Vascular Access Complications Research Articles

The role of the vascular surgeon in transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic valve stenosis in patients at increased surgical risk. Percutaneous transfemoral (TF) is the access of choice due to its reduced invasiveness and perioperative morbidity/mortality compared with the trans-axillary, aortic, and apical routes. On the other hand, vascular access complications (VACs) of the TF access are associated with prolonged hospitalization, 30-day, and 1-year mortality. In addition, the concomitance of peripheral arterial disease may require associated endovascular management. A multidisciplinary team with Interventional Cardiologists and Vascular Surgeons may minimize the rate of VACs in patients with challenging femoral-iliac access or concomitant disease of other vascular districts, thus optimizing the outcome of TF-TAVI. The aim of this study was to evaluate the role of Vascular Surgeons in TF TAVI procedures. We conducted a retrospective single-center review of all TF-TAVI procedures assisted by Vascular Surgeons between January 2016 and December 2020 in a high-volume tertiary hospital. Pre, intra, and postoperative data were analyzed by a dedicated group of Interventional Cardiologists and Vascular Surgeons. VACs were defined according with the Valve Academic Research Consortium (VARC) three guidelines. The outcomes of TF-TAVI procedures with Vascular Surgeons involvement were assessed as study's endpoints. Overall, 937 TAVI procedures were performed with a TF approach ranging between 78% (2016) and 98% (2020). Vascular Surgeons were involved in 67 (7%) procedures with the following indications: concomitant abdominal aortic aneurysm (EVAR + TAVI) - 3 (4%), carotid stenosis (TAVI + CAS) - 2 (3%), hostile femoral/iliac access, or VACs - 62 (93%). Balloon angioplasty of iliac artery pre-TAVI implantation was performed in 51 cases (conventional PTA: 38/51%-75%; conventional PTA + intravascular lithotripsy: 13/51%-25%; stenting: 5/51%-10%). TAVI procedure was successfully completed by percutaneous TF approach in all 62 cases with challenging femoral/iliac access. VACs necessitating interventions were 18/937 (2%) cases, localized to the common femoral or common/external iliac artery in 15/18 (83%) and 3/18 (17%) cases, respectively. They were managed by surgical or endovascular maneuvers in 3/18 (17%) and 15/18 (83%) cases, respectively. Fifteen/18 (83%) VACs were treated during the index procedure. There was no procedure-related mortality or 30-day readmission. In our experience, Vascular Surgeon assistance in TAVI procedures was not infrequent and allowed safe and effective device introduction through challenging TF access. Similarly, the concomitant significant disease of other vascular districts could be safely addressed, potentially reducing postoperative related mortality and morbidity. The implementation of multidisciplinary team with interventional cardiologists and vascular surgeons should be encouraged whenever possible.

Safety of Amulet Left Atrial Appendage Occluder and Watchman Device for Left Atrial Appendage Closure in Patients With Atrial Fibrillation.

