Use Of Radial Access Research Articles

SHOULD WE BE CONCERNED ABOUT USING INTRAVASCULAR LITHOTRIPSY ON THE LEFT MAIN? INSIGHT FROM ROLLING STONE RETROSPECTIVE REGISTRY

Abstract Background The use of rotational atherectomy is currently prevalent in the treatment of left main coronary artery lesions. However, it often necessitates the use of a large burr to achieve adequate debulking, which, in turn, demands highly experienced operators. Intravascular lithotripsy (IVL) is a promising, user–friendly and increasingly employed technique for calcific plaque modification before percutaneous coronary intervention. Although in many cath labs it is now routinely used to treat lesions of the three main coronary arteries, there are still concerns regarding its use in the left main, primarily due to prolonged inflations required for its optimal efficacy. Methods We conducted a retrospective analysis using data from the multicenter retrospective Rolling Stone registry. The analysis involved data from 474 patients, with a stratification between IVL procedures involving left main coronary artery (46 patients) and those that did not (428 patients). The primary effectiveness endpoint was procedural success (defined as achieving residual stenosis < 20% with TIMI III flow); secondary endpoints included the rate of procedural related adverse events, in hospital adverse events and MACE rate at 30 days and 6 months. Results Between April 2018 and January 2023, a total of 474 underwent IVL procedures. Most patients presented with calcific lesion requiring lithotripsy in non–left main segments, while IVL was performed on the left main artery in 46 patients. No significative differences were found on baseline characteristics between LM and non–LM groups. Treatment of IVL–LM lesion was marked by a high procedural success rate (97.8%) and a low incidence of procedural and peri–procedural complications. However, there was a higher rate of contrast–induced acute kidney injury in patients treated in LM (6.5% vs. 1.6%, p=0.030), although no other differences for in–hospital outcomes were observed. Furthermore, there were no differences in 30–day and 6–month follow–up outcomes between the two groups. Conclusions This study suggests that employing intravascular lithotripsy in the left main coronary artery is not only a safe procedure but also produces excellent results comparable to its application in other coronary branches. This provides a substantial level of confidence in the safety and effectiveness of IVL when used in this specific context.

Management Considerations for Acute Coronary Syndromes in Chronic Kidney Disease.

Propensity of patients with chronic kidney disease (CKD) to adverse outcomes of acute coronary syndromes (ACS) derives, in part, from imperfection in management. Dearth of data resulting from underrepresentation of patients with CKD in ACS trials and underuse of evidence-based testing and therapy compound biological risks inherent to CKD. We sought in this narrative review to critically appraise contemporary evidence and offer suggested approaches to practicing clinicians for the optimization of ACS management in patients with CKD. Updated multisociety chest pain guidelines emphasize the diversity of clinical presentations of ACS, pertinent to recognition of ACS in patients with CKD. Evolving tools to predict and prevent acute kidney injury complicating invasive management of ACS serve to support improved access to and safety of percutaneous coronary intervention (PCI) in CKD patients, who remain at elevated risk. Growth in use of radial access, advances in PCI quality, incorporation of intravascular imaging, and new options and insights in pharmacotherapy contribute to an evolving calculus of ischemic and bleeding risk in ACS with bearing on management in CKD patients. Key opportunities to improve outcomes of ACS for patients with CKD center on avoiding underuse of beneficial medical and invasive therapies; enhancing safety of therapies by leveraging evidence-based strategies to prevent acute kidney injury; and devoting specific effort to investigation of ACS management in the context of CKD.

