TF Approach Research Articles

Abstract 3498: A novel combination of tissue-informed, comprehensive genomic profiling (CGP) and non-bespoke blood-based profiling for quantifying circulating tumor DNA (ctDNA)

Abstract Background: Estimating quantitative circulating tumor fraction in liquid biopsy samples is a promising area of clinical development for monitoring therapeutic molecular response and correlates with patient outcomes. Here we introduce a sensitive measure of estimating ctDNA tumor fraction (ctDNA TF) using a novel combination of tissue-informed CGP with a non-bespoke, blood-based liquid biopsy panel. Methods: Advanced pan-solid tumor samples were sequenced with both the Tempus xF/xF+ (105/523 gene, liquid biopsy) and Tempus xT (648 genes, solid-tumor with matched buffy coat) NGS assays (samples collected within 90 days). A normal distribution was fit against the somatic variants detected in solid-tissue and variants with variant allele fractions (VAF) within two standard deviations were used as selected biomarkers in the corresponding liquid biopsy to calculate a tumor-informed ctDNA TF for each sample. Results: In the initial validation set (n=79 samples also sequenced with low-pass whole genome sequencing), the linearity of tumor-informed ctDNA TF was compared to mean VAF (R2=0.26, slope=0.55), ichorCNA (R2=0.84, slope=0.84), and tumor-naive ctDNA TF (R2=0.71, slope=0.90). In a larger validation set (n=12,080), 37.5% samples had no variants detected in both xF and/or xT. Of the remaining samples, the linearity of tumor-informed ctDNA TF was compared to mean VAF (R2=0.21, slope=0.55) and tumor-naive ctDNA TF (R2=0.65, slope=0.81). In a follow-up analysis, we required 5 or more variants be detected in both xF and xT (n=1,659 samples) and compared the linearity of tumor-informed ctDNA TF to mean VAF (R2=0.37, slope=0.64) and tumor-naive ctDNA TF (R2=0.68, slope=0.98). In samples that received xF+ profiling (n=567), 24.3% had no variants detected in both xF+ and xT. The linearity of tumor-informed ctDNA TF of the remaining samples was compared to mean VAF (R2=0.01, slope=0.26) and tumor-naive ctDNA TF (R2=0.63, slope=1.02). Increasing the required number of variants to 5 or more had marginal improvement in linearity of tumor-informed ctDNA TF to mean VAF (R2=0.12, slope=0.47) and tumor-naive ctDNA TF (R2=0.67, slope=1.13).The limit-of-blank of the tumor-informed ctDNA TF approach was established to be 0% in both xF and xF+, and the limit-of-detection was ≤0.1% demonstrating that tumor informed ctDNA TF is a sensitive measure in detecting tumor fraction at low concentration levels. Conclusion: Here we introduce a novel sensitive and specific tumor-informed, non-bespoke approach for estimating ctDNA TF. Linearity improves with increased panel size and increased variant number. These results suggest that a tumor-informed ctDNA TF can be utilized to improve the sensitivity of existing methods for estimating tumor fraction to help in treatment decisions using Tempus’ tissue and liquid comprehensive NGS genomic profiling platform. Citation Format: Terri Driessen, Christine Lo, Wei Zhu, Robert Tell, Jonathan Freaney, Halla Nimeiri, Kate Sasser. A novel combination of tissue-informed, comprehensive genomic profiling (CGP) and non-bespoke blood-based profiling for quantifying circulating tumor DNA (ctDNA) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3498.

Outcomes of Transcatheter Aortic Valve Implantation under Transfemoral Approach Versus Alternative Approach in King Chulalongkorn Memorial Hospital

