symptomatic periprocedural complications not related to the large-bore access catheter occurred (7.1%). For neurovascular interventions, a 0.096″ inner diameter access catheter could be used with both femoral and radial arterial approaches, had a high technical success rate, and had a low rate of periprocedural complications.

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&amp;lt;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&amp;lt;0,0001. Radial artery anomalies were more frequent in the female group 8,8% vs 6,5% (p&amp;lt;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&amp;lt;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&amp;lt;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.

Outcomes of temporary pacing using active fixation leads and externalized permanent pacemakers in patients with cardiovascular implantable electronic device infection and pacemaker dependency

The incidence of cardiac implantable electronic device (CIED) infections is increasing. Complete device and lead removal are recommended for all patients with definite CIED system infection. In patients with pacemaker dependency, temporary pacing before reimplantation is necessary. In this study, temporary pacing using active fixation leads (TPAFL) was evaluated. We reviewed data from consecutive patients implanted with TPAFL after transvenous lead extraction at our center between November 2014 and October 2020. TPAFL were placed in 334 patients. The mean age was 64.5 ± 16.4 years and 76.3% were males. Two hundred and forty (72%) were treated due to local pocket infection and 94 (28%) systemic infection. The indication for temporary pacing was sick sinus syndrome in 135 (40.4%) patients and complete or high-grade atrioventricular (AV) block in 199 (59.6%) patients. The most common access site for lead implantation was the ipsilateral subclavian or axillary vein (78.9%). A new permanent CIED was reimplanted at 10.3 ± 9.2 days (median 10, range: 2-70) after implantation of the temporary pacing. There were five (1.5%) adverse events related to the temporary pacing during hospitalization. The median follow-up duration was 23.1 months (interquartile range [IQR], 7.2-43.4 months). Only one patient (0.3%) developed recurrent CIED infection. TPAFL is safe and effective in pacemaker-dependent patients after infected CIED removal. The rate of temporary pacing-related complications, including lead dislodgment and reinfection of CIED is relatively low.

The Groin: A Vascular Surgeon's Achilles Heel

Surgical site infections (SSI) affecting the groin and femoral vessels, which are common access sites and target vessels of vascular surgical procedures, are of clinical and economic relevance.1 In their systematic review and meta-analysis, Gwilym et al. assessed different interventions and adjuncts delivered immediately before, during, or after skin closure, to prevent SSI in patients undergoing arterial interventions involving a groin incision.2 In their well conducted and methodologically appropriate analysis, the authors summarised relevant options for prevention of SSI following groin incision.

Subclavian-Axillary Access for Transcatheter Aortic Valve Implantation with SAPIEN 3: Results from the ACCESS Study

ABSTRACT Background The ACCESS Study is a prospective, multicenter registry to evaluate the efficacy and safety of trans-subclavian and axillary transcatheter aortic valve replacement (TAx-TAVR) with the latest-generation balloon-expandable transcatheter valve (THV). The secondary goal of this study was to determine whether the type of TAx access (left versus right, supraclavicular-subclavian versus infraclavicular-axillary, cutdown versus percutaneous) made a difference in procedural and 30-day outcomes. Methods 75 consecutive patients from March 2016 to June 2018 with hostile femoral anatomy and favorable subclavian or axillary anatomy underwent TAx-TAVR using the SAPIEN 3 THV (Edwards Lifesciences, Irvine, CA) at six experienced centers. Demographics, procedural characteristics, in-hospital, and 30-day outcomes were recorded. Results Successful TAx access was obtained in 73 (97.3%) patients. Left subclavian 32 (42.7%) and left axillary 26 (34.6%) were the most common access sites followed by right subclavian 9 (12.0%) and right axillary 6 (8.0%). Nineteen (25.3%) of the patients underwent TAx-TAVR using a complete percutaneous technique. Vascular access complications requiring intervention during hospitalization occurred in 5 (6.7%). The in-hospital total stroke rate was 5.3% with debilitating stroke occurring in 2.7% of patients and did not appear to differ based on the type of TAx access. Thirty-day mortality was 4.0%. Conclusions TAx-TAVR with the SAPIEN 3 THV is an effective and safe alternative showing high procedural success and low rates of vascular injury. The type of TAx access (left versus right, subclavian versus axillary, cutdown versus percutaneous) does not appear to make a significant difference in procedural and 30-day outcomes. Abbreviations TAVR: transcatheter aortic valve replacement; TAx: trans-subclavian-axillary; THV: transcatheter valve; TA: transapical; TC: transcarotid; TF: transfemoral; LIMA: left internal mammary artery; SEM: standard error of the mean; SD: standard deviation; STS: Society of Thoracic Surgeons; BMI: body mass index; CABG: Coronary artery bypass graft; ICU: Intensive care unit; LOS: length of stay; MI: myocardial infarction; PCI: percutaneous coronary intervention; ESRD: end-stage renal disease; TAo: trans-aortic; TIA: transient ischemic attack.

