Transradial Percutaneous Coronary Intervention Research Articles

Technical success and long-term experience of a novel radial guide-catheter shape: the JCLRAD.

Percutaneous coronary intervention (PCI) via the transradial route has been widely adopted over the transfemoral route, but guide catheter selection remains limited. We present our experience with a novel guide catheter design, the Judkin’s Curve Left- Radial (JCLRAD, Medtronic), which is optimized for transradial PCI to the left coronary system. Sequential patients who underwent PCI using the JCLRAD catheter over a 3-year period (October 1, 2017 to November 1, 2020) were included in the analysis. Prospectively collected data were extracted from the institutional NCDR CathPCI registry with supplemental medical record review to collect clinical and procedural data. PCI was performed in 2347 patients and 4070 lesions using the JCLRAD guide catheter. The mean age was 65.5 ± 11.7 years, and 72.1% of the population were male; 52.5% of patients presented with acute coronary syndrome. The lesion complexity was high (66.7% Class B2/C by ACCAHA classification) with a 7% use of atherectomy. Procedural success was 99.6% with no identified cases of iatrogenic catheter-induced coronary dissection. In this single-center retrospective study, the use of the JCLRAD was associated with a high success rate and low rates of complications, including no guide catheter-induced dissection in a cohort of patients with complex coronary anatomy. This is the first-reported large clinical experience with this novel radial left coronary system guide catheter.

Effects of Transradial Access on In-Hospital Outcomes in Percutaneous Coronary Intervention for Coronary Artery Bypass Graft: Insights from the Japanese Nationwide Database

Due to its superior safety profile and improved outcomes, trans-radial percutaneous coronary intervention (TRI) has become the preferred access in percutaneous coronary intervention (PCI) of native coronary disease. This study investigated the impact of TRI on in-hospital outcomes after PCI for coronary artery bypass graft vessels (GV-PCI). We analyzed patients who underwent GV-PCI in 2019–2022 from the Japanese nationwide registry. Patients were categorized into the TRI and trans-femoral percutaneous coronary intervention (TFI) groups. We assessed the association of TRI and in-hospital outcomes. The primary outcome was a composite of in-hospital death and major bleeding. GV-PCI was performed in 2,295 Out of 972,370 total PCI procedures. The primary outcomes occurred in 29 patients (1.3%), including 17 deaths (0.7%). Major bleeding occurred in 12 patients (0.5%), and access site bleeding in seven patients (0.3%). The TRI group (N=1,521) showed lower crude rates of the primary outcome (0.9% vs. 1.9%, p = 0.039), major bleeding (0.3% vs. 1.0%, p = 0.027), and access site bleeding (0.1% vs. 0.6%, p = 0.047) compared to the TFI group (N=774). Univariable logistic regression demonstrated a significant association of TRI with reduced primary outcome (odd ratio (OR):0.47, 95% confidence interval (CI):0.22-0.98), major bleeding (OR:0.25, 95% CI:0.07-0.80), and access site bleeding (OR:0.20, 95% CI:0.03-0.94). In the multivariable analysis, TRI was still significantly associated with a decrease in major bleeding events (OR:0.29, 95% CI:0.07-0.93). In conclusion, the use of TRI was associated with a reduction in bleeding events when referenced to TFI in the context of GV-PCI.

A comparison between radial artery compression devices for patent hemostasis after transradial percutaneous interventions.

