Use Of Radial Access Research Articles

Experience of endovascular treatment of common femoral artery pseudoaneurysm with usage Angio-Seal Closure Device

One case of successful treatment of the common femoral artery pseudoaneurysm with usage of modified technique of pseudoaneurysm neck sealing with Angio-Seal with retrograde access percutaneously is presented.A 52-year-old man was admitted in the recovery period of ischemic stroke in the left carotid basin. A total subtraction cerebral angiography was performed, which revealed severe stenosis in the bulb of the left internal carotid artery with ulcerated contour and severe stenosis in the ostium of the left vertebral artery. Hemostasis was performed by compression. A pressure dressing was applied for a day. The puncture site was without any problems on the next day. The patient received double antiplatelet therapy 5 days before endovascular surgery. Before surgery, palpation in the right inguinal region determines a rounded painful compaction. Carotid stenting on the left side, stenting of the left vertebral artery and control angiography of arteries of the right lower limb were performed by left-side femoral access. Pseudoaneurysm in the bifurcation of the right common femoral artery with a narrow neck was verified. Attempts to cure it by manual compression under angiographic control and ultrasound control were unsuccessful.After 6 days, endovascular treatment of pseudoaneurysms of the right common femoral artery with closure of the pseudoaneurysm neck was performed. The right common femoral artery was catheterized with left radial access with diagnostic catheter on a hydrophilic wire 0.035ʺ. This wire was carefully advanced into pseudoaneurysm through a defect in the common femoral artery and subsequently served as a marker. The pseudoaneurysm was punctured with miniaccess needle, then the 0.018ʺ wire passed through the pseudoaneurysm neck into the femoral artery retrogradly, focusing on the “marker” wire. A 6F radial introducer is introduced along 0.018ʺ wire. Further, this access was used to close the pseudoaneurysm neck with the Angio-Seal Closure Device 6F according to the standard method. In a control angiograms, a pseudoaneurysm did not contrast, arteries are passable without stenosis and signs of dissection. Hemostasis at the site of puncture of the radial artery was performed with a hemostatic bracelet. The patient was discharged from the clinic to continue treatment in a rehabilitation neurological center.This technique of endovascular treatment of postcatheterization pseudoaneurysms of the common femoral artery is quite simple, causing minimal discomfort for the patient. The closure is immediate and angiographically controled. The use of radial access instead of contralateral femoral access for introducing of a “marker” wire and angiographic control reduces the risk of local complications at the access site.

Complex high-risk and indicated percutaneous coronary intervention for stable angina: Does operator volume influence patient outcome?

Complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied. To define temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes. Data were analyzed on all CHIP-PCI procedures undertaken for stable angina in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by patient characteristics (age ≥80years, left ventricular (LV) ejection fraction <30%, previous CABG, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, LV support, use of rotational atherectomy or laser atherectomy). CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were associated with a greater degree of patient comorbidity and increasing procedural complexity. After adjustment for baseline difference, in-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (P = .394) and 12-month mortality (P = .638) were similar across the volume quartiles. Higher volumes quartiles were associated with a greater likelihood of same day discharge (P < .001). CHIP-PCI cases are an increasingly large population in contemporary PCI practice. Higher operator volumes were not associated with improved 12-month survival. Data were analyzed on all complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) procedures in England and Wales between 2007 and 2014. CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Median total operator volume was 29 cases with higher volumes associated with more patient comorbidity and increasing procedural complexity. In-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) all associated with increasing operator CHIP-PCI volumes. However, trends for in-hospital death (P = .394), and 12-month mortality (P = .638) were similar across the volume quartiles.

Safety and Efficacy of Femoral Access vs Radial Access in ST-Segment Elevation Myocardial Infarction

