Use Of Radial Access Research Articles

Vascular complications associated with intraaortic balloon pump supported percutaneous coronary intervention (PCI) and clinical outcomes from the British Cardiovascular Intervention Society National PCI Database.

The impact of a vascular complication (VC) in the setting of intraaortic balloon pump (IABP) supported PCI on clinical outcomes is unclear. Using data from the BCIS National PCI Database, multivariate logistic regression was used to identify independent predictors of a VC. Propensity scoring was used to quantify the association between a VC and outcomes. Between 2007 and 2014, 9,970 PCIs in England and Wales were supported by IABP (1.6% of total PCI), with 224 femoral VCs (2.3%). Annualized rates of a VC reduced as the use of radial access for PCI increased. The independent predictors of a VC included a procedural complication (odds ratio [OR] 2.9, p < .001), female sex (OR 2.3, p < .001), PCI for stable angina (OR 3.47, p=.028), and use of a glycoprotein inhibitor (OR 1.46 [1.1:2.5], p=.04), with a lower likelihood of a VC when radial access was used for PCI (OR 0.48, p=.008). A VC was associated with a higher likelihood of transfusion (OR 5.7 [3.5:9.2], p < .0001), acute kidney injury (OR 2.6 [1.2:6.1], p=.027), and periprocedural MI (OR 3.2 [1.5:6.7], p=.002) but not with adjusted mortality at discharge (OR 1.2 [0.8:1.7], p=.394) or 12-months (OR 1.1 [0.76:1.56], p=.639). In sensitivity analyses, there was a trend towards higher mortality in patients experiencing a VC who underwent PCI for stable angina (OR 4.1 [1.0:16.4], p value for interaction .069). Discussion and Conclusions Although in-hospital morbidity was observed to be adversely affected by occurrence of a VC during IABP-supported PCI, in-hospital and 1-year survival were similar between groups.

Efficacy of Rotational Atherectomy Followed by Drug-coated Balloon Angioplasty for the Treatment of Femoropopliteal Lesions—Comparison with Sole Drug–coated Balloon Revascularization: Two-year Outcomes

We aimed to evaluate the results of the combined use of rotational atherectomy (RA) followed by drug-coated balloon (DCB) treatment against DCB angioplasty alone in patients who had significantly calcified and symptomatic femoropopliteal peripheral arterial disease. Patients presented to the clinic with symptoms of chronic limb ischemia of femoropopliteal segment such as moderate or severe claudication and rest pain, who received endovascular therapy between January 2016 and January 2018 in our hospital comprised the study cohort and investigated, retrospectively. Patients with minor or major tissue loss were excluded from the study. We evaluated the effect of RA system followed by DCB with DCB alone in 121 patients and a total of 226 significantly calcified and symptomatic femoropopliteal lesions. Fifty-eight patients and 112 (49.5%) lesions were treated with RA+DCB, whereas 63 patients and 114 (50.5%) lesions were treated with DCB only. The mean age was 61.2±9.7years. Primary patency is evaluated with duplex ultrasound/angiography at 6, 12, and 24months and with angiography on 12 and 24months. Patients were followed up for 24months to assign clinically driven target lesion revascularization (TLR). Overall survival rates were 96.5% (56/58) in RA+DCB group and 93.6% (59/63) in DCB alone group both at one-year and two-year follow-up. Amputation-free survival rates of RA+DCB and DCB-only groups are 96.5% (56/58) to 87.3% (55/63) at one year, and 94.8% (55/58) to 82.5% (52/63) at two years, respectively. Baseline characteristics of groups were similar. The lesions were longer in the RA+DCB group than the DCB alone group (14.4±5.2cm vs. 10.2±3.1cm; P=0.05). The technical success rate in the RA+DCB group was superior to that of DCB-only group (95.4% vs. 84.8%, P=0.006). The 12-month and 24-month patency rates with angiography in the RA-DCB group were similar to those in the DCB-only group (85.7% vs. 74.6% and 73.2% vs. 62.7%, respectively). The rates of bailout stenting were significantly lower among patients treated with RA+DCB (n=3; 5.1% vs. n=13; 20.6%, P<0.001). The rates of flow-limiting dissections and vessel recoils after procedures were significantly in RA+DCB group (n=2; 3.4% vs. n=8; 12.6%, P<0.001) than DCB only (n=1; 1.7% vs. n=4; 6.3%, P<0.002). The freedom from TLR rate was significantly increased in the RA+DCB group at 12months (95.2% vs. 76.3%, P=0.002) and 24months (93.4% vs. 63.7%, P=0.002). The mean ankle brachial index at discharge in the RA-DCB group improved by 0.35±0.24, and in the DCB-only group, it was 0.30±0.23 (P=0.683). Combined use of RA and DCB treatment is an effective, safe, and durable method for the treatment of the complex femoropopliteal lesions. Combination of RA and DCB angioplasty reveals increased technical success, fewer flow-limiting dissections, significantly reduced TLR, and bailout stenting rates compared with sole DCB angioplasty.