Patent hemostasis (PH) is essential for preventing radial artery occlusion (RAO) after trans-radial procedures; however, it remains unclear how it should be obtained. The aim of this multicenter randomized study was to evaluate whether the use of an adjustable device (AD), inflated with a pre-determined amount of air (AoA), was more effective than a non-adjustable device (non-AD) for achieving PH, thereby reducing the incidence of RAO. We enrolled a total of 480 patients undergoing transradial procedure at 3 Italian institutions. Before the procedure, a modified Reverse Barbeau Test (mRBT) was performed in all patients to evaluate the AoA to be eventually inflated in the AD. After the procedure, patients were randomized into 2 groups: (1) AD Group, using TR-Band (Terumo) inflated with the pre-determined AoA; and 2) non-AD Group, using RadiStop (Abbott). An RBT was performed during compression to demonstrate the achievement of PH, as well as 24 hours later to evaluate the occurrence of RAO. PH was more often obtained in the AD Group compared with the non-AD Group (90% vs 64%, respectively, P less than .001), with no difference in terms of bleedings. RAO occurred more often in the non-AD Group compared with the AD Group (10% vs 3%, respectively, P less than .001). Of note, mRBT was effective at guiding AD inflation and identifying high-risk patients in whom PH was more difficult to obtain. The use of AD, filled with a predetermined AoA, allowed PH significantly more often compared with non-AD, providing a significantly reduced incidence of RAO.

Safety and Outcomes of Same-Day Discharge Versus Overnight Observation After Transradial Percutaneous Coronary Intervention: A Retrospective Cohort Study in a Tertiary Hospital in Philippines

INTRODUCTION: Since earlier days of percutaneous coronary intervention (PCI), there has been improvement in several aspects of PCI including use of transradial approach and third-generation drug-eluting stents. Despite data showing its safety, same-day discharge (SDD) PCI has not been widely practiced in our institution and country. At present, there are no published studies from the Philippines showing the safety and outcome of SDD PCI. OBJECTIVES: The primary objective of this study is to determine and compare the safety and outcomes of SDD versus overnight observation after PCI in The Medical City from 2018 to 2021. METHODS: This was a retrospective cohort study. The primary endpoint was to describe and compare the clinical profile of patients who underwent same-day versus overnight observation after PCI such as age, sex, comorbidities, indication for coronary angiogram, procedure time, total dye used, stent, and drug-eluting stent used. Incidence of major adverse cardiovascular event, mortality, readmission, and access site complications were also determined at 48 hours and 30 days after PCI. RESULTS: Ninety-three patients were included in the analysis. Reasons for undergoing PCI were a positive noninvasive stress test (45%), stable angina (40%), coronary artery disease (26%), and heart failure (20%). More single-vessel (60%) than multivessel (40%) PCIs were performed. The most frequently affected coronary artery was the LAD (82%), followed by right coronary artery (32%) and left circumflex artery (30%). Compared with patients who stayed longer after PCI, the SDD group had lower mean (±SD) body mass index (25.10 ± 3.12 vs 28.55 ± 4.95 kg/m2), less due to a positive noninvasive test (26% vs 51%), more who underwent a single-vessel PCI (78% vs 54%), lower median amount of injected dye (130 vs 188 mL), shorter median procedural time (74 vs 101.5 minutes), and greater use of sirolimus-eluting stent (22% vs 3%). No adverse outcome of interest was noted in any patient up to 30 days after hospital discharge. CONCLUSION: No adverse outcome was noted with SDD PCI. Larger, prospective, randomized comparative studies are needed to ascertain its safety before recommending SDD PCI routinely. KEYWORDS: left anterior descending artery, left circumflex artery, percutaneous coronary intervention, right coronary artery, same-day discharge

Impact of Access Site on Periprocedural Bleeding and Cerebral and Coronary Events in High-Bleeding-Risk Percutaneous Coronary Intervention: Findings from the RIVA-PCI Trial.