Background: The transfemoral approach (TF) is the access of choice for transcatheter aortic valve implantation (TAVI). However, approximately 10% of patients have anatomy or comorbidity unsuitable for TF. Objective: To analyze the outcomes of an alternative approach compared with TF in the authors’ institute. Materials and Methods: A retrospective analysis of patients undergoing TAVI in King Chulalongkorn Memorial Hospital between December 2010 and 2021 was conducted. The present study compared the baseline characteristics, outcomes, and complications of TAVI procedures, including one-year mortality, according to whether they were performed through a TF or alternative approach. Results: Among 210 patients that underwent TAVI, 188 (89.6%) were in the TF group and 22 (10.4%) were in the alternative group with seven in the trans-subclavian, nine in the transapical, and six in the transaortic. The mean age of the population was 81 years. Patients in the alternative group had more severe disease (median logistic EuroSCORE-II 19.67 versus 10.01, p<0.001). Other baseline characteristics were not different between groups. According to the Valve Academic Research Consortium 3 (VARC-3) criteria, there were higher mortality and complication rates in the alternative group but no statistical differences regarding 30-day mortality of TF at 2.1% versus alternative at 9.1% (p=0.121) and 1-year mortality of TF at 5.3% versus alternative at 13.6% (p=0.143). Hospitalization times were significantly longer in the alternative group (median hospital stay in days of TF 4 versus alternative 10, p=0.013). Although no statistical significance was found, there were trends towards a higher rate of valve malpoition for TF at 3.7% versus alternative at 13.6%, and major vascular complications for TF at 1.6% versus alternative at 9.1%. Conclusion: The authors’ institute data demonstrates alternative approach TAVI was associated with a similar mortality rate and post-procedural complication rate compared with transfemoral TAVI, except for a trend toward a higher rate of valve malposition and major vascular complications. The alternative approach TAVI may be favored in patients with high or prohibitive surgical risk unsuitable for transfemoral TAVI. Keywords: Transcatheter aortic valve implantation; TAVI; Alternative approach; Transfemoral; Operative outcomes

Abstract 220: Transradial Access Versus Transfemoral Approach for Carotid Artery Stenting: A Systematic Review and Meta‐analysis

Introduction Carotid artery stenting (CAS) has emerged as a viable alternative to carotid endarterectomy for managing carotid artery stenosis in high‐risk patients (1). While the transfemoral arterial approach (TF) remains the preferred method, it is associated with inherent limitations and potential complications (2‐4). Consequently, exploring the transradial artery access (TR) as a potential option becomes crucial in optimizing patient outcomes and procedural success rates. Limited data exists comparing the outcomes of TR approach in CAS to TF approach. This study aims to systematically review and meta‐analyze the outcomes and complication rates between TR and TF access for CAS. Methods A systematic electronic search was conducted in four databases up to May 10th, 2023. Studies with randomized or non‐randomized designs, involving CAS through TR or TF approach, were included. Outcomes of interest were stroke, transient ischemic attack (TIA), death, myocardial infarction (MI), and access site complications. A meta‐analysis was performed, analyzing pooled odds ratios (ORs) and 95% confidence intervals (CI) to assess the effect size of the vascular access approaches. Results Six studies with a total of 6,917 patients were included, out of which 602 (8.7%) underwent the TR approach, and 6,315 (91.3%) underwent the TF approach. Meta‐analysis results showed no significant difference in stroke occurrence between TR and TF groups (TR: 1.7% vs. TF: 1.9%; OR = 0.98; 95% CI 0.49 – 1.96; I2 = 0%). Similarly, no significant difference was found in death (TR: 1% vs. TF: 0.9%; OR = 0.95; 95% CI 0.38 – 2.37; I2 = 0%), MI (TR: 0.2% vs. TF: 0.3%; OR = 1.53; 95% CI 0.20 – 11.61; I2 = 0%), TIA (TR: 0.4% vs. TF: 1%; OR = 0.46; 95% CI 0.11 – 1.95; I2 = 0%), and access site complications (TR: 2.2% vs. TF: 1%; OR = 0.97; 95% CI 0.48 – 1.98; I2 = 0%). Conclusion In the comparison of TR and TF approaches for CAS, no significant differences were observed in stroke, death, MI, TIA, or access site complications. TR approach shows promise as an alternative method for CAS, offering potential benefits without increased risk of complications. However, further studies are needed to confirm these findings and establish guidelines for optimal access site selection.

Temporal trends in practice and outcomes of transcatheter aortic valve replacement. Insight from 10-year experience of a Canadian moderate volume center