In-hospital Outcomes of Rotational Atherectomy in ST-Elevation Myocardial Infarction: Results From the Multicentre ROTA-STEMI Network

BackgroundAlthough the use of rotational atherectomy (RA) is off-label in the setting of ST-elevation myocardial infarction (STEMI), it can be the only option in severely calcified culprit lesions to achieve procedural success. We sought to investigate the safety and feasibility of RA during primary percutaneous coronary intervention (PPCI). MethodsThis was a retrospective observational study of patients who underwent RA during PPCI from 12 European centres. The main outcomes were procedural success (defined as successful stent implantation with final thrombolysis in myocardial infarction [TIMI] flow 3 and residual stenosis < 30%) and in-hospital mortality. A comparison of patients presenting with and without shock was performed. ResultsIn 104 patients with RA during STEMI, the mean age was 72.8 ± 9.1 years, and 35% presented with cardiogenic shock. Bailout RA was performed in 76.9% of cases. Mean burr size was 1.42 ± 0.21 mm. Procedural success was achieved in 86.5% of cases, with no difference between shocked and nonshocked patients (94.4% vs 82.4%; P = 0.13). In-hospital stent thrombosis occurred in 0.96%, perforation in 1.9% and burr entrapment in 2.9% of cases. In spite of equally high procedural success, in-hospital mortality was higher in shocked (50%) compared with nonshocked patients (1.5%; P < 0.0001). ConclusionsPatients presenting with STEMI requiring RA, represent a high-risk population, frequently presenting with cardiogenic shock. In this analysis of selected patients, RA was performed as a bailout strategy in the majority, and, as such, RA seems to be feasible with a high procedural success rate. In the absence of cardiogenic shock, RA-facilitated PCI seems to be associated with low in-hospital mortality.

Midterm outcomes of rotational atherectomy-assisted endovascular treatment of severe peripheral arterial disease

ObjectiveWe evaluated the midterm results of atherectomy-assisted angioplasty for the treatment of femoropopliteal lesions and the identification of possible subgroups of patients with superior outcomes. MethodsWe conducted a single-center, physician-initiated, nonindustry-sponsored retrospective analysis of patients with Rutherford category ranging from II to V and de novo occlusive or stenotic lesions of the superficial femoral (SFA) and/or popliteal arteries treated with atherectomy-assisted angioplasty (Jetstream rotational atherectomy + drug-eluting ballooning). In cases of subintimal recanalization or patients without an SFA stamp, with previous ipsilateral bypass surgery, systemic coagulopathy, end-stage renal disease requiring hemodialysis, life expectancy of <12 months, and intolerance to aspirin, clopidogrel, and/or heparin were excluded. ResultsIn a total of 103 enrolled patients, the median SFA and/or popliteal lesion length was 80 mm (interquartile range, 61.2 mm) with 73 lesions being occlusive (70.9%) and 84 (81.5%) classified as Fanelli calcification score 3 and 4. Technical success was met in 96.1% of cases (n = 99) at a median operative time of 108 minutes. Adjunctive stenting was needed in 10 patients (9.8%). At a median follow-up of 18.0 ± 10.8 months, Rutherford class clinical improvement was present in 77 patients (74.8%), and 7 patients (6.79%) presented target lesion occlusion needing reintervention in 6 cases (5.82%). The primary patency rates were 97% at 12 months and 83% at 24 months with secondary patency rates of 99% at 12 months and 91% at 24 months of follow-up. There were no significant differences when treating differently located lesions, diabetic vs nondiabetic patients, or comparing experienced vs nonexperienced operators. ConclusionsThe use of rotational atherectomy and drug-eluting balloons for the treatment of severe femoropopliteal disease showed relatively low need for bailout stenting and good midterm primary patency rates. The influence of lesion location, diabetes mellitus, or operator experience did not show statistically different results in terms of patency. Longer term outcomes and comparative analysis are needed to consolidate further clinical evidence.

Percutaneous treatment of left main coronary artery disease - temporal trends from large registry and ten-year follow-up. a single centre experience