The preference for using transradial access (TRA) over transfemoral access (TFA) in patients requiring percutaneous coronary intervention (PCI) is based on evidence suggesting that TRA is associated with less bleeding and fewer vascular complications, shorter hospital stays, improved quality of life, and a potential beneficial effect on mortality. We have limited study data comparing the two access routes in a patient population with atrial fibrillation (AF) undergoing PCI, who have a particular increased risk of bleeding, while AF itself is associated with an increased risk of thromboembolism. Using data from the RIVA-PCI registry, which includes patients with AF undergoing PCI, we analyzed a high-bleeding-risk (HBR) cohort. These patients were predominantly on oral anticoagulants (OAC) for AF, and the PCI was performed via radial or femoral access. Endpoints examined were in-hospital bleeding (BARC 2-5), cerebral events (TIA, hemorrhagic or ischemic stroke) and coronary events (stent thrombosis and myocardial infarction). Out of 1636 patients, 854 (52.2%) underwent TFA, while 782 (47.8%) underwent the procedure via TRA, including nine patients with brachial artery puncture. The mean age was 75.5years. Groups were similar in terms of age, sex distribution, AF type, cardiovascular history, risk factors, and comorbidities, except for a higher incidence of previous bypass surgeries, heart failure, hyperlipidemia, and chronic kidney disease (CKD) with a glomerular filtration rate (GFR) < 60ml/min in the TFA group. No clinically relevant differences in antithrombotic therapy and combinations were present at the time of PCI. However, upon discharge, transradial PCI patients had a higher rate of triple therapy, while dual therapy was preferred after transfemoral procedures. Radial access was more frequently chosen for non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP) cases (NSTEMI 26.6% vs. 17.0%, p < 0.0001; UAP 21.5% vs. 14.5%, p < 0.001), while femoral access was more common for elective PCI (60.3% vs. 44.1%, p < 0.0001). No differences were observed for ST-segment elevation myocardial infarction (STEMI). Both groups had similar rates of cerebral events (TFA 0.2% vs. TRA 0.3%, p = 0.93), but the TFA group had a higher incidence of bleeding (BARC 2-5) (4.2% vs. 1.5%, p < 0.01), mainly driven by BARC 3 bleeding (1.5% vs. 0.4%, p < 0.05). No significant differences were found for stent thrombosis and myocardial infarction (TFA 0.2% vs. TRA 0.3%, p = 0.93; TFA 0.4% vs. TRA 0.1%, p = 0.36). In HBR patients with AF undergoing PCI for acute or chronic coronary syndrome, the use of TRA might be associated with a decrease in in-hospital bleeding, while not increasing the risk of embolic or ischemic events compared to femoral access. Further studies are required to confirm these preliminary findings.

Efficacy and safety of sheathless guiding catheter for distal radial approach

ObjectivesThis study aimed to assess the efficacy and safety of a sheathless guiding system in patients who underwent percutaneous coronary intervention (PCI) with distal radial access (DRA). BackgroundHyperion™ Sheathless® guiding catheter (Asahi Intecc, Japan), one of the latest 6-Fr guiding systems for transradial PCI characterized by novel outer dilator, is considered to facilitate smooth insertion of the catheter to the artery and may contribute to further reduction of access site complications in DRA. MethodsBetween October 2018 and January 2023, 286 patients underwent PCI with a Hyperion™ Sheathless® guiding catheter with DRA at two Japanese hospitals. Procedural success, bleeding complications, and radial artery occlusion (RAO) detected by Doppler ultrasonography were assessed. ResultsMean age of the patients was 72.7 years, and 236 patients (82.5 %) were male. The target lesions were located in the right coronary artery, left anterior descending artery, left circumflex artery, and left main trunk in 81, 44, 50 patients, and 18 patients respectively. Procedural success rate was 99.7 % with no patients requiring conversion to conventional radial access. Two patients presented with a forearm hematoma equivalent to an Early Discharge After Transradial Stenting of Coronary Arteries Study hematoma classification Grade II and 23 with Grade I. No patient presented minor or major bleeding according to the Thrombolysis in Myocardial Infarction bleeding classification. RAO at 30-day follow-up was observed in 6 out of 277 patients (2.2 %). Conclusions6-Fr sheathless guiding system for PCI via DRA is feasible and associated with a low incidence of access site complications.