Short-and-Long-Term Outcomes after Coronary Rotational Atherectomy in Patients Treated with Trans-Catheter Aortic Valve Implantation.

Background. Coronary artery disease (CAD) is a common finding among patients undergoing trans-catheter aortic valve implantation (TAVI), who often present severely calcified coronary lesions. Evidence is scarce about the use of rotational atherectomy (RA) in this setting, in particular regarding long-term outcome. Methods. RA was performed on severely calcified coronary lesions concomitant with TAVI in a consecutive series of patients treated between 2010 and 2020. Immediate and long-term clinical outcomes are reported. Results. A concomitant CAD (coronary stenosis visually > 50%) was observed in 402/845 (47.6%) consecutive patients undergoing TAVI at the University Hospital of Verona. Angioplasty was performed in 104 patients (12.3%). Among these, 19 patients (18.3%, 20 coronary arteries), were treated with RA after TAVI: 10 after implantation of a balloon-expandable trans-catheter valve and 9 after a self-expandable valve. All procedures were successful. Hypotension occurred in 3 patients (15.8%), with rapid recovery after the procedure; CI-AKI (contrast-induced acute kidney injury) in 3 patients (15.8%), of which two recovered within discharge. At a median follow-up of 21.5 months (Q1–3: 6–36) event free survival was 83.3%. Only one patient suffered a target vessel failure >2 years after RA. Neither stroke nor peri-procedural infarctions were detected. Conclusions. RA concomitant with TAVI was feasible and safe in patients treated with implantation of either self-expandable, or balloon-expandable trans-catheter aortic valves. Long-term clinical events related to the coronary procedure were extremely infrequent and the survival rate at median follow-up of 21.5 months was 83.3%.

Efficacy of Low-Pressure Inflation of Oversized Drug-Coated Balloon for Coronary Artery Disease.

Objectives This study sought to assess the efficacy of oversized drug-coated balloon (DCB) inflation at low pressure for the prevention of acute dissections and late restenosis. Background The major limitation of DCB coronary angioplasty is the occurrence of severe dissection after inflation of DCB. Methods Between 2014 and 2018, 273 consecutive patients were retrospectively studied. 191 lesions (154 patients) treated by oversized DCB inflation at low pressure (<4 atm, 2.4 ± 1.2 atm, DCB/artery ratio 1.14 ± 0.22; LP group) were compared with 135 lesions (119 patients) treated by the standard DCB technique (7.1 ± 2.2 atm, DCB/artery ratio 1.03 ± 0.16; SP group). Results Although the lesions in the LP group were more complex than those in the SP group (smaller reference diameter (2.38 mm vs. 2.57 mm, P=0.011), longer lesions (11.7 mm vs. 10.5 mm, P=0.10), and more frequent use of rotational atherectomy (45.0% vs. 28.1%, P=0.003), there was no significant difference in the NHLBI type of dissections between the two groups (11.5%, 12.0%, 5.2% vs. 12.6%, 12.6%, 2.2% in type A, B, and C, P=0.61), and no bailout stenting was required. In 125 well-matched lesion pairs after propensity score analysis, the cumulative incidence of target lesion revascularization at 3 years was 4.5% vs. 7.0%, respectively (P=0.60). Late lumen loss (−0.00 mm vs. −0.01 mm, P=0.94) and restenosis rates (7.4% vs. 7.1%, P=1.0) were similar in both of the groups. Conclusion The application of oversized DCB at low pressure is effective and feasible for preventing late restenosis comparative to the standard technique of DCB.

