Radial Artery Research Articles

Intravascular Ultrasound Assessment of Distal Trans-Radial Access in Patients Undergoing Percutaneous Coronary Intervention.

Distal trans-radial access (dTRA) for percutaneous coronary interventions (PCI) is increasingly gaining attention due to its potential to mitigate radial artery occlusion (RAO). However, a comprehensive understanding of the mechanical impact of the devices on the radial artery (RA) wall remains limited. Using a complete intravascular ultrasound (IVUS) evaluation of the RA, including also the vascular access site, we aimed to evaluate all the consequences related to the catheterization on the RA wall, starting from the vascular access, comparing conventional sheath and sheathless approaches. This is an observational, prospective, multicenter study aimed to assess the entire RA wall immediately after IVUS-guided PCI via-dTRA. IVUS assessment included quantitative measurements (minimal lumen area [MLA], minimal vessel area [MVA]) and qualitative observations (dissections, vasospasm). Study objectives included delineating RA wall structure post-PCI and comparing findings between conventional and sheathless approaches. Fifty patients (21 [42%] with conventional sheath, 29 [58%] sheathless) were enrolled between March 2023 and February 2024. Female patients were more prevalent in the convention sheath group (38% vs. 7%, p < 0.001). Sheathless approach utilized 7-French guiding catheters more frequently (33% vs. 86%, p < 0.001). Post-procedural IVUS identified dissections in 12% of cases, with no significant difference between approaches. Arterial vasospasm was present in a quarter of patients, numerically higher in the conventional sheath group (29% vs. 21%, p = 0.5). MLA and MVA were comparable between groups, though MLA and MVA were lowest at the proximal segment of the RA only in the conventional sheath group (p < 0.001). No RAO was documented during the IVUS evaluation. The intravascular assessment of dTRA after coronary interventions, utilizing either conventional or sheathless approaches, including large-bore guiding catheters, demonstrated a relatively low incidence of access-related complications such as dissection and vasospasm, without affecting the flow and patency of the proximal RA.

Ultrasonographic and functional evaluation of forearm circulation with occluded radial artery

Abstract Introduction The transradial approach (TRA) has gained popularity in cardiology procedures. This study aims to evaluate forearm and hand arterial circulation in radial artery (RA) occlusion (RAO) patients after coronary angiography (CAG) and percutaneous coronary interventions (PCI). The ulnar (UA) and anterior interosseous artery (AIA) can compensate for RAO. Methods A prospective, observational study was conducted on 40 RAO patients after CAG/PCI. Ultrasonographic and functional evaluation (Barbeau test) of collateral circulation through AIA or UA were performed. Statistical analyses were applied to evaluate various Doppler ultrasound parameters and the anatomical characteristics of the RAO. Results The RAO group mean age was 71.22 ± 9.99 years, and 45% were male. RA, UA, and AIA showed significant differences in peak systolic velocity, end-diastolic velocity, arterial diameter, total flow volume, and stroke volume (p &amp;lt; 0.01). Pulse quality over RA and UA also differed significantly (p &amp;lt; 0.0001). Blood flow direction in the distal RA segment divided patients into an antegrade flow group (50%) from AIA and a retrograde flow group (50%) from UA. The Barbeau test results varied among RAO patients, with type D being the most common. Anatomical locations of RAO included the anatomical snuffbox (10%), wrist (60%), and forearm (30%). The logistic regression model revealed that the Barbeau test results on Finger 2 (p=0.0006, OR=0.1398) and Finger 4 (p=0.004, OR 0.2843) were significant predictors for the occurrence of antegrade or retrograde blood flow in the distal RA when RAO occurred. Furthermore, when the RA was occluded, the study revealed that a palpable pulse over the RA was still possible in 15% of cases. Conclusion Ultrasonographic evaluation and the Barbeau test can assess collateral circulation and predict blood flow patterns in RAO patients. Further research is needed to validate these findings, explore additional factors influencing collateral circulation and access route selection, and investigate the clinical implications of different RAO anatomical locations in cardiology procedures.Radial Artery OcclusionThe pulse quality over RA/UA with RAO

The effect of kaolin on postprocedural radial artery compression - randomized comparison