Among patients with ST-segment elevation myocardial infarction (STEMI) referred for primary percutaneous coronary intervention (PCI), a survival benefit associated with radial access compared with femoral access remains controversial. To assess whether there is a survival benefit when radial access is used instead of femoral access among patients with STEMI referred for primary PCI. This multicenter, open-label, randomized clinical trial was conducted at 5 PCI centers in Canada. In total, 2292 patients with STEMI referred for primary PCI were enrolled between July 2011 and December 2018, with a 30-day follow-up. The primary analyses were conducted based on the intention-to-treat population. Patients were randomized to radial access (n = 1136) or to femoral access (n = 1156) for PCI. Initially, the primary outcome was bleeding, but this outcome was modified to 30-day all-cause mortality following the recommendation of the granting agency. Secondary outcomes included recurrent myocardial infarction, stroke, and Thrombolysis in Myocardial Infarction-defined major or minor bleeding. Among the 2292 patients enrolled, the mean (SD) age of the patients randomized to radial access was 61.6 (12.3) years and to femoral access was 62.0 (12.1) years, with 883 male patients in the radial access and 901 male patients in the femoral access group. The trial was stopped early following a futility analysis. Primary PCI was performed in 1082 of 1136 patients (95.2%) in the radial access group and 1109 of 1156 patients (95.9%) in the femoral access group. Bivalirudin was administered to 1001 patients (88.1%) in the radial access group and to 1068 patients (92.4%) in the femoral access group, whereas glycoprotein IIb/IIIa inhibitors were administered in only 69 patients (6.1%) in the radial access group and 68 patients (5.9%) in the femoral access group. A vascular closure device was used in 789 patients (68.3%) in the femoral group. The primary outcome, 30-day all-cause mortality, occurred in 17 patients (1.5%) assigned to radial access and in 15 patients (1.3%) assigned to femoral access (relative risk [RR], 1.15; 95% CI, 0.58-2.30; P = .69). There were no significant differences between patients assigned to radial and femoral access in the rates of reinfarction (1.8% vs 1.6%; RR, 1.07; 95% CI, 0.57-2.00; P = .83), stroke (1.0% vs 0.4%; RR, 2.24; 95% CI, 0.78-6.42; P = .12), and bleeding (1.4% vs 2.0%; RR, 0.71; 95% CI, 0.38-1.33; P = .28). No significant differences were found for survival or other clinical end points at 30 days after the use of radial access vs femoral access in patients with STEMI referred for primary PCI. However, small absolute differences in end points cannot be definitively refuted given the premature termination of the trial. ClinicalTrials.gov identifier: NCT01398254.

Barriers to use of radial access for percutaneous coronary intervention.

The aim of this study was to identify barriers to transradial access percutaneous coronary intervention (PCI). Transradial access yields fewer vascular complications, earlier ambulation, and more patient comfort. However, the adoption to practice is slow, and transfemoral access is still commonly used. We identified all PCIs done by one operator in a radial-first trainee-driven practice. The individual charts were reviewed for all PCIs using femoral access. Reasons for not using radial access were identified. Descriptive statistics were used to report reasons for not using transradial access. Analyses were performed on a per-procedure basis. Of 1,948 PCIs, 1,790 (92%) were via radial access and 158 (8%) via femoral access. Femoral access was used to bail out unsuccessful radial access in 21 PCIs (13% of all femoral PCIs, 1% of all PCIs). Radial access was unsuccessful due to failure to cannulate radial artery, radial artery spasm, and radial loop in majority of radial access failure PCIs (n = 13). Femoral access was used as a primary strategy in 137 PCIs (87% of all femoral PCIs, 7% of all PCIs), mostly due to undetectable radial artery pulse (both left and right) (n = 40). Radial access can be used for PCI safely and effectively. Inadequate radial pulse is the main barrier. Adjunctive strategies such as ulnar access and use of ultrasound may further increase the success rate of arterial access from the upper extremities.

Development and Evaluation of Novel Electronic Medical Record Tools For Avoiding Bleeding After Percutaneous Coronary Intervention.

BackgroundBleeding remains the most common complication of percutaneous coronary intervention. Guidelines recommend assessing bleeding risk before percutaneous coronary intervention to target use of bleeding avoidance strategies and mitigate bleeding events. Cedars‐Sinai Medical Center undertook an initiative to integrate these recommendations into the electronic medical record.Methods and ResultsThe intervention included a voluntary clinical decision alert to assess bleeding risk before percutaneous coronary intervention, a bleeding risk calculator tool based on the NCDR (National Cardiovascular Data Registry) risk prediction model and, when indicated, a second alert to consider 4 bleeding avoidance strategies. We tested for changes in the use of bleeding avoidance strategies and bleeding event rates by comparing procedures performed before versus after implementation of the electronic medical record–based intervention and with versus without use of the bleeding risk calculator tool. Use of radial access increased (47.6% versus 64.8%; P<0.001) and glycoprotein IIb/IIIa inhibitors decreased (12.8% versus 3.17%; P<0.001) from before to after implementation, though risk‐adjusted bleeding event rates were stable (odds ratio, 0.82; P=0.164), even for high‐risk procedures. Use versus nonuse of the bleeding risk calculator tool was associated with increased radial access and reductions in glycoprotein IIb/IIIa inhibitors, but no change in bleeding events.ConclusionsIntegrating guideline recommendations into the electronic medical record to promote assessments of bleeding risk and use of bleeding avoidance strategies was feasible and associated with changes in clinical practice. Future work is needed to ensure that bleeding avoidance strategies are not overused among lower‐risk patients, and that, for high‐risk patients, the potential benefits of elective percutaneous coronary intervention are carefully weighed against the risk of bleeding.