Novel combined topical gel of lidocaine–verapamil–nitroglycerin can dilate the radial artery and reduce radial pain during trans-radial angioplasty

IntroductionRadial approach for coronary angioplasty is accepted by many specialists in medical centers around the world. The use of radial access is associated with fewer vascular complications and the same success rate in comparison with traditional femoral access. Radial artery spasm is one of the main concerns in this method. The small size of the radial artery and high density of alpha-1 adrenergic receptors in this artery can accelerate the spasm. The objects of this study were to evaluate whether the combined topical gel of lidocaine–verapamil–nitroglycerin could dilate the radial artery and reduce patient pain and sympathetic response during radial puncture.MethodsPatients undergoing elective trans-radial angioplasty were randomized to either placebo or therapeutic gel group in single-center, double-blind study. Placebo or therapeutic gel applied 1 cm proximal to the radial styloid process. Radial artery size was measured by ultrasound. Radial pain was reported by the visual analog scale (VAS) and the sympathetic response was assessed by changes in systolic (SBP) and diastolic blood pressure (DBP) and heart rate (HR). The incidence of spasm was defined by the radial artery spasm score.Results60 patients (30 patients in each group) participated in this study. A significant increase in the size of the radial artery was observed in the group receiving therapeutic gel compared to the placebo group (mean diameter, mm: 2.95 ± 0.48 vs. 2.54 ± 0.43, p = 0.001; area, cm2: 0.07 vs. 0.05, p = 0.001). During radial puncture, the radial pain intensity was significantly decreased in patients receiving therapeutic gel (4 (1–5) vs. 2 (1–2), p = 0.003). Radial artery spasm didn’t happen in any group.ConclusionBased on our results, Pre-procedural administration of combined topical gel of verapamil-nitroglycerin-lidocaine significantly increases the size of the radial artery and effectively reduces the radial pain during radial puncture in patients undergoing trans-radial angioplasty.

Temporal Trends in Patient Risk Profile and Clinical Outcomes Following Percutaneous Coronary Intervention

BackgroundPatient selection and procedural characteristics continue to evolve in percutaneous coronary intervention (PCI). Australian data on long-term trends and outcomes are limited. This study aimed to identify long-term temporal trends in patient characteristics and outcomes in a large Australian PCI cohort. MethodsWe analysed data from 41,146 PCI procedures included in the multi-centre Melbourne Interventional Group registry to determine trends in patient characteristics, procedural practices and outcomes from 2005 to 2018. Procedures were divided into 2-yearly periods for trends analysis. ResultsTemporal trends in patient characteristics showed increases in age, proportion of males, rates of obesity, insulin-requiring diabetes mellitus, current smoking, obstructive sleep apnoea and prior PCI (all Ptrend < 0.01). Increases in the proportion of ST-elevation myocardial infarction, cardiogenic shock or out-of-hospital cardiac arrest (OHCA) were observed, and CathPCI National Cardiovascular Data Registry mortality risk scores increased over time (all Ptrend < 0.01). Use of radial access and drug-eluting stents increased, and lesions treated were more frequently ostial, left main or ACC/AHA type B2/C in recent years (all Ptrend < 0.01). In contrast, major bleeding and no reflow rates declined, however 30-day mortality, 12-month mortality and rates of stroke increased (all Ptrend < 0.01). Rates of vascular complications and 30-day target vessel revascularisation remained similar. In multivariable analysis, 2-yearly time periods were not independently associated with risk of 30-day mortality or 30-day MACE. ConclusionsOver the last 14 years, Australian PCI procedural complexity and patient risk profiles have increased. Higher mortality rates appear to relate to increased patient risk profile rather than procedural factors.