Abstract Background Mechanical compression is a standard method of postprocedural radial artery hemostasis. We investigated the use of this method and its combination with kaolin impragnated gauze patch as a new method of hemostasis. Methods We randomized 712 consecutive patients (pts) from our same day discharge program (age 66±8 years, 76% males) after coronary angiography (69%) and intervention (31%) from the proximal (PRA) and distal radial (DRA) approaches. Compression was performed by mechanical inflatable device with or without kaolin gauze : 241 versus (vs) 241 patients in proximal groups and 115 vs 115 pts in distal groups were compared. Postprocedural proximal radial artery patency was evaluated by reverse Barbeau test with finger oximetry testing. Time to hemostasis and access site complications were analyzed. Results Baseline characteristics were similar in all four groups - proximal with kaolin (PK+) and without kaolin (PK-), distal with kaolin (DK+) and without kaolin (DK-). Mean compression time was 57±20 min in PK+ vs 83±19 min in PK- groups (p&amp;lt;0.001) and 48±12 min in DK+ vs 63±12 min in DK- groups (p&amp;lt;0.001). In parallel, compression times were shorter in the distal groups compared to the corresponding proximal groups: (DK+ vs PK+; DK- vs PK-; both p&amp;lt;0.001). Postprocedural EASY grade II (&amp;lt;10cm) and III (&amp;gt; 10cm) hematomas occured more often in PRA (4,7% and 0,8%) in comparison with DRA (1,7% and 0%; p=0,03). There were no other local complications including the absence of proximal radial artery occlusion. Conclusions The use of kaolin in combination with mechanical radial artery compression was associated with shorter compression time in both PRA and DRA compared to mechanical compression alone. DRA was associated with an overall lower incidence of hematomas and also shorter compression time compared to the same PRA groups. No proximal radial artery occlusion was detected in our analysis.

Enhancing guidewire efficacy for transradial access: the EAGER randomised controlled trial

Abstract Background and Purpose The standard J tip peripheral guidewire used to perform coronary angiography was originally designed for transfemoral access and large vascular interventions over 70 years ago. The 3mm J tip on the standard wire is larger than the typical radial artery diameter and has limited ability to navigate smaller tortuous peripheral arteries increasing the risk of vessel spasm, and potentially reducing procedural success. We compared the efficacy and safety of a hydrophilic 1.5mm J tip guidewire (intervention - ‘baby J wire’) upfront versus the standard fixed core 0.035" J wire (‘control wire’). Methods Investigator initiated, blinded multicentre randomised trial conducted in Australia. Patients undergoing clinically indicated transradial coronary angiography were randomized 1:1 to either control or baby J peripheral guidewire use upfront. The primary endpoint was technical success defined as gaining access to the aortic root with the randomised guidewire. Secondary endpoints included total procedural time, time to aorta and coronary intubation, crossover rates to alternate wire or access site, fluoroscopy times, radial artery spasm, haematoma (EASY criteria), bleeding complications (BARC criteria) and vascular complications (VARC 2 criteria). Major adverse cardiac events (MACE) and clinical endpoints were adjudicated by a blinded independent clinical events committee. Results 330 patients were enrolled over a 9-month period from October 2022 to June 2023. The median age was 69 years (36% female), BMI 29kg/m2. The primary efficacy endpoint of technical success was achieved more frequently in the intervention group (96% v 85%; ARR 10.9% (95% CI 4.6 -17.2); P &amp;lt;0.001). Women were significantly more likely to benefit from the intervention related to higher failure rates with the control wire (69% vs 93% in men; P = &amp;lt; 0.001). Overall procedure times were similar between the groups (median 1135 vs 1354 seconds; P=0.094) but fluoroscopy time was lower in the baby J wire group (median 344 vs 491 seconds; P = 0.024). Radial completion of procedures was high and did not differ between groups (100% v 98%; P=0.2). Clinically significant bleeding (BARC2+) was more common in the control wire group (3% v 0%; P=0.017). There were no differences in MACE or vascular complications. Conclusion The hydrophilic 1.5mm J tip Baby J peripheral guidewire leads to greater upfront technical success and reduced fluoroscopy time for transradial coronary angiography compared to the standard 3mm J tip guidewire. The baby J hydrophilic guidewire is safe and may have key incremental benefits for the transradial approach particularly in patients with smaller diameter radial arteries including women.Primary Outcome

Deciphering postoperative hemodynamics in pediatric intensive care: insights from patient-specific computational fluid dynamics models for congenital heart disease