Abstract Background Due to a large amount of jeopardized myocardium, patients with significant left main coronary artery (LMCA) stenosis have an increased risk of death. For years coronary artery bypass grafting has been considered as the treatment of choice. Recent years brought evidence that led to the reconsideration of percutaneous coronary intervention (PCI) as a valuable alternative. Purpose The purpose of this study was to assess temporal trends in clinical practice and analyse the very long-term outcomes of LMCA PCI in a large tertiary hospital in Poland. Methods Group of 998 individuals undergoing LMCA PCI was selected from medical records of 44,989 patients hospitalized in years 2008-2021. Data on mortality were obtained from the Centre for Information Technology. Temporal trends were calculated for period 2008-2014 as compared to 2015-2021. The 10-year event rate was calculated with the Kaplan-Meier estimator, univariate (ULR), and multivariate logistic regression (MLR). Results The rate of LMCA PCI increased from 2.21% in 2008 to 6.88% in 2021 (p&amp;lt;0.001). 736 (73.8%) patients were male, the median age was 71 years (interquartile range 16). 409 (41.0%) of patients presented with acute coronary syndrome (ACS), 545 (54.6%) with chronic coronary syndrome (CCS). In the analysed periods concomitant diabetes mellitus (DM) rate increased from 27.44% to 42.5% (p&amp;lt;0.001), use of intravascular imaging (IVI) increased from 22.28% to 42.72% (p&amp;lt;0.001), use of rotational atherectomy increased from 8.36% to 18.94% (p&amp;lt;0.001). The 30-day mortality decreased from 10.31% to 4.23% (p&amp;lt;0.001), and 1-year mortality decreased from 18.66% to 12.05% (p=0.007). In the 10-year follow-up 399 (40.0%) patients died. In ULR, death was associated with femoral access (OR 1.766, 95% CI 1.308-2.386) and absorbed radiation dose (OR for increase in 1 Gy 1.192, 95% CI 1.080-1.304). The provisional stenting yielded better performance than two-stent techniques (OR 0.635, 95% CI 0.491-0.821). In MLR, death at 10 years was associated with age (OR 1.028, 95% CI 1.007-1.050), ACS (OR 1.725, 95% CI 1.134-2.624), atrial fibrillation (OR 1.540, 95% CI 1.002-2.367), lower glomerular filtration rate (OR for decrease in 1 ml/min/1.73 m2 1.011, 95% CI 1.001-1.022), and lower left ventricular ejection fraction (OR for decrease in 1% 1.045, 95% CI 1.029-1.060). Better outcomes were associated with previous revascularization (OR 0.668, 95% CI 0.453-0.986), use of IVI (OR 0.518, 95% CI 0.353-0.759), drug-eluting stents (OR 0.238, 95% CI 0.106-0.536) and bigger balloon diameter used for stent optimization (OR for increase in 1 mm 0.889, 95% CI 0.801-0.986). Conclusions In the analysed period the rate of LMCA PCI, number of complex procedures, and co-morbidities increased, yet the prognosis has improved. The 10-year death rate analysis revealed that advancements in percutaneous device technology and procedural techniques are associated with more favourable outcomes.

ISCHEMIC HEART DISEASE AND DIAGNOSTIC CORONARY ANGIOGRAPHYEPIDEMIOLOGICAL DATA AND FEMORAL VS. RADIAL APPROACH : A SERIES OF 100 CASES

Introduction: The use of radial access for coronary interventions offers advantages such as reduced access-site bleeding and improved patient comfort. However, the learning curve for radial access and conflicting findings regarding outcomes in previous studies have influenced its widespread adoption. This study aimed to comprehensively assess the effects of radial access compared to femoral access in patients with ischemic heart disease. Materials and Methods: A retrospective analysis was conducted on 100 patients who underwent diagnostic coronary angiography at Ibn Sina University Hospital. Patient demographics, clinical indications, angiographic data, and complications were compared between the radial and femoral access groups. Statistical analysis was performed using SPSS software. Results: The study included 45 patients in each group, with an average age of 63 years. Male patients accounted for 67% of the study population. The most common indications for coronary angiography were acute coronary syndrome (41%), heart failure (28%), stable angina (17%), and unstable angina (10%). The angiographic findings revealed that 79% of patients had pathological coronary angiograms, with bi-troncular involvement being the most prevalent (40.5%). Vascular complications occurred in 4% of cases, including a femoral fistula requiring vascular surgery. Conclusion: The study findings aligned with previous research, demonstrating that radial access resulted in fewer vascular and hemorrhagic complications compared to the femoral approach. However, the radial route presented challenges such as a longer procedural duration and increased radiation exposure. The decision between radial and femoral access should consider the operators experience, patient preference, and clinical factors.