In transcatheter aortic valve replacement (TAVR), data suggests an inverse association between hospital TAVR volume and worse outcomes. While most reports emanated from high volume centers, little is known about TAVR practice in moderate and low-volume centers. We analyzed the 10-year experience of a moderate TAVR volume Canadian center reporting the temporal trends in practice and outcomes. Observational single-center retrospective study involving all patients who underwent TAVR at the Centre Hospitalier de l’Université de Montréal from 2009 to 2019. The global population (412 patients) was divided into 3 cohorts reflecting the gradual evolution of TAVR procedures and post-operative care: historical cohort (HC, n = 126), transitional cohort (TC, n = 124) and contemporary cohort (CC, n = 162). TAVR case volume has gradually increased from ∼30 cases in the first years to 97 procedures in 2019. Mean age was 79.6 ± 7.8 years. Patients in CC were younger than those in HC. The mean STS score was 5.3 ± 3.6 and decreased over the 3 periods. TF approach was performed in 83% of cases and was more often used in TC and in CC in comparison with HC (all P < 0.001). Conscious sedation use in TF TAVR has increased over the 3 periods (all P < 0.001). Transapical and direct aortic accesses performed in HC and TC, were completely abandoned in CC in favor of transaxillary, trans-carotid and suprasternal accesses. Overall, median length of stay (LOS) decreased from 5 [IQI 4–9] days in HC to 2 [IQR 1–6] days in TC, and 1 [IQR 1–3] day in CC (all P < 0.05). Thirty-day mortality rate was 2.2% and significantly higher in HC (5.6%) in comparison with TC (0%; P = 0.008) and CC (1.2%; P = 0.037). One-year survival was 92.2% and was lower in HC (88.2%) in comparison with TC (95.5%; P = 0.030) and CC (93.3%; P = 0.090) ( Fig. 1 ). TAVR volume has increased with more conscious sedation in TF access and less invasive non-TF accesses, resulting in decreased LOS and improved outcome.

Extended Statement by the British Cardiovascular Intervention Society President Regarding Transcatheter Aortic Valve Implantation.

Service Specification for TAVI: Recommendations of the British Cardiovascular Intervention Society – Updated July 2019 Severe AS (sAS) is the most common primary valve disease leading to surgery or catheter intervention in Europe and North America, with a growing prevalence due to the ageing population.[3] It is a degenerative condition in which the outflow of blood from the heart is restricted by progressive narrowing of the aortic valve. This leads to symptoms of breathlessness, exertional chest pain or blackouts. Untreated, the condition causes left ventricular failure and death, with up to 40% of patients dying within 1 year of symptom onset. No medical therapy can improve outcome for this condition and therefore valve intervention is the only treatment option that alters prognosis. The standard of care for this condition has historically been surgical aortic valve replacement (sAVR), but around one-third of patients are ineligible for sAVR due to a combination of age and comorbidities. TAVI is a transformational technology; it is a much less invasive approach than sAVR and involves implantation of a new valve without the need for complex surgery or the use of a heart–lung bypass machine. This is most commonly done via the femoral arteries (transfemoral or TF approach), but it may also be accomplished via the subclavian arteries or via minimally invasive access using the cardiac apex between the ribs, directly into the aorta through a small incision. Less common approaches via the carotid arteries, axillary artery and the femoral veins or abdominal aorta have also been described. Therefore, for most patients undergoing TAVI, the procedure is performed via the femoral artery, under local anaesthesia or conscious sedation in a catheter laboratory. This results in quicker patient recovery, a shorter hospital stay and reduced use of expensive and limited resources such as cardiac operating theatres and intensive care unit beds, as well as postoperative nursing care. A number of different valve designs are available, including balloon-expandable and self-expandable devices. Each has different performance characteristics, which may be tailored to specific anatomical or patient-specific features. TAVI has been proven to be superior to medical therapy for inoperable patients and superior to sAVR in patients who are high risk for sAVR (Society of Thoracic Surgeons [STS] or Euroscore II >8%).[4–6] Trials have also shown that patients with intermediate surgical risk (STS or Euroscore II >4%) who are eligible for a TF approach have superior outcomes with TAVI.[7–9] Moreover, randomised trials have shown TAVI to be superior to sAVR in patients classified as low risk (STS <4), with outcome data so far published to 12 months.[10,11]

Comparison of the Oblique Interlaminar and Transforaminal Lumbar Epidural Steroid Injections for Treatment of Low Back and Lumbosacral Radicular Pain