Abstract Purpose Precise hemodynamic control is imperative for optimizing outcomes in children undergoing cardiac surgery, particularly in the pediatric intensive care unit (PICU). Computational fluid dynamic (CFD) models tailored to individual pediatric patients following definitive repairs for congenital heart disease hold the potential to discern and analyze the intricacies of their hemodynamic systems. This study aims to explore the applicability of patient-specific CFD models in determining optimal treatment strategies to enhance patient hemodynamics. Methods Ten postoperative pediatric patients (6 females and 4 males, median age 4.5±3.6 months, median height 62.5±5.3 cm, and median weight 6.2±1.3 kg) diagnosed with ventricular septal defect (VSD, n=5), atrial septal defect (ASD, n=2), and atrioventricular septal defect (AVSD, n=3) were enrolled. Continuous radial arterial waveforms and sporadic arterial blood draws, including lactate levels, were recorded in the PICU postoperatively. Fluid dynamics equations were employed to model major and peripheral blood vessels, utilizing a 0–1-dimensional hemodynamic model validated in previous studies and refined for this investigation. Sensitivity analysis based on correlation coefficients identified significant parameters, adjusted for replicating pressure waveforms. Comparison and re-approximation was made with actual radial artery pressure waveforms from 78 arterial waveforms and blood draws. Updated parameters were then correlated with postoperative time and lactate levels in the ICU. Results Replicated waveforms demonstrated high agreement with original arterial waveforms, with mean, maximal, and minimal blood pressure percentages of 96.7±1.8%, 96.7±2.4%, and 95.8±2.4%, respectively. Notably, systemic vascular resistance and compliance exhibited a substantial relationship with time elapsed after admission to the PICU, with correlation coefficients (R) of 0.26 and 0.43, respectively. Lactate levels demonstrated a decrease with reduced peripheral vascular resistance and an increase in vascular compliance, with R of 0.23 and 0.32, respectively, aligning with expected clinical improvement and stability. Conclusion This study successfully attained precise replication of radial artery blood pressures and intricate pressure waveforms using patient-specific CFD models in pediatric patients following congenital heart disease repairs. The insights gained shed light on the pivotal hemodynamic parameters that impact both stability and instability. This research sets the stage for theoretically informed treatments by amalgamating real-time biological information with patient-specific CFD models.Re-approximation of arterial waveformCorrelation of hemodynamic parameters

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

Abstract Background There are many feasible ways to reach the coronary arteries through a percutaneous technique. Till now, the most commonly used approach is the radial artery approach because it has the lowest risk of known vascular adverse events. However, it could not be an option in some situations as congenital radial artery hypoplasia and radial artery spasm. In these cases, the second most common access is the femoral artery access. The current literature over the brachial artery access is controversial. Our study's objective is to verify the brachial artery approach's effectiveness and safety. Methods We studied 300 patients who underwent elective coronary angiography and percutaneous angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients in a group with brachial access and 150 in a group with femoral access. Baseline clinical and demographic traits of all enrolled patients were obtained from hospital records and the cardiovascular risk factors were identified. Venous blood samples, resting 12-lead electrocardiogram and transthoracic echocardiography were done before the coronary angiography. Access, procedural and fluoroscopy times were recorded. Doppler evaluations of both brachial and femoral arteries were done the day after the procedure. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Results Our data showed that no statistically significant difference between the studied groups regarding the cardiovascular risk factors, demographic, clinical and laboratory characteristics. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, p= 0.05), but no significant difference regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not differ significantly (p=0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ±1.1 vs. 3.4 ± 0.7 minutes, p=0.05) and shorter hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, p&amp;lt;0.001). Regarding complications, both major and minor complications were significantly lower in the brachial arm (p=0.04 and 0.05, respectively). Conclusion Brachial artery access is a safe, efficient alternative and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

Sheathless versus standard guiding catheters for transradial percutaneous coronary interventions: a systematic review and meta-analysis

Abstract Introduction The sheathless trans-radial (TR) technique is a novel approach that may offer potential benefits over the conventional TR approach. We aim to comprehensively compare and analyze the safety and effectiveness of these two catheter types in trans-radial percutaneous coronary interventions (PCI). Methods We conducted comprehensive searches across PubMed, CENTRAL, WOS, Scopus, and EMBASE until July 2023. Pooled data were reported using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, along with a 95% confidence interval (CI). Results We included 12 studies with 16,988 patients. Notably, the radial artery spasm (RAS) (RR: 0.26, 95% CI: [0.09, 0.77], p = 0.02) and cross-over to the femoral site (RR: 0.22 [0.08, 0.60], p = 0.003) were significantly lower in the sheathless group. However, post-procedural radial artery occlusion (RAO) was significantly higher in the sheathless group (RR: 2.30, 95% CI: [1.52, 3.49], p = 0.0001). Also, we did not find a significant difference between both groups in success rate (RR: 1.03, 95% CI: [0.95, 1.06], p = 0.10) and all-cause mortality (RR: 0.41, 95% CI: [0.16, 1.04], p = 0.06). Conclusion The sheathless TR approach showed lower rates of RAS and femoral conversion. However, it also increased RAO. Thus, more trials are needed to confirm this technique's long-term outcomes and complications.Figure 1

Incidence and predictors of radial artery occlusion following transradial coronary procedures