Early Implementation of Veno-Venous Hemofiltration and Use of Rotational Atherectomy in a Patient with ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: A Case Report

Background: We report the case of a patient with Cardiogenic Shock (CS) in a course of acute Right Ventricular (RV) Myocardial Infarction (MI) following occlusion of the proximal Right Coronary Artery (RCA). Our case highlights the use of Continuous Veno-Venous Hemofiltration (CVVH) as a novel routine treatment option for Acute Kidney Injury (AKI) in the setting of CS and the use of Rotational Atherectomy (RA) in patients with MI. This finding has important implications for patient treatment plans in the future. Case summary: The patient was treated with the primary Percutaneous Coronary Intervention (PCI) using three drug-eluting stents in the main RCA and strong right ventricular branch. RA was used to facilitate lesion expansion and stent implantation because of massive calcification. Six hours after the procedure, AKI manifested as anuria, required CVVH for four days until hemodynamic stabilization and restoration of diuresis. Six weeks after MI, the patient underwent coronary artery bypass surgery due to advanced coronary disease in the left coronary artery. There were no peri-or post-procedural complications, and at the end of a cardiac rehabilitation program, the patient was discharged. Conclusion: RA of calcifications in the infarct-related artery may remain the only option for delivering a stent, and thus maintain patency of the supplied coronary vessel, which is essential for hemodynamically unstable patients. RA can be a safe option if extreme precautions like using small burr sizes and low speeds are used. CVVH may be the first-choice option in patients otherwise treated with RV mechanical circulatory support.

Comparison of Radial and Femoral Percutaneous Coronary Intervention.

The use of radial access for percutaneous coronary intervention is increasing in Nepal. However, there is limited study on the comparison of radial and femoral access in Nepal. This is the study comparing net adverse clinical events of radial with femoral access for intervention. This prospective study was conducted at Shahid Gangalal National Heart Center from January 2014 to June 2015 among 849 participations who underwent percutaneous coronary interventions, and 418 radial interventions were compared with 418 femoral interventions. A comparison was done in terms of 30- day rate of net adverse clinical events defined as the composite of death, myocardial infarction, stroke, target lesion revascularization and major bleeding. Incidence of net adverse clinical events was significantly lower in radial compared to femoral approach 18(4.30%) vs. 51 (12.2%), p= <0.001). Mortality observed in the radial approach was significantly lower (p=<0.001) compared to femoral. Procedure success was not significantly different p=0.629. The trans-radial approach had significantly higher crossover rate (p=0.001). Observed vascular access site complications (p=0.026) and hospital stay (p=<0.0001) were lower in the radial group. Radiation exposure measured by fluoroscopy exposure time was not significantly different between the two groups (p=0.290). Radial access is associated with a lower rate of net adverse clinical events at 30 days compared to femoral access. Radial access is safer and equally effective compared to femoral access in the context of Nepal.

Percutaneous coronary intervention in octogenarians – a real-world experience from a large non-surgical centre in the UK

Abstract Background With an ageing population, the demand for percutaneous coronary intervention (PCI) in the elderly is on the rise. Technical advances, better peri-procedural pharmacology and greater operator experience have led to improved outcomes after PCI. Octogenarians as a group, however, have been underrepresented in randomised clinical trials of coronary revascularisation. Observational studies therefore provide useful insights into the safety and efficacy of PCI in this patient population in a real-world clinical practice. Aim The aim of this study was to examine the trends in patient characteristics and clinical outcomes after PCI in octogenarians over a 10-year period in a large non-surgical PCI centre and to determine the predictors of mortality in this high risk patient cohort. Methods A total of 782 consecutive octogenarians were identified from a prospectively collected database of all patients undergoing PCI at our centre between 2007 and 2016. We analysed the characteristics of the cohort with respect to all-cause in-hospital and 1-year mortality, in-hospital Major Adverse Cardiovascular Events (MACE) rates, complexity of coronary artery disease and major comorbidities. The patients were stratified into three chronological tertiles to assess differences over time. A multivariate analysis was performed to determine predictors of mortality. Results The number of octogenarians undergoing PCI was found to have increased nearly ten-fold, from 19 in 2007 to 178 in 2016. Despite this, there were no significant differences in adverse clinical outcomes. A greater use of radial access was noted (p&amp;lt;0.0001). Increasing age, the presence of cardiogenic shock, severe left ventricular impairment, peripheral vascular disease, diabetes mellitus and low creatinine clearance were identified as independent predictors of mortality after PCI (Table 1). Conclusion PCI in octogenarians is a safe and effective revascularisation option, the use of which is increasing in the real-world clinical practice. Future PCI randomised clinical trials should include this challenging cohort to enhance the evidence base. Funding Acknowledgement Type of funding source: None