BackgroundTransforaminal epidural steroid injections (TF-ESIs) effectively deliver small amounts of drugs to inflamed sites via the ventral epidural space. However, there is a high risk of nerve damage as the needle narrowly approaches the spinal nerve. Therefore, we devised an oblique interlaminar (OIL) approach as an alternative method. We compared the efficacy of fluoroscopic-guided OIL-ESIs with that of TF-ESIs in the management of lower back and unilateral lumbosacral radicular pain.Materials and MethodsSixty-six patients were randomized to receive a fluoroscopic-guided ESI either through the OIL (n = 33, group OIL) or TF (n = 33, group TF) approach. They were evaluated for effective pain relief using the visual analogue scale (VAS) and for functional improvement using the Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ). Other outcome measures were the presence of ventral and contralateral spread of contrast, patients’ satisfaction, and adverse events.ResultsThere were no significant differences between the groups in the VAS, ODI, and RMDQ scores during the 12-week period. The differences in the ODI and RMDQ scores before and after the treatment were higher in group TF than in group OIL. The contralateral spread of contrast was higher in group OIL than in group TF. There were no significant differences in the other outcomes between the groups.ConclusionESIs delivered through the OIL approach are equally effective in pain relief and functional improvement as those delivered via the TF approach in the management of low back and unilateral lumbosacral radicular pain.

Risk modeling in transcatheter aortic valve replacement remains unsolved: an external validation study in 2946 German patients

BackgroundSurgical risk prediction models are routinely used to guide decision-making for transcatheter aortic valve replacement (TAVR). New and updated TAVR-specific models have been developed to improve risk stratification; however, the best option remains unknown.ObjectiveTo perform a comparative validation study of six risk models for the prediction of 30-day mortality in TAVRMethods and resultsA total of 2946 patients undergoing transfemoral (TF, n = 2625) or transapical (TA, n = 321) TAVR from 2008 to 2018 from the German Rhine Transregio Aortic Diseases cohort were included. Six surgical and TAVR-specific risk scoring models (LogES I, ES II, STS PROM, FRANCE-2, OBSERVANT, GAVS-II) were evaluated for the prediction of 30-day mortality. Observed 30-day mortality was 3.7% (TF 3.2%; TA 7.5%), mean 30-day mortality risk prediction varied from 5.8 ± 5.0% (OBSERVANT) to 23.4 ± 15.9% (LogES I). Discrimination performance (ROC analysis, c-indices) ranged from 0.60 (OBSERVANT) to 0.67 (STS PROM), without significant differences between models, between TF or TA approach or over time. STS PROM discriminated numerically best in TF TAVR (c-index 0.66; range of c-indices 0.60 to 0.66); performance was very similar in TA TAVR (LogES I, ES II, FRANCE-2 and GAVS-II all with c-index 0.67). Regarding calibration, all risk scoring models—especially LogES I—overestimated mortality risk, especially in high-risk patients.ConclusionsSurgical as well as TAVR-specific risk scoring models showed mediocre performance in prediction of 30-day mortality risk for TAVR in the German Rhine Transregio Aortic Diseases cohort. Development of new or updated risk models is necessary to improve risk stratification.Graphic abstract

Transradial Retrieval of Broken Catheter After Complex PCI- A Nightmare

Transradial access has now a days become a standard of care for percutaneous coronary angiography &amp; intervention. This approach has demonstrated significant reduction in bleeding rate, length of hospital stay and improvement in clinical outcomes when compared to the traditional TF approach. However this novel approach may lead to severe catheter kinking &amp; twisting and further manipulation may require unraveling the catheter and avoiding complication. The fracture of a guide catheter is an uncommon complication during percutaneous coronary intervention (PCI). It sometimes occurs during engagement of the right coronary ostium, when there is excessive twisting of the guide catheter. An interesting case of complete fracture of a 6 Fr Ikari guide catheter in the brachial artery during transradial coronary intervention is presented.&#x0D; Ibrahim Card Med J 2018; 8 (1&amp;2): 66-70

Mid-Term Outcomes after Transapical and Transfemoral Transcatheter Aortic Valve Implantation for Aortic Stenosis and Porcelain Aorta with a Systematic Review of Transfemoral versus Transapical Approach.