Abstract Background Transradial access for percutaneous coronary procedures has grown in popularity because of its advantages over the femoral approach. However, the benefit is overshadowed by an increased rate of radial artery occlusion (RAO). We aim to assess incidence and predictors of RAO after transradial catheterization. The anatomic variations of the radial artery (RA) were also studied. Methods This prospective study enrolled 427 patients who underwent coronary angiography or angioplasty via transradial access. An ultrasound evaluation of forearm arteries was performed. In case of RAO, another ultrasound check-up was performed after 1 month and 3 months of the procedure. Results Our study population includes 288 patients (32.6% female). The mean age was 61.9 ± 11.1 years. RAO occured in 48 patients (11.24%), among whom spontaneous recanalization was observed within 3 months in 15 patients (32.6%). On multivariate analysis, a younger age (OR 0.642 [CI 95%: 0.480 – 0.858], P = 0.031), low periprocedural systolic blood pressure, (OR 0.598 [CI 95%: 0.415 – 0.862], P = 0.007), a small radial diameter (OR 0.371 [CI 95%: 0.323 – 0.618], P = 0.031), insufficient anticoagulation (OR 0.287 [CI 95%: 0.163 – 0.505], P &amp;lt; 0.001), occlusive hemostasis (OR 0.128 [CI 95%: 0.047 – 0.353], P &amp;lt; 0.001), and a long duration of hemostasis emerged as independent predictors of radial occlusion. The overall incidence of radial artery anatomic variations was 14,8% (n=63). Among these patients, 40 (63.5%) had a high radial origin, 18 (28.6%) had extreme radial artery tortuosity, and 5 (7.9%) had a full radioulnar loop. Conclusion The incidence and prevalence of radial artery occlusion is expected to increase. Insufficient heparinization and occlusive hemostasis are the main modifiable predictors. The preventive strategy should focus primarily on these 2 predictive factors.

Effects of nicorandil, isosorbide mononitrate or diltiazem on radial artery grafts after coronary artery bypass grafting: the randomized ASRAB-pilot trial

Abstract Background The optimal chronic oral antispastic medication after coronary artery bypass grafting (CABG) using radial artery (RA) grafts is controversial. Purpose This pilot trial aimed to preliminarily compare the efficacy and safety of nicorandil, isosorbide mononitrate, or diltiazem in patients who underwent CABG using RA grafts. Methods This was a single-center, randomized, open-label, parallel-group pilot trial. Eligible patients who underwent CABG using RA grafts within 3 days were randomized in a 1:1:1 ratio to receive oral doses of nicorandil (15 mg daily), isosorbide mononitrate (50 mg daily), or diltiazem (180 mg daily) for 24 weeks post-CABG. The primary outcomes were RA grafts failure (defined as modified FitzGibbon Grade B, S, or O) at 1- and 24-weeks, assessed by coronary computed tomography angiography (CCTA). The secondary outcomes include major adverse cardiovascular event (MACE, a composite of all-cause death, myocardial infarction, stroke, and unplanned revascularization) and angina recurrence. Results Among 150 randomized participants, 149 patients (full analysis set, mean age 56.8 years, 13.4% females, 83.9% with acute coronary syndrome, 49.7% with diabetes) with 177 RA grafts completed at least once CCTA assessment, including 50 patients with 64 RA grafts in the nicorandil group, 50 patients with 57 RA grafts in the isosorbide mononitrate group, and 49 patients with 56 RA grafts in the diltiazem group, respectively. (Figure 1). At 1-week post-CABG, the RA graft failure rates were numerically lower with nicorandil vs. diltiazem (19.4% vs. 25.0%, difference: -5.6% [95% CI -20.6% to 9.3%]; P = 0.49) and isosorbide mononitrate vs. diltiazem (18.2% vs. 25.0%, difference: -6.8% [95% CI -21.8% to 8.6%]; P =0.41). Nicorandil vs. isosorbide mononitrate showed similar rates (19.4% vs 18.2%, difference: 1.2% [95% CI −13.3% to 15.2%]; P =0.88). At 24 weeks, a numerically trend indicating a larger reduction in RA graft failure rates between nicorandil vs. diltiazem (16.1% vs 27.8%, difference: -11.7% [95% CI -26.6% to 3.4%]; P =0.17), and isosorbide mononitrate vs. diltiazem (12.5% vs 27.8%, difference: -15.3% [95% CI -29.8% to -0.2%]; P =0.06). Nicorandil vs. isosorbide mononitrate remained similar (16.1% vs 12.5%, difference: 3.6% [95% CI -9.6% to 16.4%]; P =0.59). Per-protocol set analysis results were consistent with full analysis set analysis (Table 1). During the follow-up, 6 patients with MACEs and 7 with angina recurrence were observed (MACE: 2 in nicorandil, 2 in isosorbide mononitrate, and 2 in diltiazem; angina recurrence: 1, 3, and 3 in the respective groups). Conclusions In this underpowered pilot trial, treatment with nicorandil or isosorbide mononitrate showed a numerically considerable but not statistically significant benefit on RA grafts outcome compared to diltiazem up to 24-week post-CABG. Larger hypothesis testing trial is warranted.Figure 1:The study flow diagramFigure 2:Primary outcomes in FAS and PP

Cuff-less Wearable Biosensor in Continuous Noninvasive Human Radial Artery Pulse Waveform and Blood Pressure Measurement Using Self-mixing Interferometry