Comparison of two simple treatment algorithms for iatrogenic femoral artery pseudoaneurysm: ultrasound guided manual compression vs. ultrasound guided thrombin injection

Abstract Background Postcatheterization femoral pseudoaneurysm (PSA) is a common access site related complication after endovascular procedures with potentially deleterious effect on patient outcome. There is still lack of consensus about the optimal treatment. Objective We analyze the incidence of PSA in a large cohort of patients undergoing state of the art procedures in current cardiology, identify independent risk factors for PSA formation and assess our experience in PSA treatment comparing two simple treatment algorithms: ultrasound guided manual compression vs. ultrasound guided thrombin injection as a first line treatment. Methods and results In this single-centre, retrospective study 29.802 patients from January 2013 to May 2018 underwent femoral artery catheterization. Sheath removal was carried out according to standard operating procedures of the clinic. In 228 patients, a PSA was diagnosed. Thus, overall incidence of PSA amounted to 0.8%. Of 228 patients with a PSA, 117 (51%) patients were primarily treated with ultrasound guided manual compression with an overall success rate of 34% at next day follow up. All other patients (n=111, 49%) were primarily treated with ultrasound guided thrombin injection with an overall success rate of 99% at next day follow up. Low rates of periprocedural complications were noted with either hemostasis technique. Analysis of laboratory characteristics revealed that efficacy of ultrasound guided manual compression is dependent on INR whereas efficacy of ultrasound guided thrombin injection is independent of INR (p=0.0253). There was also a higher rate of significant hemoglobin drop with ultrasound guided manual compression versus ultrasound guided thrombin injection (0.78 mg/dl ± 0.09 vs 0.26 mg/dl ± 0.08, p=0.038). Time to mobilization was significantly shorter after ultrasound guided thrombin injection (UGTI: mean time 23.4 h ± 3.1 h, UGMC: mean time 27.1 h ± 10.2 h, p=0.0002). Multivariate logistic regression analysis revealed that female gender, age (&amp;gt;75 years), oral anticoagulation and anemia are independent risk factors for PSA formation. Conclusions Almost 0.8% of patients undergoing cardiac catheterization via femoral access acquire PSA, for which independent risk factors could be identified. Interventional cardiologist operated ultrasound guided thrombin injection is highly effective and safe as a first line treatment and reduces blood loss compared to ultrasound guided manual compression. Funding Acknowledgement Type of funding source: None

Clinical Profile of Patients Undergoing Temporary Transvenous Pacing in a Tertiary Cardiac Care Centre in Nepal

Introduction: Temporary transvenous pacemaker insertion is an emergency lifesaving procedure for patients with hemodynamically unstable and life-threatening bradyarrythmias. The aim of this study was to analyze demographics, indications, route of insertion and complications in patients undergoing temporary transvenous pacemaker implantation. Methods: This was a retrospective observational study conducted at a tertiary-care center in Nepal. The hospital records of patients who had undergone temporary transvenous pacemaker implantation between July 2015 and June 2019 were reviewed. Results: A total of 343 patients with mean age of 65.52±16.09 years received temporary transvenous pacing. Out of these 205 (59.8%) were males. Greater proportion of patients were between the age group of 70-80 years (n=76, 22.2%). Hypertension (n=97, 28.3%) was the most common comorbidity noted. The most common indication for temporary pacing was symptomatic complete heart block 165 (59.6%). Total of 288 (84%) patients received permanent pacemakers while 55(16%) had reversible cause so TPI was removed. Right Femoral vein was the most common (99%) venous access site. Among the 343 patients, complications were observed in 29 (8.4%) of cases during and after the temporary transvenous pacemaker insertion. The overall mortality stood low at 2% (n=7). Conclusion: Temporary transvenous pacemaker insertion is required in elderly population presenting with bradyarrythmias and occasionally in acute myocardial infarction presenting with bradyarrythmias as complication. Temporary pacemaker insertion was overall a safe procedure with infrequent serious complications; however, strategies to avoid and alleviate such complications (RV perforation) should be sought and implemented.

Clinical Profile of Patients Undergoing Temporary Transvenous Pacing in a Tertiary Cardiac Care Centre in Nepal

Introduction Temporary transvenous pacemaker insertion is an emergency lifesaving procedure for patients with hemodynamically unstable and life-threatening bradyarrythmias. The aim of this study was to analyze demographics, indications, route of insertion and complications in patients undergoing temporary transvenous pacemaker implantation.&#x0D; MethodsThis was a retrospective observational study conducted at a tertiary-care center in Nepal. The hospital records of patients who had undergone temporary transvenous pacemaker implantation between July 2015 and June 2019 were reviewed.&#x0D; ResultsA total of 343 patients with mean age of 65.52±16.09 years received temporary transvenous pacing. Out of these 205 (59.8%) were males. Greater proportion of patients were between the age group of 70-80 years (n=76, 22.2%). Hypertension (n=97, 28.3%) was the most common comorbidity noted. The most common indication for temporary pacing was symptomatic complete heart block 165 (59.6%). Total of 288 (84%) patients received permanent pacemakers while 55(16%) had reversible cause so TPI was removed. Right Femoral vein was the most common (99%) venous access site. Among the 343 patients, complications were observed in 29 (8.4%) of cases during and after the temporary transvenous pacemaker insertion. The overall mortality stood low at 2% (n=7).&#x0D; ConclusionTemporary transvenous pacemaker insertion is required in elderly population presenting with bradyarrythmias and occasionally in acute myocardial infarction presenting with bradyarrythmias as complication. Temporary pacemaker insertion was overall a safe procedure with infrequent serious complications; however, strategies to avoid and alleviate such complications (RV perforation) should be sought and implemented.