We have aimed to analyze early and mid-term outcomes of patients undergoing transapical/transfemoral transcatheter aortic valve implantation (TA-/TF-TAVI) for aortic stenosis and porcelain aorta (PAo) in our institution. Additionally, we postulated that the TA approach may be associated with a more favorable neurological outcome than the TF approach; hence, a systematic literature review was conducted. Between 2011 and 2017, 15 patients with PAo underwent TA-TAVI and 4 patients with PAo TF-TAVI at our institution. The assessment of PAo was done either intraoperatively after aborted sternotomy or via computed tomography for elective TAVI. We conducted mid-term follow-up. Furthermore, a systematic review was performed to compare the mortality and neurological outcomes of TF and TA-TAVI approaches. TA/TF-TAVIs were performed with 100% device success, without paravalvular leakage ≥ 2 and without procedural death. The 30-day mortality/stroke rates were 6.6%/0% in TA-TAVI and 0%/25% in TF-TAVI, respectively. The 6-month, 1-year, and 2-year survival rates were in TA/TF-TAVI 93%/75%, 82%/66.6%, and 50%/0%, respectively.The pooled results derived from the literature review were as follows: The prevalence of PAo in the TAVI population is 9.74%; the mean logistic EuroSCORE is 41.9% in TA-TAVI versus 16.2% in TF-TAVI; the mean 30-day mortality is 5.9% in TA-TAVI versus 6.3% in TF-TAVI, and the mean stroke is 0.8% in TA-TAVI versus 9% in TF-TAVI. TA-TAVI shows promising early and mid-term outcomes in patients with PAo. TF-TAVI performed in patients with PAo is likely to be associated with higher rates of stroke than TA-TAVI.

Impact of androgen deprivation therapy on apparent diffusion coefficient and T2w MRI for histogram and texture analysis with respect to focal radiotherapy of prostate cancer

PurposeAccurate prostate cancer (PCa) detection is essential for planning focal external beam radiotherapy (EBRT). While biparametric MRI (bpMRI) including T2-weighted (T2w) and diffusion-weighted images (DWI) is an accurate tool to localize PCa, its value is less clear in the case of additional androgen deprivation therapy (ADT). The aim of this study was to investigate the value of a textural feature (TF) approach on bpMRI analysis in prostate cancer patients with and without neoadjuvant ADT with respect to future dose-painting applications.Methods28 PCa patients (54–80 years) with (n = 14) and without (n = 14) ADT who underwent bpMRI with T2w and DWI were analyzed retrospectively. Lesions, central gland (CG), and peripheral zone (PZ) were delineated by an experienced urogenital radiologist based on localized pre-therapeutic histopathology. Histogram parameters and 20 Haralick TF were calculated. Regional differences (i. e., tumor vs. PZ, tumor vs. CG) were analyzed for all imaging parameters. Receiver-operating characteristic (ROC) analysis was performed to measure diagnostic performance to distinguish PCa from benign prostate tissue and to identify the features with best discriminative power in both patient groups.ResultsThe obtained sensitivities were equivalent or superior when utilizing the TF in the no-ADT group, while specificity was higher for the histogram parameters. However, in the ADT group, TF outperformed the conventional histogram parameters in both specificity and sensitivity. Rule-in and rule-out criteria for ADT patients could exclusively be defined with the aid of TF.ConclusionsThe TF approach has the potential for quantitative image-assisted boost volume delineation in PCa patients even if they are undergoing neoadjuvant ADT.

Evolution of Length of Stay After Surgical and Transcatheter Aortic Valve Implantation Over 8 Years in 1,849 Patients >75 Years of Age and Comparison Between Transfemoral and Transsubclavian Transcatheter Aortic Valve Implantation

Minimized length of hospitalization (LoS) and lower risk of hospitalization-related complications are key requirements in the treatment of aortic valve disease, mainly in the elderly candidates. Our objective was to evaluate evolution of LoS after surgical (SAVR) or transcatheter aortic valve implantation (TAVI) and its predictors. We enrolled 1,849 elderly (aged >75) patients receiving SAVR or TAVI from 2009 to 2016. In the surgical cohort (n = 1,006) the mean LoS slightly decreased from 13.81 ± 9.27 days (2009) to 10.96 ± 3.77 (2016); in the TAVI cohort (n = 843), LoS passed from 13.33 ± 9.17 (2009) to 6.21 ± 4.30 days (2016). All-cause mortality at 1 month was 3.77 % (SAVR) versus 4.7% (TAVI) (p >0.05). Among Transfemoral TAVI (TF, n = 681), and Transsubclavian TAVI (TS, n = 62), average LoS was comparable (7.38 days ± 7.11 vs 7.31 ± 4.32; median 6.0 and 6.0 days, p = 0.07). Procedural success was reached in 93% (TF) and in 85.4% (TS) (p = 0.20). There were no meaningful differences among TF and TS in terms of VARC-2 postprocedural morbidity, except for the rate of vascular access-related complications; these occurred in 8.8% of cases in the TF group versus 1.6% in the TS group (p = 0.05). In conclusion the present analysis showed a faster improvement in terms of LoS for TAVI compared with SAVR over 8 years of activity. The 2 strategies presented comparable all-causes mortality at 30 days. LoS, rates of procedural success and complications were comparable among TF and TS TAVI; nonetheless, vascular access-related complications were more frequent in the TF cohort. This suggests the validity of the TS route as an alternative to the TF approach.