Cuff-less Wearable Biosensor in Continuous Noninvasive Human Radial Artery Pulse Waveform and Blood Pressure Measurement Using Self-mixing Interferometry

Arterial-myocardial coupling in primary AL amyloidosis. A validation study of vascular involvement

Abstract Background Primary AL amyloidosis is a rare yet lethal systemic disorder. Previously published own and others’ work indicated that vascular involvement in AL cardiac amyloidosis defined as low blood pressure or paradoxical vasodilation may independently affect survival. Mechanistic data will pave the way to validate the clinical role of vascular involvement in these patients. Purpose We sought to explore the presence of arterial-myocardial coupling in AL amyloidosis by investigating associations between markers of vascular and cardiac involvement. Methods We consecutively recruited n=152 newly diagnosed patients with AL amyloidosis that underwent thorough vascular examination including reactive vasodilation (flow mediated vasodilation, FMD and vasodilation in response to cold-pressor test) using high resolution ultrasonography. Arterial stiffness was evaluated by carotid-femoral pulse wave velocity (PWV) and aortic pressures and markers of arterial wave reflections were estimated using radial artery tonometry. In a subgroup of patients, transthoracic echocardiography (n=152) and cardiac magnetic resonance (CMR) (n=59) were performed. Results Vascular reactivity correlated with global longitudinal strain (GLS), left ventricle ejection fraction (LVEF)/GLS ratio and worse LV volumes. Vasodilation post-cold pressure test was correlated with LV mass. cSBP exhibited a negative correlation with markers of heart involvement, wall thickness markers, GLS, and CMR tissue characterization markers. A positive correlation between cSBP and LVEF, rotation and twist strain, myocardial work and contractility markers and late gadolinium enhancement (LGE). cDBP was associated with systolic function and contractility markers, with myocardial work indices and LGE. A negative relationship with GLS, LA strain, RV GLS and LA diameter and E/e’ was noted. In addition, T2 was negatively correlated with cDBP. SBP was correlated positively with LVEF, contractility markers, and LGE myocardium and negatively correlated with biomarkers of heart involvement, GLS, CMR structure and tissue characterization. DBP was positively correlated with LGE and myocardial work. A negative relation with NTproBNP, E/e’, RVSP, LA diameter and T2 mapping was noted. Time of wave reflections (Tr) was negatively correlated with rotation strain and positively correlated with circumferential strain, LA strain and LV structure. Ai@75 was positively correlated with myocardial work and contractility markers, and LGE. Ai@75 was negatively correlated with markers of heart involvement, LV structure, E/e’, worse GLS and adverse CMR tissue characterization. Conclusion Markers of peripheral vascular dysfunction were associated with cardiac structure and function acquired both with echocardiography and CMR in AL amyloidosis. This arterial-myocardial coupling supports the clinical role of peripheral vascular involvement in this disease and warrants further investigation.

Dapagliflozin enhances arterial and venous compliance during exercise in heart failure with preserved ejection fraction

Abstract Background Systemic arterial compliance and venous capacitance are typically impaired in patients with heart failure with preserved ejection fraction (HFpEF), contributing to hemodynamic congestion with stress. Sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduce hemodynamic congestion and improve clinical outcomes in patients with HFpEF, but the mechanisms remain unclear. Purpose This study tested the hypothesis that SGLT2i dapagliflozin would improve systemic arterial compliance and venous capacitance during exercise in patients with HFpEF. Methods In this secondary analysis from the RCT trial, patients with HFpEF underwent invasive hemodynamic exercise testing at baseline and following treatment for 24 weeks with dapagliflozin or placebo. Patients were required to display pulmonary capillary wedge pressure (PCWP) ≥25 mmHg during exercise at the time of baseline evaluation. Radial artery pressure (BP) was measured continuously using a fluid-filled catheter with transformation to aortic pressure, central hemodynamics were measured using high-fidelity micromanometers, and stressed blood volume was estimated (eSBV) from hemodynamic indices fit to a comprehensive cardiovascular model. Results A total of 37 patients completed the study and were included in this analysis (21 dapagliflozin and 16 placebo). Patients were predominantly women (24/37, 65%) and older (mean age 67 years). There was no statistically significant effect of dapagliflozin on resting BP, but dapagliflozin reduced systolic BP during peak exercise (estimated treatment difference [ETD], -18.8 mmHg, 95% CI: -33.9 to -3.7, P=0.016) (Figure 1A). Dapagliflozin improved exertional total arterial compliance (TAC) index (ETD, 0.06 mL/mmHg/m2, 95% CI: 0.003 to 0.11, P=0.039) (Figure 1B) and aortic root characteristic impedance (ETD, -2.6 mmHg/ml*sec, 95% CI: -5.1 to -0.03, P=0.048) during peak exercise, with no significant effect on systemic vascular resistance. Dapagliflozin reduced eSBV at rest and during peak exercise (ETD, -292 mmHg, 95% CI: -530 to -53, P=0.018) (Figure 1C), and improved venous capacitance evidenced by a decline in ratio of eSBV to total blood volume (ETD, -7.3%, 95% CI -13.3 to -1.3, P=0.020). Each of these effects of dapagliflozin during peak exercise were also observed during matched 20W exercise intensity. Improvements in TAC index and eSBV were correlated with decreases in body weight, and reduction in systolic BP with treatment was correlated with the change in eSBV during exercise (r=0.40, P=0.019) (Figure 2A). Decreases in BP were correlated with reduction in PCWP during exercise (r=0.56, P&amp;lt;0.001) (Figure 2B). Conclusion In patients with HFpEF, treatment with dapagliflozin improved systemic arterial compliance and venous capacitance during exercise, while reducing aortic characteristic impedance, suggesting a reduction in arterial wall stiffness. These vascular effects may partially explain the clinical benefits with SGLT2i in HFpEF.