Rates of the Trans-radial Approach in Elective and Emergency Coronary Angiography in Iraq: A Cross-Sectional Study.

Background and aims The trans-radial access is becoming the default approach in many cardiac centers worldwide. Data from the Middle East, including Iraq, on the trends and rates of the use of trans-radial access are scarce. The aim of this study is to determine the rates of trans-radial approach (TRA) versus transfemoral approach (TFA) in patients with coronary artery syndromes undergoing coronary angiography and/or percutaneous coronary intervention (PCI) in Iraq. Methods In this multicenter prospective study, we collected 885 cases of coronary artery disease undergoing coronary angiography/PCI from three main cities of the Kurdistan Region in Iraq from 2022 to 2023. Results Of the total sample, 57.2% were diagnostic coronary angiography and 42.8% were PCI, 57.1% of all cases were TFA and 42.9% were TRA, and 64.3% of PCI cases were performed through TFA. Eghty-two percent of total emergency PCI included (primary PCI) cases underwent the procedure through the TFA, and only 18% of such cases were through the TRA. The overall crossover rate between both approaches happened in 14 (3.6%) cases. Conclusions Despite its main benefits, the radial access use in the Cath lab is yet underused in our region. Further steps in training programs are indicated to popularize the use of radial access among interventional cardiologists in addition to transfemoral access.

Periprocedural myocardial infarction in patients undergoing complex versus noncomplex percutaneous coronary intervention.

Limited data are available on the risk of periprocedural myocardial infarction (MI) in patients undergoing complex versus noncomplex percutaneous coronary intervention (PCI). We assessed the risk of periprocedural MI according to the fourth Universal definition of myocardial infarction (UDMI) and several other criteria among patients undergoing elective PCI in a prospective, single-center registry. Complex PCI included at least one of the following: 3 coronary vessels treated, ≥3 stents implanted, ≥3 lesions treated, bifurcation with 2 stents implanted, total stent length >60 mm, treatment of chronic total occlusion, and use of rotational atherectomy. Between 2017 and 2021, we included 1010 patients with chronic coronary syndrome, of whom 226 underwent complex PCI (22.4%). The rate of periprocedural MI according to the fourth UDMI was significantly higher in complex compared to noncomplex PCI patients (26.5% vs. 14.5%, p < 0.001). Additionally, periprocedural MI was higher in the complex PCI group using SCAI (4% vs. 1.1%, p = 0.009), ARC-2 (13.7% vs. 8.0%, p = 0.013), ISCHEMIA (5.8% vs. 1.7%, p = 0.002), and EXCEL criteria (4.9% vs. 2.0%, p = 0.032). SYNTAX periprocedural MI occurred at low rates in both groups (0.9% vs. 0.6%, p = 0.657). Complex PCI was an independent predictor of the fourth UDMI periprocedural MI (odds ratio [OR] 1.54, 95% confidence interval [CI]: 1.04-2.27, p = 0.031). In patients with chronic coronary syndrome undergoing elective PCI, complex PCI is associated with a significantly higher risk of periprocedural MI using multiple definitions. These findings highlight the importance of considering upfront this risk in the planning of complex PCI procedures.