Abstract 17923: Acute Limb Ischemia Due to Dissection and Thrombosis of Anomalous Right Subclavian Artery: A Rare Complication of Trans-Radial PCI

Introduction: Right subclavian artery (RSA) normally originates from brachiocephalic artery, but in 0.4-1.8% of the general population it may arise directly from the aortic arch distal to the left subclavian artery. We present a case of acute limb ischemia due to dissection and thrombosis of anomalous right subclavian artery (ARSA) following transradial PCI. Case: A 60-year-old female presented with anterior STEMI. Coronary angiogram was performed via right transradial approach. During the procedure the aortic arch was noted to be exceedingly tortuous and coronary artery catheterization was difficult. Post-procedure, patient reported right arm pain. Her right hand was cold with bluish discoloration, nonpalpable right radial, ulnar and brachial artery pulses which prompted a CTA of the chest and right upper extremity. Imaging revealed ARSA with dissection and thrombosis of the RSA extending to mid-brachial artery and absent opacification of radial/ulnar arteries. The patient underwent right brachial artery cutdown, axillary artery thrombectomy and stenting of ARSA dissection. Post procedure, her pulses were palpable with triphasic doppler signals in the radial and ulnar artery. Four months later, surveillance CTA of chest showed patent stent without additional evidence of dissection (Figure 1). Discussion: ARSA is a rare anatomical variation of the origin of the RSA but also the most common abnormality of the aortic arch. ARSA anomaly is often asymptomatic, but approximately 10% is associated with tracheo-esophageal symptoms; the most frequent among them is dysphagia. Only 60% of coronary procedures using transradial approach are successful in the presence of ARSA. This congenital variant makes it difficult to approach the ascending aorta by the right transradial route, as it requires the catheter to curve back to reach the aortic root. Prompt recognition of this anomaly during the procedure and alternate access routes can avoid these severe complications.

Forearm Compartment Syndrome due to Transradial PCI in STEMI: Case Series of What Can Go Wrong and Lesson Learned

The trans-radial approach (TRA) is shown to be superior in reducing bleeding complications and associated with lower mortality with a similar procedural success rate in ST-Elevated Myocardial Infarction (STEMI) patients compared to the trans-femoral approach. Nevertheless, complications such as forearm hematoma and, in rare cases, acute compartment syndrome (ACS) may develop, thus requiring a prompt surgical procedure. Here, we present two successful emergency fasciotomy cases as ACS treatment following primary percutaneous coronary intervention after STEMI. Both patients show normal neurological and muscular function and normal artery flow on both hands afterward.

Cardiovascular Outcomes of Transulnar Versus Transradial Percutaneous Coronary Angiography and Intervention: A Regression Matched Meta-Analysis

Transradial access (TRA) and transulnar access (TUA) are in close vicinity, but TRA is the preferred intervention route. The cardiovascular outcomes and access site complications of TUA and TRA are understudied. Databases, including MEDLINE and Cochrane Central registry, were queried to find studies comparing safety outcomes of both procedures. The outcome of interest was in-hospital mortality and access site bleeding. Secondary outcomes were all-cause major adverse cardiovascular events, crossover rate, artery spasm, access site large hematoma, and access site complications between TUA and TRA. A random-effect model was used with regression to report unadjusted odds ratios (ORs) by limiting confounders and effect modifiers, using software STATA V.17. A total of 4,796 patients in 8 studies were included in our analysis (TUA=2,420 [50.4%] and TRA=2,376 [49.6%]). The average age was 61.3 and 60.1years and the patients predominantly male (69.2% vs 68.4%) for TUA and TRA, respectively. TUA had lower rates of local access site bleeding (OR 0.58, 95% confidence interval 0.34 to 0.97, I2=1.89%, p=0.04) but higher crossover rate (OR 1.80, 95% confidence interval 1.04 to 3.11, I2=75.37%, p=0.04) than did TRA. There was no difference in in-hospital mortality, all-cause major adverse cardiovascular events, arterial spasm, and large hematoma between both cohorts. Furthermore, there was no difference in procedural time, fluoroscopy time, and contrast volume used between TUA and TRA. TUA is a safer approach, associated with lower access site bleeding but higher crossover rates, than TRA. Further prospective studies are needed to evaluate the safety and long-term outcomes of both procedures.

Evidence-based practice to reduce limb complications after transradial PCI.

Evidence-based practice to reduce limb complications after transradial PCI.