Temporal trends in major bleeding after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction from 2003 to 2017: the Western Denmark Heart Registry

Abstract Background Management of patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) has changed during the last two decades. Introduction of more potent platelet inhibitors may carry an increased risk of bleeding complications, while other therapeutic options, such as use of radial artery access and proton pump inhibitors may reduce bleeding risk. The combined impact of these treatment changes on bleeding risk in patients with STEMI remains unknown. Purpose To examine temporal trends in 1-year risk of major bleeding after STEMI treated with primary PCI from 2003 to 2017. Methods We used the Western Denmark Heart Registry to identify first-time PCI-treated patients undergoing primary PCI for STEMI from 2003 to 2017. Patients were divided into 4 calendar periods based on the time of STEMI. The main outcome was 1-year risk of major bleeding defined as a hospital admission for bleeding using a validated definition with high accuracy. Additionally, the 1-year risk of major bleeding in STEMI patients was compared with the risk in an age- and sex-matched general population cohort without prior coronary artery disease. Results From 2003 to 2017, we identified 18,540 patients treated with primary PCI for STEMI (median age 64 years, 75% men)and 92,700 age- and sex-matched individuals. The 1-year risk of major bleeding after STEMI was similar across the different time periods; 4.1% in 2003-2006, 3.8% in 2007-2010, 3.8% in 2011-2014, and 4.5% in 2015-2017. The adjusted HR for bleeding in STEMI patients was 1.03 (95% CI 0.83-1.26) when comparing the latest period with the earliest period. The age- and sex-matched general population exhibited a 1-year risk of major bleeding of around 1% in all time periods (Figure 1). Conclusions Despite changes in management, the 1-year risk of major bleeding remained stable around 4% after primary PCI-treated STEMI from 2003 to 2017. This risk was approximately 4 times higher than the bleeding risk observed in an age- and sex-matched general population.

Impact of the thin-walled sheath on the distal radial artery occlusion: a randomized trial

Abstract Background Distal transradial access (dTRA) has been increasingly accepted as an alternative to the transradial access (TRA) for coronary angiography (CAG) and/or percutaneous coronary intervention (PCI). Although the dTRA has been significantly associated with better patient comfort, shorter haemostasis time, and fewer vascular access-related complications, such as haematoma and proximal radial artery occlusion (pRAO), it has also been associated with an increased risk of distal radial artery occlusion (dRAO). Purpose The aim of the present study was to investigate whether the 6-Fr thin-walled sheath was superior to the conventional radial sheath with respect to the incidence of distal radial artery occlusion (dRAO) at 24 h after CAG and/or PCI via dTRA. Methods A prospective, single-centre trial of patients who were randomized to undergo CAG and/or PCI with either a 6-Fr thin-walled sheath or a 6-Fr conventional sheath. The primary endpoint was the incidence of dRAO at 24 h postoperatively, as evaluated by Doppler ultrasound. The second endpoints included the puncture success rate, puncture time, the incidence of pRAO, pain during the sheath placement, and other vascular-associated complications. Results A total of 620 patients were included in the study. The mean age of the patients was 66.6± 9.7 years (median age 69.0 years [interquartile range 60.0- 74.0 years]), and 66.3% were men. The baseline patient and procedural characteristics were similar between the two groups. For the primary endpoint, the incidence of dRAO at 24 h after the procedure was 1.0% (3/314) in the thin-walled sheath group and 3.6% (11/306) in the conventional sheath group (RR= 0.266, 95%CI= 0.075-0.943, P= 0.027) according to the intention-to-treat (ITT) analysis. For secondary endpoints, the incidence of pRAO was 0.3% (1/314) in the thin-walled sheath group and 2.3% (7/306) in the conventional sheath group (P= 0.029). No significant difference was observed between the thin-walled sheath and the conventional sheath groups regarding the puncture success rate (92.4% vs. 92.5%, P= 0.952). The severity of pain experienced during the sheath placement was similar between the two groups (VAS 2 vs. 2 P=0.426). Other secondary endpoints, including procedural outcomes and other puncture-related outcomes and access-related complications, were not significantly different between the two groups. Conclusion A thin-walled sheath can reduce the incidence of early-term dRAO in patients who underwent CAG and/or PCI via the dTRA.The primary endpoint of the trial