Cardiogenic shock and radial access in patients with an acute ST elevation myocardial infarction

Abstract Background Cardiogenic shock (CS) in patients (pts) with acute ST elevation myocardial infarction (STEMI) is the strongest predictor of hospital mortality. Radial in contrast to femoral access in STEMI pts might be associated with a lower mortality. However, little is known on radial access in CS pts. Methods We retrospectively analysed all STEMI pts between 2009 and 2015 who sufferend from CS and who were included into the ALKK PCI registry. Pts treated via a radial access were compared to those treated via a femoral access. Results Between 2009 and 2015 23796 STEMI pts were included in the registry. 1763 (7.4%) of pts were in CS. The proportion of radial access was 6.6%: in 2009 4.0% and in 2015 19.6%, p for trend &amp;lt;0.0001 with a strong variation between the participating centres (0% to 37%). Conclusions Radial access was only used in 6.6% of STEMI pts presenting in CS. However, a significant increase in the use of radial access was observed over time (2009: 4%, 2015 19.6%, p&amp;lt;0.001), with a great variance in its use between the participating hospitals. Despite similar pt characteristics the difference in hospital mortality according to access site has to be interpretated with caution. Funding Acknowledgement Type of funding source: None

Association between bleeding avoidance and outcomes: Japanese coronary intervention registry report in collaboration with ACC-NCDR

Abstract Background Bleeding avoidance strategies (BASs) such as radial access and closure device use for femoral access have been increasingly being implemented but its association with bleeding events among East Asians with reported higher bleeding risk remains unclear. Purpose To demonstrate the performance of the National Cardiovascular Data Registry (NCDR) CathPCI bleeding risk score, 10-year trend of BAS utilization rate and its relationship with observed bleeding within a Japanese PCI quality improvement initiative established in collaboration with the American College of Cardiology-NCDR. Methods A cohort of 19,656 consecutive Japanese patients undergoing PCI was included. First, we assessed the discrimination of the validated NCDR CathPCI bleeding score in the study population. We then assessed temporal trends in the implementation of BAS for PCI and calculated the observed versus expected bleeding rate [O/E ratio] in four time periods (T1: 2008–2011, T2: 2012–2013, T3: 2014–2015, T4: 2016–2018). In multivariable logistic models, we calculated the correlation between BAS use and bleeding rates in individual time frames. Results During the study period, the application of BAS increased from 42.2% (T1) to 90.3% (T4) and observed bleeding rate declined from 10.2% (T1) to 7.3% (T4). The discrimination of the NCDR CathPCI bleeding risk score was acceptable in the Japanese population (c-statistics 0.760–0.845). The calculated O/E ratio declined from 1.34 (T1) to 1.14 (T4). The use of radial access and vascular closure devices after transfemoral access use was associated with 46.7–56.6% and 25.6–47.5% bleeding reduction rates, respectively. The correlation between greater BAS adoption and the decline in bleeding rates was greater among elective cases than urgent/emergent cases. Conclusion Our findings support the positive impact of the adoption of BAS in Japanese patients undergoing PCI. This study demonstrates the value of common data standards and risk adjustment developed in registries to support high quality care. Trends in BAS use &amp; Bleeding Rate Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science

Combination of fondaparinux with radial access is associated with low rates of in-hospital MACE and major bleeding events in patients with acute coronary syndrome