Prevalence of Upper Extremity Function following Transradial Percutaneous Coronary Intervention

Background and Aim: The most frequently used technique for percutaneous coronary intervention (PCI) is the transradial approach (TRA). The purpose of the present study was to determine the prevalence of upper extremity function following transradial percutaneous coronary intervention. Patients and Methods: This cross-sectional study was conducted on 280 patients hospitalized for percutaneous coronary intervention in the Cardiology Department of MTI Lady Reading hospital, Peshawar and Lahore General Hospital from March 2022 to December 2022. Patients with palpable radial artery and non-occlusive flow confirmed by Doppler ultrasound examination were enrolled. Patients were divided into two groups: Group-I (underwent transradial approach (TRA)) and Group-II (treated with transfemoral PCI (TF-PCI). All the clinical outcomes were measured after 6 months follow-up. SPSS version 27 was used for data analysis. Results: Of the total 280 patients, the Group-I and Group-II had 220 and 60 patients respectively. During follow-up, the Group-I patients had higher incidence of upper extremity dysfunction (UED) (34.8%) than control or group-II patients (12.8%). Wrist extension, flexion, and elbow extension was the prime reasons for the upper extremity dysfunction. Smokers were three time at higher risk of developing upper extremity dysfunction. Conclusion: It has been observed that UED appears to occur twice as frequently in group-I as in group-II. Reduced rate of site complication and enhanced patient’s satisfaction has been found in group-I as compared to group-II. Keywords: Upper extremity function, percutaneous coronary intervention, transradial approach

Safety and efficacy of using Judkins left 3.5 guiding catheters for transradial right coronary artery intervention.

There is limited data about the use of a Judkins left (JL) 3.5 guiding catheter for routine transradial right coronary artery (RCA) percutaneous coronary intervention (PCI). This study investigated the safety and efficacy of JL3.5 for RCA PCI. Patients with acute coronary syndrome (ACS) who underwent transradial RCA PCI between November 2019 and November 2020 at the Second Hospital of Shandong University were included. The study retrospectively compared JL 3.5 vs. other routine guiding catheters (GCs), including Judkins right (JR) 4.0 and Amplatz (left). Logistic multivariable analysis was used to analyze the factors associated with transradial RCA PCI success rate, in-hospital complications, and extra support. The study included 311 patients: 136 in the routine GC group and 175 in the JL 3.5 group. There were no significant differences between the two groups regarding in-hospital complications, extra support technics, or success. The multivariable analyses showed that coronary chronic total occlusion (CTO) was negatively associated with intervention success (OR = 0.06, 95% CI: 0.016-0.248, p < 0.001) but positively with extra support (OR = 8.74, 95% CI: 1.518-50.293, p = 0.015). Tortuosity was associated with extra support (OR = 16.50, 95% CI: 3.324-81.589, p = 0.001). In the JL 3.5 group, the left ventricular ejection fraction (OR = 1.11, 95% CI: 1.03-1.20, p = 0.006), CTO (OR = 0.07, 95% CI: 0.008-0.515, p = 0.009), and tortuosity (OR = 0.17, 95% CI: 0.03-0.95, p = 0.043) were independently associated with intervention success. JL 3.5 appears to be as safe and effective as the JR 4.0 and Amplatz (left) catheters for RCA PCI. When using the JL 3.5 catheter for RCA PCI, heart function, CTO, and tortuosity should be considered.

Comparative analysis of percutaneous revascularization practice in the United States and the United Kingdom: Insights from the BMC2 and BCIS databases.