P5517Impact of admission during ON vs OFF hours on mortality in unselected ST-elevation myocardial infarction patients referred in percutaneous coronary intervention centers:insights from the ORBI registry

Abstract Background The effect of admission during OFF-hours on patient's outcome in ST Segment Elevation Myocardial Infarction remains controversial when a strategy for reperfusion between primary Percutaneous Coronary Intervention (pPCI) and fibrinolysis is chosen. We aimed to evaluate the impact of time of admission on all cause mortality in unselected STEMI patients referred to pPCI centers. Methods Data from 10850 consecutive patients admitted in the nine interventional cardiology centers in Britany for STEMI in the 24 first hours following the beginning of symptoms were collected in a network registry. Characteristics and clinical outcome of patients admitted during ON-hours (Monday through Friday 8h am-6h30 pm) were compared to OFF-hours patients (night shifts, weekends and non-working Holydays). Clinical outcome was all-cause in hospital mortality, major bleeding, and mechanical complications in STEMI. Results A total of 4644 confirmed STEMI patients (57.2%) were admitted during OFF-hours and 6206 (42.8%) patients during ON-hours. Baseline characteristics were well balanced between the two groups including features of high risk STEMI such as ventricular fibrillation (3.7% vs 3.6% p=0, 8), cardiogenic shock (6.9% vs 7.6%, p=0.1), mechanical complications (3,2% vs 2,7%, p=0,2). The population was older in the ON group (63.7 vs 62.2, p&lt;0.0001). Time from symptom onset to First Medical Contact (FMC) were slightly longer for patients presenting during on-hours (97 min vs. 95 min, p&lt;0,03). Time from FMC to angiography was longer during OFF-hours compared to ON-hours (100 min vs. 92 min p&lt;0,0001). Time from arrival in the PCI center to angioplasty was higher in the OFF period (40 mn vs 38 mn, p&lt;0.0001). The reperfusion treatment was different between the two periods, with more fibrinolysis and less PCI in OFF group (PCI: 76.7% vs 79.6%, p&lt;0,0001; Fibrinolysis: 11.4% vs 8.9%, p&lt;0,0001). The use of radial access (RA) was uniform in both group (66,8% and 66.6%; p=0,9) and not different whatever the admission time. The use of radial access increased meaningfully from 2008 for the two periods (RA OFF group: 84.4% vs 38,6%, RA ON group: 88.6% vs 38.7%) There was no impact of admission time on in-hospital all cause mortality in the entire population (5,3% vs 5,4% p=0,7), and on the Timi 3 flow for the patients treated with primary angioplasty (On group: 94% vs 94,3%, p=0.5). The bleeding complications were similar in both groups (2,5% vs 2,6%, p=0,8). Conclusions Even though the time of reperfusion is slightly longer in patients admitted for STEMI during off-hours, no difference was observed in the PTCA technique and success rates as well as in the in-hospital mortality and bleeding rates. A long term patient follow-up would be necessary before definite conclusions.

Clinical impact of complex percutaneous coronary intervention in patients with coronary artery disease.