P111 RADIAL ACCESS FOR THE PERCUTANEOUS TREATMENT OF CHRONIC CORONARY OCCLUSIONS: A SINGLE CENTER EXPERIENCE

Abstract Background In the last years the improvement of interventional techniques for the treatment of coronary total occlusions (CTO) trough percutaneous coronary intervention (PCI) allowed a significant increase of the number and success rate of these procedures. At the same time, transradial access is increasingly being used for CTO–PCI even though there are concerns about its efficacy in this setting because of the higher procedural complexity. Aim of our study was to review the procedural success of all the CTO–PCI performed in our center according to the vascular access utilized. Methods We retrospectively evaluated all the CTO–PCI performed in our center from January 2018 to December 2019. These procedures were divided in two groups according to the vascular access employed: all femoral access procedures (Group 1) or procedures with at least one radial access (Group 2). The primary end–point of the study was the procedural success. Major procedural complications, the duration of the procedure and the volume of contrast used were also evaluated. Results A total of 66 CTO procedures have been performed: 15 procedures in Group 1 (66 ± 14 years, 80% males) and 51 in Group 2 (66 ± 9 years; 80% males, P= NS). In Group 2, 14 procedures were performed using only radial access whereas in 38 procedures a combination of radial and femoral access have been utilized. There were no significant differences in the main cardiovascular risk factors between the two groups. In Group 2, 5 procedures were performed by retrograde approach while in Group 1 all procedures were performed by antegrade approach. There were no significant differences between Group 1 and Group 2 in terms of contrast volume used (376 ± 137 mL and 345 ± 101 mL respectively, P=0.40) or in terms of procedure time duration (132 ± 49 min and 149 ± 71 min respectively, p=0.13). Procedural success was similar in the two groups: 86% in Group 1 and 80% in Group 2 ( P=0.86). There was one only major clinical complications in group 1 ( one stroke) and no complications in Group 2. Conclusion In our experience, the use of radial access alone or in combination with a single femoral access is safe and effective to perform CTO–PCI.

Practice Pattern Variation in Adoption of New and Evolving Percutaneous Coronary Intervention Procedures.

Assess factors contributing to variation in the use of new and evolving diagnostic and interventional procedures for percutaneous coronary intervention (PCI). Evidence-based practices for PCI have the potential to improve outcomes but are variably adopted. Finding possible drivers of PCI procedure-use variability is key for efforts aimed at establishing more uniform practice. Veterans Affairs Clinical Assessment, Reporting, and Tracking Program data were used to estimate a proportion of variation attributable to hospital-, operator-, and patient-level factors across (a) radial arterial access, (b) intravascular imaging/optical coherence tomography, and (c) atherectomy for PCI. We used random-effects models with hospital, operator, and patient random effects. Overlap between levels generated cumulative variability estimates greater than 100%. A total of 445 operators performed 95,391 PCI procedures across 73 hospitals from 2011 to 2018. The rates of all procedures increased over this time. 24.45% of variability in the use of radial access was attributable to the hospital, 53.04% to the operator, and 57.83% to patient-level characteristics. 9.06% of the variability in intravascular imaging use was attributable to the hospital, 43.92% to the operator, and 21.20% to the patient. Lastly, 20.16% of the variability in use of atherectomy was attributed to the hospital, 34.63% to the operator, and 57.50% to the patient. The use of radial access, intracoronary imaging, and atherectomy is influenced by patient, operator, and hospital factors, but patient and operator-level effects predominate. Efforts to increase the use of evidence-based practices for PCI should consider interventions at these levels.

Impact of a Comprehensive ST‐Segment–Elevation Myocardial Infarction Protocol on Key Process Metrics in Black Americans

Impact of a Comprehensive ST‐Segment–Elevation Myocardial Infarction Protocol on Key Process Metrics in Black Americans

Periprocedural Outcomes of Rotational Atherectomy-Assisted Balloon Angioplasty in Isolated Atherosclerotic Popliteal Artery Lesions: The ISO-POP Trial.

Treatment of calcified popliteal artery lesions represents an ongoing challenge for vascular specialists. Biomechanical forces of external compression, torsion and elongation that occur with locomotion in the popliteal segment can lead to stent fractures and occlusions. The aim of our study was to assess the procedural success rate of atherectomy in combination with balloon angioplasty for isolated calcified popliteal artery lesions. Between January 2020 and December 2022, 62 patients with isolated atherosclerotic lesions of the popliteal artery underwent endovascular treatment by use of rotational atherectomy (Phoenix, Philips USA, (subgroup A) or Jetstream, Boston USA, (subgroup B), atherectomy systems) and additional balloon angioplasty in two vascular centers. The primary outcome measures were: 1. periprocedural clinical and technical success (<30% residual stenosis and no need for bailout stenting due to flow-limiting dissection) and 2. postprocedural increase in the ankle brachial index of more than 0.1. The overall rate of bailout stenting was 4.8%, whereas the procedural success rate was 98.4%. The rate of procedural complications included 3.7% and 5.7% peripheral embolizations in the subgroups A and B, respectively, and no vessel perforations were noted. All embolizations were successfully treated by catheter aspiration or capture in the pre-treatment placed filter system. In addition, 1 (3.7%) pseudoaneurysm in the groin was reported in subgroup A and treated by surgical means. Median ABI of the affected limbs improved from 0.55 (0.2) to 0.70 (0.2) in subgroup A and from 0.50 (0.2) to 0.95 (0.1) in subgroup B (DABI of 0.15 versus 0.45, p < 0.001). The combination of rotational atherectomy and balloon angioplasty in the popliteal artery showed reproducible outcomes in 2 centers, with low incidence of complications and low rates of bail-out stenting. These findings may contribute to more liberal use of such devices especially in segments with high risk for stent factures and occlusions.