Distal versus conventional transradial access for coronary angiography: a pooled analysis from the randomized RAPID trial

Abstract Background Transradial access (TRA) is the recommended approach for coronary procedures considering safety benefits over femoral access with radial artery occlusion (RAO) being the most frequent complication. Although usually not clinically significant, the presence of RAO affects potential future procedures and medical treatments. Distal TRA (dTRA) has been suggested to reduce the risk of postprocedural RAO compared to conventional TRA (cTRA) with, however, inconsistent results in clinical trials. Purpose This study aimed to compare the efficacy and safety of dTRA versus cTRA in patients undergoing diagnostic coronary angiography. Methods The RAPID trial is a single-center, open-label, 2x2 factorial, randomized study of patients undergoing coronary angiography through a 6-F radial access. The trial was stopped early by the data and safety monitoring board after the second pre-planned interim analysis and inclusion of 600 participants. Patients were randomized to dTRA or cTRA with further stratification according to periprocedural heparin use and preexisting oral anticoagulation. The primary endpoints were the incidence of RAO assessed by vascular ultrasound and puncture-site related bleedings. Results The final study population consisted of 298 patients randomized to dTRA and 302 patients to cTRA. Periprocedural heparin was administered in 382 patients (63.7%) and percutaneous coronary intervention was performed in 161 cases (26.8%) without differences between the study groups (p=0.700 and p=0.465; respectively). Distal TRA was associated with a significantly increased number of puncture attempts (2.4 ± 2.0 versus 1.5 ± 1.2; p&amp;lt;0.001) and failed punctures leading to access site crossover (11.7% versus 5.0%; p=0.003). Consequently, the total procedure time was longer in the dTRA group (30 min versus 25 min; p=0.004) without increasing fluoroscopy time (p=0.320), dose area product (p=0.245), or contrast volume (p=0.884). Patent hemostasis was achieved in 91.7% of patients with cTRA. The rates of RAO (16.1% versus 15.6%, p=0.855) and puncture-site related bleedings (6.7% versus 8.3%; p=0.466) were similar in both groups. Conclusions According to this study, dTRA does not reduce the risk of RAO or bleeding events compared to cTRA.

The management of high flow arteriovenous fistula and possible solutions.

The development of a high flow rate arteriovenous fistula (AVF) can expose the patient to development of heart failure due to increased cardiac preload and pulmonary hypertension. AVF flow measurement (Qa) is considered a screening tool for AVF surveillance, aiming to evaluate the access dysfunction and prevent complications, like a non-maturation, suspected stenosis, high-flow AVF, and distal ischemia. In the upper arm AVF, a high Qa may develops, which can expose the patient to the risk of high-output heart failure and ischemia. Although, the exact threshold to define high-flow access is not universally accepted, AVF with a Qa of 1-1.5 L/min or cardio-pulmonary recirculation (Qa/CO) >20% are considered at risk. In our work we describe the treatment performed in three patients with high flow AVF treated with DRIL technique with interposition of a Prosthetic Patch, revascularization procedures such as distal inflow revision or RUDI and with innovative technique a "tench snout," removal the previous anastomosis and reconstruction of the integrity of the radial artery at the terminal in pre and post anastomosis. A PTFE prosthetic segment measuring 5 cm in length and 5 mm in diameter was interposed, terminally anastomosed with the efferent cephalic vein and terminally lateral with the radial artery, reducing the anastomosis to approximately 4 mm. All treated patients showed a clear improvement in the clinical picture in particularly heart failure. The calculation of the post-intervention flow rate approximately 1500 mL/min. The patient on hemodialysis with arteriovenous fistula must be constantly monitored with clinical examination, monitoring during the hemodialysis session and color Doppler ultrasound of the AVF with calculation of the flow rate. The surgical technique used for flow reduction is chosen on the surgical experience of each operator with the main objective of preserving the autologous AVF.