For the revascularization of patients with clinical and anatomical complexities, several technical skills are often required. However, the prognostic effect of complex percutaneous coronary intervention (C-PCI) on the clinical outcomes is not well known. The aim of this study was to investigate the relationship between the C-PCI and mid-term clinical outcomes. We assessed 1062 patients who underwent PCI with newer-generation drug-eluting stent and stratified the patients according to whether they had complex PCI (C-PCI, n = 358) or non-complex PCI (non-C-PCI, n = 704). C-PCI was defined as a procedure with at least 1 of the following features: 3 vessels treated, ≥ 3 stents per vessel implanted, ≥ 3 lesions treated, use of a 2-stent technique, the total stent length per vessel > 60mm, chronic total occlusion, unprotected left main coronary artery stenting, and rotational atherectomy use. All-cause death and major adverse cardiac and cerebrovascular events (MACCE; cardiovascular death, non-fatal myocardial infarction, and non-fatal ischemic stroke) were evaluated. The median follow-up period was 1.9 (0.8-3.0) years. The baseline SYNTAX score was significantly higher in the C-PCI group than in the non-C-PCI group [20 (14-27) vs. 10 (6-17), p < 0.001]. Kaplan-Meier analysis showed that the cumulative incidences of all-cause death (log-rank p = 0.12) and MACCE (log-rank p = 0.64) did not differ between the two groups. On multivariable Cox analysis, C-PCI did not adversely affect the clinical outcomes. Despite a high rate of anatomically complex coronary lesions, the patients who underwent C-PCI had comparable "hard" clinical outcomes with those of non-C-PCI.

Coronary perforation complicating percutaneous coronary intervention in patients presenting with an acute coronary syndrome: An analysis of 1013 perforation cases from the British Cardiovascular Intervention Society database

BackgroundThe evidence base for coronary perforation occurring during percutaneous coronary intervention in patients presenting with an acute coronary syndrome (ACS-PCI) is limited and the specific role of acute pharmacology in its clinical presentation unclear. Methods and resultsUsing the BCIS PCI database, data were analysed on all ACS-PCI procedures performed in England and Wales between 2007 and 2014. Multiple regressions were used to identify predictors of coronary perforation and its association with outcomes. Propensity score matching was used to evaluate the association between differing P2Y12 inhibitors or glycoprotein inhibitors (GPI) and CP. During 270,329 ACS-PCI procedures, 1013 coronary perforations were recorded (0.37%) with a stable annual incidence. In multiple regression analysis, covariates associated with increased frequency of coronary perforation included age, female gender, CTO intervention, number and length of stents used, and rotational atherectomy use, whilst differing P2Y12 inhibitors were not predictive. Using propensity score matching, use of a GPI was independently associated with tamponade (OR 1.50, [1.08–2.06], p = 0.014). The adjusted odds ratios for all clinical outcomes were adversely affected by coronary perforation. ConclusionsCoronary perforation is an infrequent event during ACS-PCI but is closely associated with adverse clinical outcomes. GPI use was associated with higher rates of tamponade.

Uncommon use of rotational atherectomy: management of coronary artery perforation

Uncommon use of rotational atherectomy: management of coronary artery perforation

Koroner Girişimlerde Radiyal Arter Spazmını Öngördürmede Farklı Anksiyete Öz-Değerlendirme Ölçeklerinin Etkinliğinin Karşılaştırılması

Objective: Radial artery spasm (RAS), is a major drawback for the routine use of radial Access during coronary interventions and anxiety is a well-documented predictor of RAS. In this study, we aimed to assess the relationship between RAS and level of anxiety (LOA) which was quantified with different scales. Material and Methods: 123 consecutive patients scheduled for elective coronary angiography were enrolled. Demographic and procedural relevant features were noted, and then, patients were asked to fill three anxiety scales; Beck Anxiety Inventory (BAI), Spielberger State Anxiety Inventory (SSAI) and Spielberger Trait Anxiety Inventory (STAI). Clinical RAS was accepted to exist if 2 or more of predefined clinical features had been met. Results: RAS was observed in 20 patients (16.3%). In the RAS (+) group, the frequency of female gender, low body mass index, total procedure time, and procedures carried out with more than one puncture attempts were significantly higher, whereas smokers were less. BAI and SSAI scores of RAS (+) group were significantly higher. According to the pre-defined cut-off values of all abovementioned scales, only SSAI based comparison revealed the higher frequency of patients with considerable LOA in RAS(+) group (%, 45 vs 75, p=0.013). When regression analyses were performed, total procedure time (HR: 2.96, 95% CI=0.96-9.11; p=0.032) and having an SSAI score over 40 (HR: 2.49, 95% CI=1.09?5.71; p=0.024) were designated as independent predictors of RAS. Conclusion:Anxiety is a considerable risk factor for RAS occurrence but the testing method of LOA also matters. Regarding our results, SSAI was an accurate one for anticipating RAS.