Efficacy and safety of transcatheter valve-in-valve replacement for Mitroflow bioprosthetic valve dysfunction.

Bioprostheses with pericardial leaflets mounted externally on the stent pose a high risk for valve-in-valve (ViV) procedures. This study analyzed the efficacy and safety of ViV procedures for treating structural valve deterioration (SVD) in Mitroflow bioprostheses. Between January 2012 and August 2017, 11 patients (mean age 80.3 ± 5.6 years) were treated for SVD of Mitroflow bioprostheses with transcatheter ViV procedures (six transapical [TA] and five transfemoral [TF]) using balloon expandable bioprostheses. All patients but one were in NYHA class III-IV. Mean STS PROM, euroSCORE I, and euroSCORE II were 8 ± 6.5%, 27.8 ± 11.5%, and 12 ± 5.9%, respectively. Two patients had a "porcelain aorta." The size of implanted valves were 23 mm in 10 cases and 26 mm in one case. One patient suffered a coronary occlusion during a TF approach. The mean volume of contrast used in TF implants was 163 ± 69.8 mL. No contrast media were used in TA procedures. There was one in-hospital death (10%). At 1 year of follow-up, peak and mean aortic gradients were 25.5 ± 5.8 mmHg and 15.5 ± 5.7 mmHg, respectively. One patient had mild paravalvular regurgitation. Cumulative survival was 90.9% at 1 year, 70.7% at 2 years, and 53% at 3 years. ViV procedures with balloon-expandable aortic valves provide good hemodynamic and clinical mid-term results for treating patients with a degenerated Mitroflow aortic bioprosthesis. Special care must be taken in small aortic roots, when the stented valve is in the supra-annular position to avoid coronary ostial obstruction.

A new concept of transforaminal ventral facetectomy including simultaneous decompression of foraminal and lateral recess stenosis: Technical considerations in a fresh cadaver model and a literature review.

Percutaneous endoscopic surgery for the lumbar spine, which was established in the last decade, requires only an 8-mm skin incision and causes minimal damage to the paravertebral muscles; thus, it is considered to be a minimally invasive technique for spinal surgery. It has been used to perform percutaneous endoscopic discectomy via two main approaches: the TF approach is a posterolateral one through the intervertebral foramen and can be done under local anesthesia; the IL approach is a more traditional one through the interlaminar space and is difficult to perform under local anesthesia. Recently, these techniques have been applied for lumbar spinal stenosis (LSS), the TF method for foraminal stenosis under local anesthesia, and the IL method for central and lateral recess stenosis under general anesthesia. In this study, using a fresh human cadaver model, we performed simultaneous decompression of the lateral recess and foraminal stenosis at L4-5 using the TF approach. Computed tomography confirmed enlargement of the lateral recess and intervertebral foramen. This technique, which can be performed under local anesthesia, should benefit elderly patients with LSS and poor general condition due to multiple comorbidities. Finally, we introduce the concept of percutaneous transforaminal ventral facetectomy using a spinal percutaneous endoscope. J. Med. Invest. 64: 1-6, February, 2017.

Transradial approach for coronary angiography and intervention in the elderly: A meta-analysis of 777,841 patients

BackgroundStudies showing an advantage of transradial approach (TR) for coronary angiography and intervention (PCI) compared to the transfemoral approach (TF) predominantly included a younger population. Therefore, we conducted a meta-analysis of published studies to determine the efficacy of TR in the elderly population. Methods and resultsA comprehensive search identified 16 studies [3 randomized controlled studies, 13 observational] comprising 777,841 elderly patients undergoing PCI. TR was used in 99,201 patients and TF in 678,640 patients. The results from observational studies showed that TR was associated with a lower rate of vascular complications (0.4% vs. 0.8%, OR 0.36, 95% CI 0.30–0.44), stroke (0.3% vs. 0.4%, OR 0.81, 95% CI 0.66–1.0) and death (2.0% vs. 2.2%, OR 0.51, 95% CI 0.41–0.63). RCTs confirmed findings from observational studies for both significant reduction in vascular complications (2.7% vs. 7%, OR 0.37, 95% CI 0.23–0.60) and stroke (0.4% vs. 1.4%, OR 0.31, 95% CI 0.10–0.97) but showed no effect on mortality (3.3% vs. 2.8%, OR 1.20, 95% CI 0.69–2.09). However, among patients with ST elevation myocardial infarction (STEMI), TR was associated with a mortality benefit (5% vs. 7%, OR 0.48, 95% CI 0.25–0.90, p=0.02). Access site crossover rate was higher for TR compared to the TF approach (11% vs. 3%, p=0.0003) but there was no difference in contrast media use, procedure duration, fluoroscopy time and door to balloon time for STEMI. ConclusionTR for PCI in the elderly is associated with a reduced risk of stroke, lower rate of vascular complications overall and a mortality benefit for patients presenting with STEMI. The access site cross rate for TR is higher compared to TF but remains acceptably low. TR should be the preferred strategy for PCI in the elderly to optimize clinical benefit in this high-risk group.