Abstract Background Fondaparinux and radial access use were associated with lower rates of cardiovascular events in patients with acute coronary syndrome (ACS). The benefits of combining these two treatment strategies are not well described. Methods In 1167 consecutive patients admitted for ACS who underwent an invasive treatment strategy, data on the primary combined endpoint – major bleeding (OASIS-5 criteria) and major adverse cardiovascular events (MACE) – were prospectively collected for the hospitalization period and compared according to anticoagulation regimen (Fondaparinux or Enoxaparin) and arterial access site (femoral vs radial). Results Overall, mean age was 65±12 years, 57% were male, 32% had diabetes and 17% presented with ST segment elevation myocardial infarction (STEMI). Fondaparinux and radial access were used in 756 (65%) and 554 (48%) patients, respectively. An endpoint occurred in 112 patients (9.6%) – MACE in 79 (6.8%) and major bleeding in 42 (3.6%). Endpoint was 3.4% in Fondaparinux plus radial access, 9.9% for Fondaparinux plus femoral access, 8% Enoxaparin plus radial access and 19.9% in enoxaparin plus femoral access (p&amp;lt;0.001). Fondaparinux use was associated with a significant reduction in the rate of the primary endpoint in both radial (RR 0.42 CI 95% 0.19–0.90; p&amp;lt;0.05) and femoral (RR 0.5 CI 95% 0.33–0.79; p&amp;lt;0.001) access patients. The primary endpoint was also reduced in the radial access patients regardless if Fondaparinux (RR 0.33 CI 95% 0.18–0.62; p&amp;lt;0.001) or Enoxaparin (RR 0.40 CI 95% 0.21–0.74; p&amp;lt;0.01) was used. In multivariable analysis (adjusted for age, sex, diabetes, heart failure, previous CABG, creatinine, ejection fraction, haemoglobin, STEMI, and hospital length of stay) Fondaparinux (OR 0.50 CI 95% 0.31–0.79; p&amp;lt;0.01) and radial access (OR 0.39 CI 95% 0.23–0.66; p&amp;lt;0.001) where both independently associated with lower rates of primary endpoint. There was no interaction between both variables (p=0.83). Conclusion The use of fondaparinux plus radial access was associated with the lowest rates of MACE and major bleeding when compared with either strategy alone and therefore, is a very attractive approach to be used routinely in patients with ACS. Funding Acknowledgement Type of funding source: None

Transradial access for thrombectomy in acute stroke: A systematic review and meta-analysis

ObjectiveTransradial access has recently been gaining more popularity in various neurointerventional procedures. To this day, a systematic review and meta-analysis investigating the outcomes of transradial access for mechanical thrombectomy in acute stroke have not been performed. MethodsPubMed, Embase, and Scopus databases were systematically searched. Studies published in the last ten years reporting on the use of transradial access for acute stroke intervention were eligible. The DerSimonian–Laird random effects model was used, and the primary endpoints included puncture to reperfusion time, end mRS, TICI reperfusion, mortality, and access site complications. ResultsA total of 515 records were identified. Fourteen observational studies reported on the use of radial access for thrombectomy, with 10 of these studies (n = 309) included in the meta-analysis. Mean puncture to reperfusion time associated with the transradial access was 46.864 ± 6.601 min. Favorable end mRS of ≤ 2 was reported in 37.1 % ± 7.3 % of patients. TICI ≥ 2B was achieved in 84.6 % ± 3.4 % of patients. All-cause mortality was observed in 9.3 % ± 4.8 % of patients. Transradial access had low complications with only 1.4 % ± 0.7 % of stroke cases. When the transradial studies were compared to the contemporary randomized clinical trials using the standard transfemoral access, no significant differences were found in all of these primary outcomes. ConclusionThis meta-analysis study demonstrates that transradial access for mechanical thrombectomy in acute stroke may be a feasible and safe alternative. Future prospective studies are needed to validate these results.

Comparison of acute kidney injury with radial vs. femoral access for patients undergoing coronary catheterization: An updated meta-analysis of 46,816 patients.