Impact of percutaneous coronary intervention extent, complexity and platelet reactivity on outcomes after drug-eluting stent implantation

BackgroundRisk stratification after percutaneous coronary intervention (PCI) is mainly based on demographics and clinical presentation (stable coronary artery disease [CAD] vs. acute coronary syndromes [ACS]). We investigated the impact of PCI extent and complexity on 2-year clinical outcomes after successful implantation of drug-eluting stents (DES) and whether this effect is influenced by clinical presentation and/or high platelet reactivity (HPR) on clopidogrel. Methods and resultsPatients from the prospective, multicenter Assessment of Dual Antiplatelet Therapy with Drug-Eluting Stents study were stratified according to PCI complexity, with complex PCI (C-PCI) defined as ≥3 stents implanted, bifurcation PCI with 2 stents, rotational atherectomy use for severely calcified lesions, or left main or saphenous vein graft (SVG) PCI. Major adverse cardiac events (MACE; cardiac death, myocardial infarction, and stent thrombosis) were compared at 2-year follow-up in patients with and without C-PCI. Successful DES PCI was performed in 8582 patients—2255 (26.3%) with C-PCI. C-PCI was independently associated with higher 2-year risk of MACE (adjusted HR [adjHR]: 1.56; 95%CI: 1.29–1.89; p<0.0001), MI (adjHR: 1.71; 95%CI: 1.37–2.14; p<0.0001), and ST (adjHR: 2.26; 95%CI: 1.42–3.59; p=0.0006). The association between C-PCI vs. non–C-PCI and the risk of MI and ST was greater in stable CAD than in ACS (Pinteraction=0.04 and 0.03, respectively). SVG PCI, 2-stent bifurcation treatment, and implantation of ≥3 stents were independently associated with MACE. ConclusionsPatients undergoing extensive and more complex PCI experienced worse outcomes after successful PCI. Considering the extent and complexity of PCI revascularization may improve risk stratification.

The use of rotational atherectomy in high-risk patients: results from a high-volume centre.

Rotational atherectomy (RA) is indicated for fibrocalcified lesions when traditional percutaneous coronary intervention (PCI) could not be successfully performed. In some of the high-risk patients the RA procedure is the last resort for successful revascularisation. Such patients are, among others, those in whom coronary artery bypass grafting (CABG) is not feasible. The aim of the study was to assess in-hospital and one-year outcomes of PCI with RA in high-risk patients without other revascularisation options (RA-only group), in comparison to lower-risk patients undergoing RA. We evaluated data of 207 consecutive patients who underwent PCI with RA. Primary endpoints were one-year all-cause mortality and one-year major adverse cardiac events (MACEs). Secondary endpoints were in-hospital outcomes. During the study 35% of patients fulfilled the inclusion criteria to the high-risk group. Those patients had significantly lower left ventricular ejection fraction, more often prior CABG, higher admission glucose level, and higher EuroSCORE II and Syntax Score. Procedural success was similar in both groups (85% in RA-only group vs. 91% in remaining patients, p = 0.18). In-hospital outcomes were similar, except more frequent no/slow-flow phenomenon in the RA-only group. The MACE and mortality rates in one-year follow-up were not statistically different in both groups (19% vs. 18%, p = 0.82 and 11% vs. 9%, p = 0.64, respectively). Despite the high-risk characteristics of the study subgroup, no significant differences between in-hospital and one-year outcomes were found in comparison to lower-risk RA patients. Complex PCI with RA in patients without other revascularisation options should be taken into consideration.

From debulking to delivery: sequential use of rotational atherectomy and Guidezilla\u2122 for complex saphenous vein grafts intervention