TCTAP C-036 Combined Use of Rotational Atherectomy and Intra-Vascular Shockwave Lithotripsy in Heavily Calcified Lesion

TCTAP C-036 Combined Use of Rotational Atherectomy and Intra-Vascular Shockwave Lithotripsy in Heavily Calcified Lesion

482 Triple Therapy Versus Dual Antiplatelet Therapy for Dolichoectatic Vertebrobasilar Fusiform Aneurysms Treated With Flow Diverters: The Last Frontier?

INTRODUCTION: Dolichoectatic vertebrobasilar fusiform aneurysms (DVBFAs) have poor natural history when left untreated and high morbimortality when treated with microsurgery. Flow diversion (FD) with dual-antiplatelet therapy (DAPT) is feasible but carries a high risk of perforator occlusion and progression of brainstem compression. Seeking better hopes for these patients, experts across the US started using triple-therapy (DAPT plus oral anticoagulation) after FD treatment in attempt to improve their clinical outcomes. The rationale was to preserve perforator patency while vessel remodeling occurs. The current study is the result of this multicenter effort. METHODS: Retrospective data collection from 8 US centers. Only DVBFAs treated with flow-diversion and either triple-therapy or DAPT alone were included. Patient and aneurysms' characteristics, and clinical and angiographic outcomes were compared. RESULTS: The groups (DAPT, n = 13 vs Triple-therapy, n = 14) were similar in age, sex, clinical presentation, baseline disability, aneurysm characteristics, median number of flow-diverters, and adjunctive coiling. Radial access use was significantly higher in the triple-therapy group (71.4% vs. 15.3%, P = 0.006). Acute ischemic stroke rate was lower in the triple-therapy group (7.1% vs. 30.8%, P = 0.167). Overall rate of modified Rankin Scale score decline due to either ischemic stroke or worsening of brainstem compression was significantly lower in the triple-therapy group (7.1% vs. 69.2%, P = 0.001). Overall rate of hemorrhagic complications was numerically higher in the triple-therapy group (28.6% vs. 7.7%, P = 0.162). The rate of moderate-to-severe disability at last follow-up was significantly lower in the triple-therapy group (21.4% vs. 76.9%, P = 0.007). I. CONCLUSIONS: Patients with DVBFAs treated with FD and triple-therapy had less ischemic strokes, less symptom progression, and overall better outcomes at last follow-up than similar patients and aneurysms managed with DAPT alone.

Planned versus unplanned rotational atherectomy for plaque modification in severely calcified coronary lesions

BackgroundEvidence on the optimal timing of RA is scarce, although increased periprocedural complications for unplanned procedures have been reported.AimsTo compare planned versus unplanned use of rotational atherectomy (RA) for plaque modification in patients with severely calcified coronary lesions.MethodsProcedural and 1-year follow-up data of planned (n = 562 lesions in 448 vessels of 416 patients) and unplanned (n = 490 lesions in 435 vessels of 403 patients) RA between 2008 and 2020 were analyzed using the propensity score methods. The primary composite endpoint was target lesion failure (TLF), defined as cardiovascular death (CVD), target vessel myocardial infarction (TVMI), or target lesion revascularization (TLR).ResultsAngiographic success was > 99% in both groups. Fluoroscopy time and contrast volume were significantly lower in planned RA (p < 0.001). Periprocedural complications including slow-flow, coronary dissection, and MI occurred in 4.8% after planned, and in 5.7% after unplanned RA. TLF occurred in 18.5% after planned, and in 14.7% after unplanned RA. Weighted subdistribution hazard ratios for TLFs revealed an unfavorable 1-year outcome for planned RA (sHR 1.62 [1.07–2.45], p = 0.023), which was driven by TLR (sHR 2.01 [1.18–3.46], p = 0.011), but not by CVD, or TVMI. No differences were observed in all-cause mortality.ConclusionsUnplanned RA was associated with favorable outcome when compared to planned RA. Thus, RA can safely be reserved for lesions that prove untreatable by conventional means. Randomized and prospective trials are needed to evaluate a predominant use of rotational atherectomy as a bailout strategy in the future.Graphical abstract