Abstract PR305

Background & Objectives: The purpose of this systematic review is to emphasize the efficacy of a parasagittal interlaminar (PIL) approach. Materials & Methods: In this systematic review, we included five studies that compared parasagittal IL with either midline IL (MIL) or TF-LESI. A total of 296 patients who had undergone different types of LESI were observed across the five studies; the average pain and functional improvements were calculated and compared amongst groups. Results: Two comparative studies between PIL and MIL approach followed-up 137 patients between 6 and 12 months after injection. Results showed better pain (54.3% vs. 22.8%) and functional improvement (45.7% vs. 24.8%) using the parasagittal approach at the 6 month period (Figure 1:A,B). A 12 month follow-up for pain and function improvements with the PIL approach is superior to the MIL approach (53.4% vs. 14.7%) and (55% vs. 27.7%), respectively. A comparative analysis of PIL and TF injections in 159 patients showed slightly better pain improvements (45.7% vs 40.09%) in the PIL group (Figure 1:C) at 6-month follow-up period. A 12 months follow-up between PIL and TF showed a near equivalent effectiveness for pain (58.9% vs. 63.2%) and functional improvement (47.3% vs. 48.1%). Third LESI injection were more common in the TF group (30%) than the PIL group (18.8%) and a number of repeated injections were generally lower among PIL than MIL group.Conclusion: Results of this systematic review showed better outcomes with a PIL as compared to a MIL, and near equivalent efficacy as compared to the TF approach. If we consider that TF injections are associated with greater risk, increasing reimbursement costs for TF-LESI, and that the FDA issued a warning based on unfavorable reports of TF injections. The Parasagittal IL approach should be considered as an efficacious and cost-effective alternative for TF injections. Disclosure of Interest: None declared

Short and long-term outcomes of alcohol septal ablation with the trans-radial versus the trans-femoral approach: A single center-experience

BackgroundAlthough the trans-radial approach (TR) has been applied to various subsets of patients in percutaneous coronary intervention, the feasibility, efficacy, acute procedural and long-term outcomes of TR versus trans-femoral approach (TF) for alcohol septal ablation (ASA) have not yet been determined. ObjectivesThe aim of this study was to compare the short and long-term outcomes of ASA with the TR approach compared to the TF approach. MethodsWe retrospectively analyzed 240 patients who underwent an ASA procedure at our institution from November 1999 to November 2015. The TR approach was performed in 172 cases and the TF approach in the remaining 68 cases. ResultsThe use of TR approach progressively increased from 62% in 1999–2005 to 91% in 2011–2015 (p=0.0001). The TF and TR group had similar age, baseline NYHA class (NYHA 3 or 4) and mean left ventricular outflow tract peak gradient before ASA. Total contrast used (TR: 73.2±47.2ml; TF: 88.7±49.3ml, p=0.11), total radiation Air kerma area product (TR: 43.7±48.0Gycm−2; TF: 55.9±48.2Gycm−2; p=0.39) and peak left ventricular outflow tract gradient immediately after ASA (TR: 19.1±19.6mmHg; TF: 20.4±18.0mmHg, p=0.63) were similar in both groups.Procedural success was 91.9% and 91.2% in the TR and TF groups, respectively (p=0.53). At 30days, there was 2 intra-hospital death (1 in TF and 1 in TR), 1 major stroke in the TF group and 1 coronary artery dissection in the TR group. Vascular complications were less frequent in the TR group (0.58% vs. 7.3%; p=0.002). The mean length of follow-up was 4.56±4.34years (IQR 0.69–8.2; median 2.92years; maximum: 15.5years). By Kaplan–Meier estimate, the observed survival in the overall cohort was comparable to the expected survival for a sex and age-matched comparable general French population at 10years (86.9 vs. 83.6%, p=0.88). Survival was similar between the TR and TF group (92.1% vs. 89.7% at 6years, respectively; p=0.71). ConclusionsAlcohol septal ablation from the radial approach can be performed with similar acute and long-term success, but with lower vascular complications compared to the femoral approach.