Left atrial appendage (LAA) closure is an alternative to chronic anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation. Multiple devices were used for LAA closure, with the Amplatzer Amulet LAA Occluder (Abbott,Chicago, IL, USA) and Watchman device (Boston Scientific,Marlborough, MA, USA) being the most commonly used in clinical practice. In August 2021, the FDA approved the use of the Amplatzer Amulet LAA Occluder. There is still a knowledge gap in the safety profile of the Amplatzer Amulet LAA Occluder device in comparison to the Watchman device. The aim of this study was to assess and compare the safety profile peri-procedure and post-procedure between the Amplatzer Amulet LAA Occluder and Watchman devices. Patients who underwent LAA closure using Watchman or Amulet devices from July 2015 to August 2020 at the American University of Beirut Medical Center were included in the analysis. Primary endpoints included peri-operative and post-procedural complications (thromboembolic events, bleeding complications, vascular access complications, pericardial effusion/tamponade, device positional complications and in-hospital death). The study included 37 patients (21 had Watchman devices, 16 had Amplatzer Amulet LAA Occluder devices, and 28 were men, mean age 76.57 ± 9.3 years). Seven patients developed post-procedural iatrogenic atrial septal defects (four in the Watchman group vs three in the Amulet group, p-value=0.982). Three patients developed pericardial effusion (one in the Watchman vs two in the Amulet group, p-value=0.394). Only one patient developed peri-device leak (one in the Watchman group vs none in the Amulet group, p-value=0.283). One device could not be deployed (one in the Amulet group vs none in the Watchman group, p-value=0.191). None of the patients developed in-hospital death, cardiac tamponade, device embolism, device thrombosis, stroke/transient ischemic attack (TIA), cranial bleeding, or arrhythmias after the procedure. The rate of peri-operative complications was similar between both groups. Both groups displayed low rates of adverse events in the peri-operative and post-operative periods. There was no significant difference in the safety profile of Amplatzer Amulet LAA Occluders and Watchman devices. There was a low incidence of peri-operative and post-operative adverse events with the implanted devices.

Does central venous stenosis affects the brachial artery flow volume and peripheral vascular resistive index in patients on maintenance hemodialysis? A retrospective study.

A well-functioning vascular access (VA) is crucial for the patients on maintenance hemodialysis (HD). Central venous stenosis (CVS) is a common, yet, overlooked complication of VA as its diagnosis is challenging. Moreover, its effect on the flow volume (FV) and the peripheral resistive index (RI) was not well discussed before. Despite the availability of doppler ultrasound (DUS) in most centers, direct visualization of central veins using DUS is quite difficult. This is a retrospective single-center self-controlled cohort study that was conducted in a specialized vascular access management tertiary center in Japan and included all patients with CVS who underwent percutaneous transluminal angiography (PTA) with or without vascular stenting in the period from January 2014 to September 2022. The patients were divided according to their VA type into arteriovenous fistula (AVF), and arteriovenous graft (AVG) groups, then subdivided, according to the type of stenosis, into two subgroups: CVS, and mixed central and peripheral venous stenosis (MVS) groups. The FV and RI of the feeding artery were compared in the same procedure before and after PTA to assess the impact of the procedure itself. Data of 485 percutaneous transluminal angiography procedures (PTA), performed in 95 patients during the period from January 2014 to September 2022, were collected. FV and RI were significantly affected in the patients with MVS than patients with CVS. After PTA, both FV and RI were significantly improved. The improvement rate of FV and RI after PTA were significantly higher in patients with MVS than patients with CVS. However, it was difficult to determine the cut-off value to diagnose or to assess the improvement of CVS. Our findings suggest that FV and RI measurement by DUS are good tools, along with the clinical findings for assessment of CVS in certain situations.

Thoracic aortic aneurysms, a single center's 10-years experience and analysis of outcomes.