International registry comparisons provide insight into regional differences in clinical practice patterns, procedural outcomes, and general trends in population health and resource utilization in percutaneous coronary intervention (PCI). We sought to compare data from a state-wide PCI registry in the United States with a national registry from the United Kingdom (UK). We analyzed all PCI cases from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium and the British Cardiovascular Intervention Society registries from 2010 to 2017. Procedural characteristics and in-hospital outcomes were stratified by PCI indication. A total of 248,283 cases were performed in Michigan and 773,083 in the United Kingdom during the study period. The proportion of patients with a prior diagnosis of diabetes in Michigan was nearly double that in the United Kingdom (38.9% vs. 21.0%). PCI for ST-elevation myocardial infarction was more frequent in the UK (25% UK vs. 14.3% Michigan). Radial access increased in both registries, reaching 86.8% in the UnitedKingdom versus 45.1% in Michigan during the final study year. Mechanical support utilization was divergent, falling to 0.9% of cases in the United Kingdom and rising to 3.95% of cases in Michigan in 2017. Unadjusted crude mortality rates were similar in the two cohorts, with higher rates of post-PCI transfusion and other complications in the Michigan population. In a real-world comparison using PCI registries from the US and UK, notable findings include marked differences in the prevalence of diabetes and other comorbidities, a greater proportion of primary PCI with more robust adoption of transradial PCI in the United Kingdom, and divergent trends in mechanical support with increasing use in Michigan.

Meta-Analysis on the Safety and Efficacy of Transradial Approach in Chronic Total Occlusion Percutaneous Coronary Intervention

The aim of this study was to compare the efficacy and safety of transradial approach (TRA) in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with the efficacy and safety of transfemoral approach (TFA). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies (OS) reporting the outcomes of TRA versus TFA in CTO PCI. The primary end point was procedural success. Secondary end points included access-site complications, in-hospital adverse events, procedural efficacy outcomes, and 30-day all-cause mortality. A total of 28,754 CTO PCI cases from 19 studies were included (2 RCTs and 17 OS). The pooled mean J-CTO score is 2.3. The main analysis showed a trend toward a higher success rate for TRA (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.00 to 1.38), but this was not the case in the secondary analysis, which included only RCTs and OS with moderate risk of bias (OR 0.99, 95% CI 0.81 to 1.22). TRA was associated with significant reductions in access-site complications (OR 0.33, 95% CI 0.24 to 0.45) and major bleeding (OR 0.34, 95% CI 0.20 to 0.59), and a similar risk of other in-hospital adverse events and 30-day mortality (p >0.05) to that of TFA. Moreover, there was less fluoroscopy time (minutes) and contrast volume use (ml) in the transradial CTO PCI (mean difference: -6.19 [-10.98 to -1.40] and -22.14[-34.56 to -9.72], respectively). In conclusion, the transradial PCI in appropriate CTO lesions was associated with a lower incidence of access-site complications/major bleeding than was TFA and a similar other periprocedural complications rate, without compromising procedural success.

Radial artery pseudoaneurysm following transradial percutaneous coronary intervention

Radial artery pseudoaneurysm following transradial percutaneous coronary intervention

Upper Extremity Function Following Transradial Percutaneous Coronary Intervention: Results of the ARCUS Trail

Background: Regardless of the recent rise in the number of articles published on transradial access (TRA) for diagnostic coronary intervention and complications of the upper extremity may be underestimated. The aim of this study to investigate the prevalence of upper extremity disorder by comparing the transradial and transfemoral artery percutaneous coronary intervention (TR-PCI). Study Design: This was cross-sectional study and conducted in the Ayub teaching hospital Abbotabad, for six months July 2022 to December 2022. Materials and Methods: The total participants were 250 which included 200 TRA and 50 TFA participants and involving any type of cerdiointervention, thrombectomies for acute ischemic stroke, and carotid artery stents. The participants were selected by sampling technique were interviewed in the Khyber teaching hospital Peshawar. We analyzed dependent and independent variables. Data analysis statistically by SPSS 22 version. The upper extremity scores were analyzed using Chi-squared test. Results: There were total 250 participants which include 80%TRA and 20% TFA in this research. The majority of the participants in TRA were in the age group (59.2±6.7) years and in TFA group (55.5±7.1) years. The baseline characteristics of the total participants was no significant difference between transradial artery (TRA) and transradial femoral artery (TFA). During follow-up, Cochran's Q-test revealed a significant increase in UED in the intervention extremity of the TRA group p=0.003 and in the TFA group's right upper extremity (p=0.001). During follow-up, 1% TRA participants had RAO, which recanalized over time. Three weeks after the procedure, 10% of participants in the TRA group were referred to a hand specialist then TFA participants. Conclusion: Transradial arterial access (TRA) for percutaneous coronary artery intervention has been linked to lower access site complication rates and higher patient satisfaction when compared to transfemoral access (TFA) after 3 weeks follow up. Keywords: Transradial artery (TRA), Transfemoral artery (TFA), Rotational acetabular osteotomy (RAO).