A tale of two registries: Trends and outcomes of percutaneous coronary intervention in two transatlantic populations.

Key Points Patients undergoing percutaneous coronary intervention (PCI) in the state of Michigan have more comorbidities compared to patients undergoing PCI in the United Kingdom. While the adoption of radial artery access for PCI has increased steadily over time in both Michigan and the United Kingdom, the use of radial access was significantly greater in the UK at all time points compared to Michigan for all PCI indications. The use of mechanical support during PCI has increased over time in Michigan but decreased over time in the United Kingdom.

Comparative Study of Transradial Versus Transfemoral Route Percutaneous Coronary Intervention in Acute ST-Elevation Myocardial Infarction.

Introduction Percutaneous coronary intervention (PCI) is the first choice of treatment for myocardial infarction (MI). However, entry site failure is still one of the major complications faced by the interventionist. Hence the present study compared the efficacy and complications of radial and femoral approaches in PCI in ST-elevation myocardial infarction (STEMI). Methods A hospital-based prospective study was conducted on patients with acute STEMI. A total of 100 patients were enrolled that were randomly divided into two groups of 50 each, i.e., patients that had undergone PCI by radial approach (N=50) and those who had undergone PCI by femoral approach (N=50). Results The male-to-female ratio was 1.5:1 and 1.6:1 in the transradial (TR) and transfemoral (TF) groups, respectively. With respect to age, both the groups were dominated by the age group of 50-60 years, with 42% in the TR group and 34% in the TF group having an age >60 years. The mean access time, fluoroscopy time, and procedural time in the TR group were 6.0 ± 0.7 minutes, 5.9 ± 0.6 minutes, and 29.55 ± 0.9 minutes, respectively. In the TF group, the mean access time, fluoroscopy time, and procedural time were 5.1 ± 0.5 minutes, 5.5 ± 0.7 minutes, and 26.7 ± 2.1 minutes, respectively. In the TR group, ecchymosis and loss of radial pulse were observed in 10% of the patients, thrombophlebitis in 4%, and bleeding complications in 2%. While in the TF group, ecchymosis was observed in 26%, followed by thrombophlebitis (24%), minor hematoma, and bleeding complications (14%). Conclusion The present study emphasizes the use of radial access in patients with ST-segment elevation acute coronary syndrome, as this approach was associated with significant clinical benefits. Moreover, bleeding complications were more in patients undergoing TF intervention.

Abstract 11496: Radial Access for Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry

Introduction: Use of radial access for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has been increasing. Methods: We examined the clinical characteristics and procedural outcomes of patients who underwent CTO PCI with radial versus femoral access in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO, NCT02061436). Results: Of 10,954 patients who underwent CTO PCI at 55 centers in 7 countries between 2012 and 2022, 2,578 (24%) had a radial-only approach. Patients who underwent radial-only access were younger (63 ± 10 vs. 65 ± 10, years, p&lt;0.001), more likely to be men (84% vs. 81%, p=0.001), and had a significantly lower prevalence of comorbidities compared with the femoral group, including diabetes mellitus (39% vs. 45%, p&lt;0.001) and coronary artery bypass graft surgery (57% vs. 64%, p&lt;0.001). In addition, radial-only cases had lower angiographic complexity with lower J-CTO (2.0 ± 1.3 vs. 2.5 ± 1.2, p&lt;0.001) and PROGRESS-CTO (1.2 ± 1.0 vs. 1.3 ± 1.0, p&lt;0.001) scores. After adjusting for potential confounders, radial-only access was associated with a lower risk of access site complications (odds ratio [OR]: 0.45, 95% confidence interval [CI], 0.22-0.91), similar technical success (OR: 0.87, 95% CI, 0.74-1.04) and major adverse cardiovascular events (MACE) (OR: 0.65, 95% CI, 0.40-1.07), compared with the femoral access group (Figure 1). Conclusions: Radial-only access was used in 24% of CTO PCIs and was associated with lower access site complications, and similar technical success and MACE compared with the femoral access group.