Influence of Transcatheter Aortic Valve Replacement Strategy and Valve Design on Stroke After Transcatheter Aortic Valve Replacement: A Meta-Analysis and Systematic Review of Literature

The study undertook a systematic review to establish and compare the risk of stroke between the 2 widely used approaches (transfemoral [TF] vs. transapical [TA]) and valve designs (CoreValve, Medtronic, Minneapolis, Minnesota vs. Edwards Valve, Edwards Lifesciences, Irvine, California) for transcatheter aortic valve replacement (TAVR). There has been a rapid adoption and expansion in the use of TAVR. The technique is however far from perfect and requires further refinement to alleviate safety concerns that include stroke. All studies reporting on the risk of stroke after TAVR were identified using an electronic search and pooled using established meta-analytical guidelines. 25 multicenter registries and 33 single-center studies were included in the analysis. There was no difference in pooled 30-day stroke post-TAVR between the TF and TA approach in multicenter (2.8% [95% confidence interval (CI): 2.4 to 3.4] vs. 2.8% [95% CI: 2.0 to 3.9]) and single-center studies (3.8% [95% CI: 3.1 to 4.6] vs. 3.4% [95% CI: 2.5 to 4.5]). Similarly, there was no difference in pooled 30-day stroke post TAVR between the CoreValve and Edwards Valve in multicenter (2.4% [95% CI: 1.9 to 3.2] vs. 3.0% [95% CI: 2.4 to 3.7]) and single-center studies (3.8% [95% CI: 2.8 to 4.9] vs. 3.2% [95% CI: 2.4 to 4.3]). There was a decline in stroke risk with experience and technological advancement. There was no difference in the outcome of 30-day stroke between TAVR and surgical aortic valve replacement. Our findings suggest that the risk of 30-day stroke after TAVR is similar between the approaches and valve types. There has been a decline in stroke risk after TAVR with improvements in valve technology, patient selection, and operator experience.

Radialer Zugang bei Koronarinterventionen

There is ongoing discussion about the optimal access site for PCI and stent implantation. The transradial access (TRA) is being increasingly used over the past years. Recent studies in patients with acute coronary syndrome (RIVAL study) and in patients with STEMI (RIFLE-STEACS study), revealed a reduced access site-related bleeding and a better cardiovascular outcome in patients with TRA compared to patients with transfemoral access (TFA). This was especially true in high risk patients and in experienced interventionalists in centres with high radial volume. Within this manuscript we will describe the pros and cons of the TRA versus the TF approach as well as current evidence from the literature. In conclusion the TRA should be the favourite and first choice approach for almost all of our patients.

TCT-402 Comparison of procedural and long-term outcomes between transradial and transfemoral approach for triple vessel coronary artery disease intervention

The feasibility, safety and efficacy between TR and TF approach for coronary interventional treatment have been compared in some complicated situations including AMI, unprotected left main coronary artery disease. However, in terms of triple vessel disease intervention, there is still no comparison

Experimental study and three-dimensional simulation of premixed hydrogen/air flame propagation in a closed duct

An experimental and numerical study of premixed hydrogen/air flame propagation in a closed duct is presented. High-speed schlieren photography is used in the experiment to record the changes in flame shape and location. The pressure transient during the combustion is measured using a pressure transducer. A dynamic thickened flame model is applied to model the premixed combustion in the numerical simulation. The four stages of the flame dynamics observed in the experiment are well reproduced in the numerical simulation. The oscillations of the flame speed and pressure growth, induced by the pressure wave, indicate that the pressure wave plays an important role in the combustion dynamics. The predicted pressure dynamics in the numerical simulation is also in good agreement with that in the experiment. The close correspondence between the numerical simulation and experiment demonstrate that the TF approach is quite reliable for the study of premixed hydrogen/air flame propagation in the closed duct. It is shown that the flame wrinkling is important for the flame dynamics at the later stages.