BackgroundPercutaneous coronary interventions (PCI) of old calcified saphenous vein grafts (SVGs) is challenging and is associated with a considerably high risk of adverse ischemic events in the short- and long-term as compared to native coronary arteries. We report a case in which a non-dilatable, calcified SVG lesion is successfully treated with rotational atherectomy followed by PCI and stenting with local stent delivery (LSD) technique using the Guidezilla™ guide extension catheter (5-in-6 Fr) in the “child-in-mother” fashion.Case presentationA 70 years-old man with a dilated ischemic cardiomyopathy, triple coronary artery bypass grafting (CABG) in 1990 and chronic renal failure (baseline GFR: 45 ml/min/1.73 m2) underwent a coronary angiography for a Non-ST segment elevation myocardial infarction (NSTEMI). Native coronary circulation was completely occluded at the proximal segments. Grafts angiography showed a tandem calcified lesions of SVG on distal right coronary artery (RCA) and an ostial stenosis of the SVG on first obtuse marginal branch (OM1). Left internal mammary artery on the mid left anterior descending artery was patent. Ad Hoc PCI of SVG on RCA was attempted. The proximal calcified stenosis has been crossed with a 1.5 x 12 mm balloon only with the support of Guidezilla™, however the non-compliant (NC) balloon 2.5 x 15 mm was unable to break the hard and calcified plaque. After several attempts, the procedure was interrupted with a suboptimal result. An elective transradial PCI of SVG on RCA with rotational atherectomy was performed. Two runs with 1.25 mm burr and 2 runs with 1.5 mm burr were carried out. Then, the use of distal anchoring balloon warranted support and tracking, made as centring rail for the advance of the tip of the “mother-and-child” catheter into the SVG. During slow deflation of the balloon, the Guidezilla™ was advanced distal to the stenoses to be stented, thus allowing the placement of two long drug eluting stents according to a LSD technique.ConclusionsRotational atherectomy is a feasible option for non-dilatable stenoses in old SVGs when there is no evidence of thrombus or vessel dissection and the subsequent use of “mother-and-child” catheter has a key role, especially in case of radial approach, for long stents delivery.

Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset

ObjectivesThe authors sought to determine the relationships between left radial access (LRA) or right radial access (RRA) and clinical outcomes using the British Cardiovascular Intervention Society (BCIS) database. BackgroundLRA has been shown to offer procedural advantages over RRA in percutaneous coronary intervention (PCI) although few data exist from a national perspective around its use and association with clinical outcomes. MethodsThe authors investigated the relationship between use of LRA or RRA and clinical outcomes of in-hospital or 30-day mortality, major adverse cardiovascular events (MACE), in-hospital stroke, and major bleeding complications in patients undergoing PCI between 2007 and 2014. ResultsOf 342,806 cases identified, 328,495 (96%) were RRA and 14,311 (4%) were LRA. Use of LRA increased from 3.2% to 4.6% from 2007 to 2014. In patients undergoing a repeat PCI procedure, the use of RRA dropped to 72% at the second procedure and was even lower in females (65%) and patients >75 years of age (70%). Use of LRA (compared with RRA) was not associated with significant differences in in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 0.90 to 1.57; p = 0.20), 30-day mortality (OR: 1.17, 95% CI: 0.93 to 1.74; p = 0.16), MACE (OR: 1.06, 95% CI: 0.86 to 1.32; p = 0.56), or major bleeding (OR: 1.22, 95% CI: 0.87 to 1.77; p = 0.24). In propensity match analysis, LRA was associated with a significant decrease in in-hospital stroke (OR: 0.52, 95% CI: 0.37 to 0.82; p = 0.005). ConclusionsIn this large PCI database, use of LRA is limited compared with RRA but conveys no increased risk of adverse outcomes, but may be associated with a reduction in PCI-related stroke complications.

Abstract 116: Independent Prognostic Value of Guideline-Directed Medical Therapy, Radial Access, and Door-to-Balloon Time in Predicting STEMI In-Hospital Mortality

Background: Systems-based strategies to improve STEMI care have traditionally focused on improving door to balloon time (D2BT) performance. However, prompt guideline-directed medical therapy (GDMT) and use of radial access for PCI are also associated with reduced mortality in patients with STEMI. The incremental value of each facet of STEMI care on mortality is unknown. Methods: On 7/15/14 we implemented a comprehensive four-step STEMI protocol at our institution: (1) ED physician cath lab activation (2) Safe STEMI Handoff Checklist with GDMT decision support (3) immediate transfer to an immediately available cath lab and (4) radial access for PCI. The protocol was intended to minimize care variability in GDMT (aspirin, P2Y12 inhibitor, and anticoagulant) prior to PCI, use of radial access for PCI, and D2BT. We studied consecutive patients with STEMI treated with PCI at our center (1/1/11-12/31/16) to assess the incremental prognostic value of these STEMI care processes using logistic regression models. Results: Of 1272 participants mean age was 61+/-12 years and 68% were men. STEMI presenting location was 25% primary ED, 69% inter-hospital transfer, and 6% in-hospital. The rates of GDMT prior to PCI (74% vs 83%, P&lt;0.001) and radial access for PCI (19% vs. 67%, P&lt;0.001) improved and median D2BT (106 [81-140] vs. 90 [68-109], P&lt;0.001) decreased after implementation of the comprehensive four-step STEMI protocol. In a multivariable model, GDMT prior to PCI (OR 0.42, 95% CI 0.25-0.71, P=0.001), radial access for PCI (OR 0.44, 95% CI 0.23-0.82, P=0.002), and decreasing D2BT (10min decrease: OR 0.96, 95% CI 0.94-0.99, P=0.007) were each independently associated with reduced odds of in-hospital mortality. Step-wise modeling of the risk of in-hospital mortality demonstrated that GDMT prior to PCI, radial access for PCI, and D2BT performance provided incremental prognostic value when added in stepwise order of the occurrence of these care processes in clinical practice (Figure). Conclusions: Prompt GDMT administration, radial access for PCI, and D2BT performance add incremental prognostic value. Expanding STEMI systems of care from a singular focus on D2BT to a comprehensive focus on multi-faceted STEMI care offers an opportunity to further improve STEMI outcomes.