Early results of a simplified protocol over standard in patients undergoing transcatheter aortic-valve replacement

Abstract Introduction Transcatheter aortic-valve replacement (TAVR) procedure has been simplified, being now a less-invasive minimalist strategy the standard of treatment. Therefore, length of hospitalization has decreased, and early-discharge (ED) (&amp;lt;72 hour) protocols are in development. Lately, additional techniques to optimize TAVR procedure have arisen, such as the use of radial approach as the secondary access, conscious sedation, cusp overlap projection (COP) to better control the implantation depth in self-expanding (SE) valves, or atrial pacing (AP) after deployment to test atrioventricular (AV) conduction. With the combination of these 4 maneuvers, we have developed an ED protocol, and hereby present the immediate results. Methods We prospectively studied 176 patients who underwent staged and transfemoral TAVR procedure with our novel protocol between May 2020 and December 2021 (Protocol) and compared them with a retrospective cohort of 175 patients who underwent standard TAVR between January 2018 and April 2020 (Standard). The protocol cohort included the use of conscious sedation with midazolam and fentanyl, routine radial approach as the secondary access, use of the CO projection, and AP after deployment in the absence of complete AV block, at rates of 70 to 120 beats/min (or until AV Block was observed) in 10 beats/min increments for a total of 20 beats at each increment. As part of this protocol, patients remained in general cardiology ward, avoiding ICU stay, with rapid recovery and early mobilization (After 6 hours in the absence of bleeding). In the absence of complications patients were discharged within 24–48 hours and reviewed a week and a month later in clinic. Initial assessment included EKG, echocardiogram, in hospital and 30-day follow-up. Results Median patient age was 80 years old and 49.9% were female. Despite higher rates of hypertension in the standard cohort (p=0.038), no significant differences could be appreciated in baseline demographics, EKG or imaging findings (Table). Even with higher rates of predilation, CO and AP, the length of procedure and the use of contrast was lower in the protocol cohort. Rates of intraprocedural AV block were similar among groups (p=p.21), but AP led to a significant lower need of temporary pacemaker surveillance (p&amp;lt;0.0001). The use of radial access also tend to diminish immediate bleeding and vascular complications. According to protocol, the median length of stay was reduced to 2 [1; 4] days (p&amp;lt;0.0001). At a 30-day follow up, the incidence of major adverse cardiac events was low and similar among groups (p=0.67) (Figure), with no significant differences in the incidence of permanent pacemaker implantation, heart failure admission, bleeding o vascular complication (Figure) Conclusion A simplified TAVR protocol combining radial access, CO, AP can be adopted safely, leading to TAVR patients early discharge, with no major events on an immediate 30-day follow-up. Funding Acknowledgement Type of funding sources: None.

Intervenção coronária percutânea com alta no mesmo dia. Onde estamos?

With the evolution of percutaneous coronary intervention techniques and their greater safety, the use of radial access, the greater need to optimize resources in health management and the greater demand from patients for an agile service to solve their problems, the discharge on the same day after percutaneous coronary interventions have been gaining ground in the global scenario as a feasible strategy. The objective of this article was to demonstrate that there is already a scientific basis for this, which extends from the financial aspect, and the patient’s experience, to the technical details related to the safety of the strategy. A structured protocol based on evidence and on the most recent recommendations from two major medical societies is also proposed. Selecting patients well, training the multidisciplinary team and educating the patient are fundamental parts for the success of the strategy.