Combination Therapy With Nicardipine and Isosorbide Dinitrate to Prevent Spasm in Transradial Percutaneous Coronary Intervention (from the NISTRA Multicenter Double-Blind Randomized Controlled Trial)

Verapamil and nitroglycerin are widely used to prevent radial artery spasm (RAS) during percutaneous cardiovascular procedures. However, these agents are not typically available in most African countries and consequently, isosorbide dinitrate is often the only spasmolytic treatment. Our aim was to compare the efficacy of isosorbide dinitrate alone versus isosorbide dinitrate used together with nicardipine to prevent RAS during transradial coronary procedures. This was a randomized controlled double-blind multicenter trial. Patients (n=1,523) were randomized to receive either a sole therapy of isosorbide dinitrate (n=760) or the combination of isosorbide dinitrate and nicardipine (n=763). Our primary end point was the occurrence of RAS; defined as considerable perceived hindrance of catheter advancement. Our secondary end points were severe RAS; defined as (1) severe arm pain, (2) the need for either morphine or midazolam treatment, and (3) necessity for crossover to the contralateral radial or femoral artery. RAS incidence was reduced with the combination therapy versus isosorbide dinitrate alone (15% vs 25%, p <0.001), with a number needed to treat of 10 patients. There was also a significant reduction in the incidence of the secondary end points with combination therapy (3.6% vs 8.2%, p <0.001), with a number needed to treat of 22 patients. This result was driven by reductions in both femoral crossover (0.5% vs 2.4%, p=0.003) and the use of morphine or midazolam injections (1.6% vs 3.5%, p=0.02) with combination therapy. In conclusion, we demonstrated the superiority of the combination therapy of isosorbide dinitrate and nicardipine over isosorbide dinitrate alone in reducing the incidence of RAS.

Abstract 14166: Predictors of Mortality in Patients With In-Hospital STEMI After Implementation of a Comprehensive STEMI Protocol

Introduction Patients who experience in-hospital ST-elevation myocardial infarction (iSTEMI) comprise a uniquely high-risk cohort owing to multiple factors including delays in diagnosis and treatment. Improvements in quality care metrics are needed to more fully understand the reasons for the poor outcomes, including high mortality, in this population. Methods Consecutive patients with iSTEMI who were treated with percutaneous coronary intervention (PCI) between 01/01/2011-07/15/2019 at a single, tertiary referral center were included. A comprehensive iSTEMI protocol (CSP) was implemented on 7/15/2014, incorporating: (1) nursing chest pain protocol, (2) improved electronic access to electrocardiographic studies, (3) checklist for initial triage and management, (4) 24/7/365 catheterization lab readiness, and (5) radial-first PCI approach. Process metrics and clinical outcomes were compared pre- and post-CSP implementation, and multivariable logistic regression analysis was performed to assess for predictors of in-hospital mortality. Results Among 125 iSTEMI patients, the post-CSP group (n=81) were younger with more active smoking and heart failure relative to the pre-CSP group (n=44). CSP implementation resulted in an increased use of trans-radial PCI (14.6 vs. 70.4%, p&lt;0.001), greater rate of ECG-to-first device activation &lt; 90 minutes (36.4% vs. 76.5%, p&lt;0.001), and decreased median ECG-to-first device activation time (114 vs. 64 minutes, p&lt;0.001). In-hospital mortality was numerically lower in the post-CSP group (18.2% vs. 9.9%, p=0.295). On multivariable analysis, the presence of shock was the only independent predictor of in-hospital mortality (OR: 26.05, 95% CI [5.5-211.6], p&lt;0.001). Conclusions The adoption of a CSP conferred marked improvements in key care metrics in patients with iSTEMI. Its use holds promise in reducing mortality among a vulnerable population at high risk of death owing to underlying shock.