Use of rotational atherectomy for reducing significant dissection in treating de novo femoropopliteal steno-occlusive disease after balloon angioplasty.

BackgroundDevelopment of arterial dissection is thought to be an important key factor for bailout stenting in femoropopliteal disease. We aimed to evaluate the difference in dissection rate and outcomes between the treatment group with rotational atherectomy and without it.MethodsFrom January 2011 to October 2016, we compared the angiography after balloon angioplasty (BA) of de-novo, femoropopliteal, steno-occlusive lesions whether they were treated by rotational atherectomy prior to the BA or not. Fifty-nine lesions (8 occlusions; 3 involving popliteal segment; lesion length: 86.3 ± 66.8 mm) in 44 patients (29 males; mean age 66.9 ± 9.7 years) were enrolled for this review.ResultsForty-two lesions were treated using rotational atherectomy, prior to BA while 17 were recanalized firstly by BA. Clinical and lesion characteristics were not different between the groups. However, the rate of significant arterial dissection (type C to F) was lower in the atherectomy group (88.2% vs. 42.9%; P = 0.001). In multivariate analysis, use of the atherectomy device was the only risk factor for prevention of development of significant dissection (P = 0.013; OR = 0.12; 95% CI: 0.025–0.642). Patients were treated either by the angioplasty alone, drug coated balloon or stent insertion. There was lower trend in target vessel revascularization and primary patency toward the atherectomy group (low rank P = 0.108 and 0.166), however secondary patency was significantly better (low rank P = 0.001).ConclusionsRotational atherectomy before BA reduced the rate of significant dissection and therefore, might be a valuable option for minimizing need of bailout stenting.

Vascular Access Site and Outcomes in 58,870 Patients Undergoing Percutaneous Coronary Intervention With a Previous History of Coronary Bypass Surgery: Results From the British Cardiovascular Interventions Society National Database

ObjectivesUsing the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, access site choice and outcomes of patients undergoing PCI with previous coronary artery bypass grafting (CABG) were studied. BackgroundGiven the influence of access site on outcomes, use of radial access in PCI-CABG warrants further investigation. MethodsData were analyzed from 58,870 PCI-CABG procedures performed between 2005 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes. ResultsThe number of PCI-CABG cases and the percentage of total PCI increased significantly during the study period. Femoral artery (FA) utilization fell from 90.8% in 2005 to 57.6% in 2014 (p < 0.001), with no differences in the rate of change of left versus right radial use. In contemporary study years (2012 to 2014), female sex, acute coronary syndrome presentation, chronic total occlusion intervention, and lower operator volume were independently associated with FA access. Length of stay was shortened in the radial cohort. Unadjusted outcomes including an access site complication (1.10% vs. 0.30%; p < 0.001), blood transfusion (0.20% vs. 0.04%; p < 0.001), major bleeding (1.30% vs. 0.40%; p < 0.001), and in-hospital death (1.10% vs. 0.60%; p = 0.001) were more likely to occur with FA access compared with radial access. After adjustment, although arterial complications, transfusion, and major bleeding remained more common with FA use, short- and longer-term mortality and major adverse cardiac event rates were similar. ConclusionsIn contemporary practice, FA access remains predominant during PCI-CABG with case complexity associated with it use. FA use was associated with longer length of stay, and higher rates of vascular complications, major bleeding, and transfusion.

Long-term outcomes of rotational atherectomy of underexpanded stents. A single center experience.