U-Net and Its Variants Based Automatic Tracking of Radial Artery in Ultrasonic Short-Axis Views: A Pilot Study

Background/Objectives: Radial artery tracking (RAT) in the short-axis view is a pivotal step for ultrasound-guided radial artery catheterization (RAC), which is widely employed in various clinical settings. To eliminate disparities and lay the foundations for automated procedures, a pilot study was conducted to explore the feasibility of U-Net and its variants in automatic RAT. Methods: Approved by the institutional ethics committee, patients as potential RAC candidates were enrolled, and the radial arteries were continuously scanned by B-mode ultrasonography. All acquired videos were processed into standardized images, and randomly divided into training, validation, and test sets in an 8:1:1 ratio. Deep learning models, including U-Net and its variants, such as Attention U-Net, UNet++, Res-UNet, TransUNet, and UNeXt, were utilized for automatic RAT. The performance of the deep learning architectures was assessed using loss functions, dice similarity coefficient (DSC), and Jaccard similarity coefficient (JSC). Performance differences were analyzed using the Kruskal–Wallis test. Results: The independent datasets comprised 7233 images extracted from 178 videos of 135 patients (53.3% women; mean age: 41.6 years). Consistent convergence of loss functions between the training and validation sets was achieved for all models except Attention U-Net. Res-UNet emerged as the optimal architecture in terms of DSC and JSC (93.14% and 87.93%), indicating a significant improvement compared to U-Net (91.79% vs. 86.19%, p &lt; 0.05) and Attention U-Net (91.20% vs. 85.02%, p &lt; 0.05). Conclusions: This pilot study validates the feasibility of U-Net and its variants in automatic RAT, highlighting the predominant performance of Res-UNet among the evaluated architectures.

Distal solution for an (un)conventional radial artery complication: a Case Report

Abstract Background The European Society of Cardiology (ESC) guidelines recommend transradial access (TRA) for coronary angiography due to its advantages, including lower mortality and bleeding complications. Arterial pseudoaneurysms are rare but challenging complications of TRA, occurring in 0.009%-0.05% of procedures. Non-surgical management, especially in cases with large (&amp;gt;1 mm) necks or late discovery, can be difficult due to the limited effectiveness of echo-guided compression and risks of echo-guided thrombin injection, like thrombin embolization leading to necrosis. Case Summary An 82-year-old underwent successful non-surgical management of a large-neck pseudoaneurysm following TRA for a primary percutaneous coronary intervention (PCI) of the left anterior descending (LAD) artery. Clinical examination revealed a pulsatile mass at the puncture site, diagnosed via ultrasound as a pseudoaneurysm with a &amp;gt;1 mm neck. Through distal radial access (DRA), an initial 5Fr sheath was upsized to 8Fr based on ultrasound findings, achieving complete pseudoaneurysm exclusion. Follow-ups confirmed pseudoaneurysm sealing and radial artery patency. Discussion This case illustrates an effective non-surgical approach to managing large-neck pseudoaneurysms post-TRA, utilizing an upsized sheath technique. It underscores the importance of innovative non-surgical strategies in complex cases, providing a safe and effective alternative to traditional management methods.

Corrigendum: Increasing the sensor channels: a solution for the pressing offsets that cause the physiological parameter inaccuracy in radial artery pulse signal acquisition

Corrigendum: Increasing the sensor channels: a solution for the pressing offsets that cause the physiological parameter inaccuracy in radial artery pulse signal acquisition

Decreased Incidence of Radial Artery Vasospasm Using a Distal Transradial Approach in Diagnostic Cerebral Angiography: A Comparison of 200 Consecutive Cases.

Radial artery vasospasm is a common complication of radial artery catheterization. During the implementation of distal transradial approach (dTRA), we observed a decreased incidence of radial artery vasospasm on radial artery angiography following access that was not well detailed in the literature. The purpose of this study was to characterize the phenomenon of radial artery vasospasm in the context of different radial artery access points for diagnostic cerebral angiography. We retrospectively reviewed consecutive patients undergoing diagnostic cerebral angiography from September 2023 to March 2024. Hundred conventional transradial approach (cTRA) and 100 dTRA diagnostic cerebral angiograms were performed. Following sheath insertion, all angiographic runs were reviewed, and a classification scheme was used to detail radial artery vasospasm occurrence. Radial artery vasospasm was lower in the dTRA approach compared with the cTRA approach (P = .019). A change in radial artery diameter was noted in 47 (47%) patients in the cTRA group vs 28 (28%) patients in the dTRA group. Radial artery diameter distal to the sheath was smaller in the cTRA group (2.30 ± 0.41) compared with the dTRA group (2.42 ± 0.48) (P = .021). Patients with Grade II/III spasm were younger (58 years vs 62 years; P = .029) and had a higher percentage of females (77.3% vs 62.4%; P = .030). Grade II/III spasm patients had a higher percentage of the cTRA approach compared with the dTRA approach (62.7% vs 42.4%; P = .008). These procedures were significantly longer with Grade II/III procedure time of 18:00 minutes vs 15.59 minutes in the Grade I group. Number of vessels catheterized was not significantly different between groups (P = .262). dTRA for diagnostic cerebral angiography is associated with a lower incidence of radial artery vasospasm compared with cTRA. Operators seeking to obviate radial artery vasospasm may consider using the dTRA approach for diagnostic cerebral angiography.