Comparative Study of Radiation Exposure of Patients undergoing Transradial and Transfemoral Coronary Angiogram and Percutaneous Coronary Intervention

Introduction: Coronary artery disease (CAD) is now the leading cause of death worldwide. Percutaneous coronary interventions (PCIs) are an important group of technologies for the diagnosis and treatment of patients with CAD. PCI is usually performed using the transfemoral (TF) approach but the transradial (TR) approach has been increasingly used as an alternative to TF approach due to less vascular complications, earlier ambulation and improved patient comfort. Accurate assessment of radiation exposure during PCI is paramount important as radiation has many short and long term hazards. TR and TF route has distinct advantages and disadvantages. But in respect of radiation exposure of patients there are controversial evidence between TR and TF approach. Objective: To compare the radiation Exposure in patients with percutaneous coronary intervention by TR and TF approach. Materials and Methods: This prospective observational comparative study was conducted in the National Institute of Cardiovascular Diseases, Dhaka, from June 2015 to May 2016. A total of 200 patients were selected and categorized into two groups (Group I= Trans radial, n =100) and (Group II = Trans femoral, n= 100). Again divided into subgroups (group Ia, trans radial CAG = 70, group IIa, trans radial PCI =30) and (group IIa, trans femoral CAG =70, group IIb, trans femoral PCI = 30). Then different outcome variables were evaluated and compared. Results: Patient demographics were the same in both groups. Fluoroscopy time during TR and TFCAG and PCI was (4.4.±1.6 min vs 4.1±3.9 min, p=0.61) and (11.7±1.3 min vs 11.1±1.5 min, p=0.13) respectively. Regarding radiation dose during TR and TF coronary angiogram, Dose area product(DAP) were (2732±1195.5 mGym2vs 2434±488.0 mGym2, p=0.07&amp;) and Air Kerma (AK) were (307.6 ±112.2 mGy vs 283.7±48.5 mGy, p=.10) with statistically no significant difference of radiation dose (DAP and AK) between two groups. Utilization of Contrast volume during TR and TF angiogram (64.8±8.9 vs 68.2±7.5, p=0.01) were less in trans radial group. Also Utilization of Contrast volume in TR-PCI and TF- PCI (168.0±13.0 vs 177.7±19.9 ml ,p=0.03) were less in trans radial PCI. Conclusion: The basis of the results, no significant differences were found in patient of radiation dose in both TR and TF group. Furthermore utilization of contrast volume was lower in trans-radial CAG and PCI. Trans radial CAG and PCI can be performed with the same safety as for the trans femoral approach. Medicine Today 2022 Vol.34(2): 130-135

Upper Extremity Function following Transradial Percutaneous Coronary Intervention: Results of the ARCUS Trial.

Objectives To determine the incidence of upper extremity dysfunction (UED), after a transradial percutaneous coronary intervention (TR-PCI). Background Transradial approach (TRA) is the preferred approach for coronary interventions. However, upper extremity complications may be underreported. Methods The ARCUS was designed as a prospective cohort study, including 502 consecutive patients admitted for PCI. Patients treated with transfemoral PCI (TF-PCI) acted as a control group. A composite score of physical examinations and questionnaires was used for determining UED. Clinical outcomes were monitored during six months of follow-up, with its primary endpoint at two weeks. Results A total of 440 TR-PCI and 62 control patients were included. Complete case analysis (n = 330) at 2 weeks of follow-up showed that UED in the TR-PCI group was significantly higher than that in the TF-PCI group: 32.7% versus 13.9%, respectively (p=0.04). The three impaired variables most contributing to UED were impaired elbow extension, wrist flexion, and extension. Multivariate logistic regression showed that smokers were almost three times more likely to develop UED. Conclusions This study demonstrates that UED seems to occur two times more in TR-PCI than in TF-PCI at 2 weeks of follow-up. However, no significant long-term difference or difference between the intervention arm and the contralateral arm was found at all timepoints.