Trans-radial access for percutaneous coronary intervention or angiography has gained popularity amongst interventional cardiologists. Radial access is also thought to reduce the incidence of acute kidney injury (AKI) in the immediate post-operative period. The purpose of the present study was to perform a comprehensive updated systematic review and meta-analysis comparing the incidence of AKI following the radial vs. femoral route of coronary catheterization. An electronic literature search of the PubMed, BioMed Central, Scopus, Cochrane Central Register of Controlled Trials and Google Scholar databases up to 1st January 2020 was performed. A total of 14 studies were included, 2 of which were randomized controlled trials (RCTs), and 6 studies utilized propensity score matching. Comparison of the data of 21,479 patients in the radial group and 25,337 patients in the femoral group indicated a reduced incidence of AKI with the radial route [odds ratio (OR):0.66, 95% CI: 0.54-0.81, P<0.0001, I2=74%]. Similar results were obtained with sub-group analyses for RCTs (OR: 0.87, 95% CI: 0.77-0.98, P=0.02, I2=0%), retrospective studies (OR: 0.57, 95% CI: 0.36-0.90, P=0.02, I2=86%) and propensity score-matched studies (OR: 0.63, 95% CI: 0.48-0.83, P=0.0009, I2=45%). Multivariable-adjusted ORs of AKI for the radial vs. femoral route were extracted from non-RCTs and pooled for a meta-analysis, which also demonstrated similar results (OR: 0.70, 95% CI: 0.57-0.88, P=0.002, I2=70%). Within the limitations of the study, the present results indicate that, as compared to femoral access, the use of trans-radial access for coronary catheterization is associated with a significantly reduced incidence of AKI. A reduction of AKI by ~34% may be expected with the use of radial access.

Sex Differences in Radial Access for Percutaneous Coronary Intervention in Acute Coronary Syndrome Are Independent of Body Size

Radial access reduces bleeding and is associated with improved survival following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). We evaluated the association between sex, markers of body size and radial access, and its impact on bleeding and mortality following PCI for ACS. From 2013-2016, consecutive patients treated with PCI for ACS across 30 centres were prospectively entered into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariate logistic regression was used to analyse predictors of the primary endpoint of PCI access site and secondary endpoints of major bleeding and mortality. A total of 16,330 ACS patients (40.9% ST elevation myocardial infarction [STEMI]) underwent PCI (23.5% female). Women were older with significantly lower weight and height compared to men. Women had lower radial access use (41.6% versus 51.0%, p<0.001), with higher 30-day major bleeding (2.4% versus 1.4%, p<0.001) and mortality (4.4% versus 3.4%, p<0.001) than men. Female sex independently predicted lower radial access use (OR 0.75, 95% CI 0.68-0.83, p<0.001) while body surface area, height and body mass index did not. Female sex was an independent predictor of higher 30-day major bleeding (OR 1.38, 95% CI 1.05-1.81, p=0.019) and mortality in STEMI patients (OR 1.31, 95% CI 1.01-1.70. p=0.039). Radial access was associated with lower major bleeding (OR 0.70, 95% CI 0.53-0.91, p=0.009) and mortality (OR 0.60, 95% CI 0.48-0.75, p<0.001). Radial access, despite being associated with lower bleeding and mortality, was used less frequently in women, independent of co-morbidities and objective markers of body size.

Adoption of same day discharge following elective left main stem percutaneous coronary intervention

BackgroundThis study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI. MethodsWe analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality. ResultsSDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30–1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17–1.41) and those requiring ON stay (OR 0.58 95%CI 0.25–1.34). ConclusionsWe did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.

Use of Rotational Atherectomy in Patients With LV Systolic Dysfunction “Works Better Where it Matters the Most”

Use of Rotational Atherectomy in Patients With LV Systolic Dysfunction “Works Better Where it Matters the Most”

Clinical outcomes of PCI with rotational atherectomy: the European multicentre Euro4C registry.