ObjectivesTo analyze the procedural and long‐term outcomes of the use of rotational atherectomy (RA) in underexpanded stents in our cohort and to provide an overview of currently available data on this technique.BackgroundStent underexpansion (SU) has been related to stent thrombosis and restenosis. RA has been used to treat undilatable SU as a bail‐out strategy with encouraging results.MethodsThis is an observational, single‐center study. We included patients who underwent stentablation between 2013 and 2017. Baseline demographics, procedural results, in‐hospital major adverse cardiac events (MACE), and long‐term follow‐up MACE were retrospectively collected.ResultsA total of 11 patients (90.9% males, mean age 65.4 ± 18.6) were included in this study. Median left ventricle ejection fraction was 53.5% [46.2‐55]. Median calculated Syntax score was 16 [9‐31] and 45.5% of patients were admitted for acute coronary syndrome. Radial approach was used in 63.6% of cases. Most patients only required one burr (45% used a 1.5 mm diameter burr) during the intervention. Procedural success was achieved in 90.9% of the cases. Acute lumen gain was 42.7% [30.7‐61.49]. There were no in‐hospital deaths or MACE. At a median follow‐up of 26 months, only one patient (9.1%) suffered MACE in the context of acute coronary syndrome, and two patients (18.2%) required non‐target lesion revascularization. No deaths were reported.ConclusionsRA of under expanded stents is a feasible option with a high rate of procedural success. At long‐term follow‐up, all of them were alive and 90.9% of patients remained free from MACE.

Temporal changes in radial access use, associates and outcomes in patients undergoing PCI using rotational atherectomy between 2007 and 2014: results from the British Cardiovascular Intervention Society national database

AimsAccess site choice for cases requiring rotational atherectomy (PCI-ROTA) is poorly defined. Using the British Cardiovascular Intervention Society PCI database, temporal changes and contemporary associates/outcomes of access site choice for PCI-ROTA were studied. Methods and ResultsData were analysed from 11,444 PCI-ROTA procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes. ResultsFor PCI-ROTA, radial access increased from 19.6% in 2007 to 58.6% in 2014. Adoption of radial access was slower in females, those with prior CABG, and in patients with chronic occlusive (CTO) or left main disease. In 2013/14, the strongest predictors of femoral artery use were age (OR 1.02, [1.005-1.036], P = .008), CTO intervention (OR 1.95, [1.209-3.314], P = .006), and history of previous CABG (OR 1.68, [1.124-2.515], P = .010). Radial access was associated with reductions in overall length of stay, and increased rates of same-day discharge. Procedural success rates were similar although femoral access use was associated with increased access site complications (2.4 vs. 0.1%, P < .001). After adjustment for baseline differences, arterial complications (OR 15.6, P < .001), transfusion (OR 12.5, P = .023) and major bleeding OR 6.0, P < .001) remained more common with FA use. Adjusted mortality and MACE rates were similar in both groups. ConclusionsIn contemporary practice, radial access for PCI-ROTA results in similar procedural success when compared to femoral access but is associated with shorter length of stay, and lower rates of vascular complication, major bleeding and transfusion.

An Overview of Care Changes in the Last 6 Year in Primary PCI in ST-Elevation Myocardial Infarction in a Tertiary University Brazilian Hospital

Abstract Background: Although new studies and guidelines can be considered useful tools, it does not necessarily mean they are put into clinical practice. Objective: The aim of the current analysis was to assess the changes in primary percutaneous coronary intervention (PCI) and mortality in a tertiary university hospital in southern Brazil during a six-year period. Methods: We have included consecutive patients with ST-elevation myocardial infarction (STEMI) who underwent primary PCI between March 2011 and February 2017. Previous clinical history, characteristics of the procedure, and reperfusion strategies were collected. In-hospital, short and long-term mortalities were also evaluated. The significance level adopted for all tests was 5%. Results: There was an increase in the use of radial access in patients from 20.0% in 2011 to 62.7% in 2016 (ptrend 0.05). However, a lower in-hospital mortality was observed in patients treated through radial access (p < 0.001). Cardiogenic shock occurred in 11.1%, without statistical differences in the period (ptrend = 0.39), while long-term mortality rate decreased from 80.0% in 2011 to 27.3% in 2016 in this patient group (ptrend = 0.29). Conclusions: During a 6-year follow-up period, primary PCI characteristics underwent important modifications. Radial access became widely used, with a decrease in mortality with the use of this route, while aspiration thrombectomy became a rare procedure. The incidence of cardiogenic shock remained stable, but has shown a reduction in its mortality.