Despite the use of rotational atherectomy (RA) in interventional cardiology for over three decades, data regarding factors affecting the clinical outcomes of the RA procedure remain scarce. The aim of the present study was to describe the contemporary use and outcomes of RA in Europe. We conducted, for the first time, a prospective international registry in 8 European countries and 19 centres and included patients treated by percutaneous coronary intervention with RA. Between October 2016 and July 2018, 966 patients with complete data were recruited. Mean age was 74.5 years, 72.4% were male and 43.4% had diabetes. Initial presentation was an acute coronary syndrome (ACS) for 25.1% of the patients. Clinical success was observed in 91.9% of the procedures. The rate of in-hospital major adverse cardiac events (MACE) - defined as cardiovascular death, myocardial infarction, target lesion revascularisation, stroke and coronary artery bypass grafting - was 4.7%. At one year, the rate of MACE was 13.2%. Factors independently associated with the occurrence of MACE at one year were female gender, renal failure, ACS at admission, depressed left ventricular ejection fraction (LVEF) and presence of a significant left main coronary artery (LMCA) lesion. Despite the high level of complexity of the studied population, RA turned out to be an effective procedure with a low rate of in-hospital complications and demonstrated good immediate and midterm results.

The impact of coronary perforation in percutaneous interventions involving the left main stem coronary artery in the United Kingdom 2007-2014: Insights from the British Cardiovascular Intervention Society database.

Percutaneous coronary intervention (PCI) is increasingly utilized for treatment of coronary disease involving the unprotected left main stem (ULMS). However, no studies to date have examined the outcomes of such interventions when complicated by coronary perforation (CP). Using the British Cardiovascular Intervention society (BCIS) database, data were analyzed on all ULMS-PCI procedures complicated by CP in England and Wales between 2007 and 2014. Multivariate logistic regressions were used to identify predictors of ULMS CP and to evaluate the association between this complication and outcomes. During 10,373 ULMS-PCI procedures, CP occurred more frequently than in non-ULMS-PCI (0.9 vs. 0.4%, p < .001) with a stable annual incidence. Covariates associated with CP included number of stents used, female gender, use of rotational atherectomy and chronic total occlusion (CTO) intervention. Adjusted odds of adverse outcomes for ULMS-PCI complicated by CP were higher for peri-procedural complications including cardiogenic shock, tamponade, side-branch loss, DC cardioversion, in-hospital major bleeding, transfusion requirement, and peri-procedural myocardial infarction. There were also significantly increased odds for in-hospital major adverse cardiac events (MACCE, OR 8.961, 95% CI [4.902-16.383]) and 30-day mortality (OR 5.301, 95% CI [2.741-10.251]). CP is an infrequent event during ULMS-PCI and is predicted by female gender, rotational atherectomy, CTO interventions or number of stents used. CP was associated with significantly higher odds of mortality and morbidity, but at rates similar to previously published all-comer PCI complicated by CP.

Outcomes of Impella-supported high-risk nonemergent percutaneous coronary intervention in a large single-center registry.

We aimed to evaluate the early and one-year outcomes of Impella-supported high-risk nonemergent percutaneous coronary intervention (PCI). The evidence for the use of mechanical circulatory support (MCS) devices in high-risk nonemergent PCI is limited and nonconclusive. We performed a single-center retrospective study including all patients who underwent high-risk nonemergent PCI supported by Impella 2.5/CP at our institution between January 2009 and June 2018. This patient population was propensity score matched with subjects undergoing PCI with no MCS. The primary endpoint was major adverse cardiac events (MACE: all-cause death, myocardial infarction [MI], and target lesion revascularization) at one-year follow-up. Two-hundred fifty patients undergoing Impella-supported nonemergent PCI were matched to 250 controls. The two groups were well balanced in terms of clinical and angiographic characteristics. Left main PCI was performed more frequently among Impella-supported patients (26% vs. 11%, p < .001), who also had numerically higher prevalence of rotational atherectomy use (44% vs. 37%, p = .10) and a higher number of vessels treated (1.8 ± 0.8 vs. 1.3 ± 0.6, p < .001), compared with controls. Impella-supported patients suffered a higher incidence of periprocedural MI (14.0% vs. 6.4%, p = .005), major bleeding (6.8% vs. 2.8%, p = .04), and need for blood transfusions (11.2% vs. 4.8%, p = .008). However, at one-year follow-up there were no differences in the rates of MACE (31.2% vs. 27.4%, p = .78) or any of its individual components between Impella-supported patients and controls. Although Impella-supported patients suffer a higher incidence of periprocedural adverse events (partially linked to more aggressive PCI), the incidence of one-year MACE was similar between the Impella and control group.