Thoracic aortic aneurysms (TAAs) are an increasingly prevalent pathology with significant associated morbidity and mortality. Thoracic endovascular aortic repair (TEVAR) is the primary line of treatment. The purpose of this study was to analyse a single center's experience in the treatment of TAAs and identify possible risk factors for worse outcomes. A retrospective review of our institutional database was done to identify all patients treated for TAAs in a 10-year period, from 1 January 2012 to 31 December 2022. Data were extracted from patients' medical records. Primary outcome was all-cause mortality and secondary outcomes were procedure related morbidity (vascular access complications, medullary ischaemia, stroke, endoleaks, migration, aneurysm sac enlargement >5mm) and need for reintervention at 1-, 6- and 12-month follow-up. A descriptive and inferential analysis of the data was performed. Statistical analyses were conducted using the IBM Statistical Package for Social Sciences (SPSS) software. We identified 34 patients treated for TAAs in this period. Mean age was 68years [47-87] and 79.4% of patients were male. Mean aneurysm diameter was 63mm [35-100], 55.9% fusiform and 44.1% saccular. The majority (91.2%) were located at the descending thoracic aorta and 3 (8.8%) of them extended to the aortic arch. The most common aetiology was degenerative in 22 patients (64.7%), followed by aortic dissection in 8 patients (23.5%). Elective surgery was performed in 19 (61.3%) patients and 12 (38.7%) had urgent repair. TEVAR was the treatment of choice in 24 (77.4%) patients, and the remaining 7 (22.6%) were treated with hybrid surgery. Mean length of hospital stay was 10days [2-80] (6 days for elective repair versus 16days for urgent repair, p = .016). Follow-up period ranged from 1month to 10years. At 1 year follow-up, all-cause mortality was 15%, morbidity was 30% (with 6 (22%) patients having a type Ia endoleak) and need for reintervention was 22%. Aneurysm diameter was a significant risk factor for procedure related morbidity (median diameter of 73.5mm versus 56.0mm in patients with no morbidity; p = .027). The presence of type Ia endoleak was significantly associated with higher reintervention rates (p = .001), but not with higher mortality rates (p = .515). Age, female sex, aetiology and urgent repair weren't associated with any significant differences in the outcomes. TEVAR proved to be effective in the treatment of TAAs, with good outcomes at short and mid-term follow-up. TAAs should be diagnosed earlier and be promptly treated when meeting criteria to prevent worse outcomes.

Point-of-Care Arterio-Venous Fistula Ultrasound in the Outpatient Hemodialysis Unit-A Survey on the Nurses' Perspective.

The preservation of complication-free arterio-venous fistulas (AVF) for long-term hemodialysis (HD) use is associated with better overall patient outcomes, which is why this is a current goal in any HD center. Point-of-care ultrasound (POCUS) for in-center AVF assessment has proven its benefits in the identification of vascular access (VA) complications and as an additional tool to avoid blind cannulation. The current study aims to assess the change in the HD nurses' perceptions regarding AVF POCUS use in the HD center. The nursing staff anonymously answered a Likert scale questionnaire with five questions related to various aspects of AVF POCUS utility shortly after the technique had been implemented and at a 5-year follow-up. The results showed an overall positive attitude toward this method, both at implementation and at follow-up, with no statistically significant score changes for four out of the five items assessed. However, we found a statistically significant reduction in the nurses' cannulation confidence scores at the 5-year follow-up (p < 0.01). Overall, AVF POCUS implementation is regarded as a useful tool, with major benefits both for the patient and for the medical team. The current study results aim to support the introduction of AVF POCUS assessment as a standard practice from the nursing staff's viewpoint. This study was not registered.

Clinical impact of cerebral protection during transcatheter aortic valve implantation.

Embolization of debris can complicate transcatheter aortic valve implantation (TAVI) causing stroke. Cerebral embolism protection (CEP) devices can divert or trap debris. To evaluate the efficacy of CEP during TAVI vs the standard procedure. PubMed, SCOPUS and DOAJ 1/01/2014-04/12/2023. Randomized and observational studies comparing CEP versus standard TAVI, according to PRISMA. stroke. death, bleeding, vascular access complications, acute kidney injury and infarct area. Two investigators independently assessed study quality and extracted data. Twenty-six articles were included (540.247 patients). The primary endpoint was significantly lower (RR = 0.800 95%CI:0.682-0.940; p = 0.007) with CEP. Similarly, death rates were significantly lower with CEP (RR = 0.610 95%CI:0.482-0.771; p < 0.001). No difference was found for bleeding (RR = 1.053 95%CI:0.793-1.398; p = 0.721), vascular complications (RR = 0.937 95%CI:0.820-1.070; p = 0.334) or AKI (RR = 0.982 95%CI:0.754-1.279; p = 0.891). Use of CEP during TAVI is associated with improved outcomes. Future studies will identify patients who benefit most from CEP.

In-hospital outcomes of transcatheter aortic valve replacement in patients with chronic and end-stage renal disease: a nationwide database study

BackgroundChronic kidney disease (CKD) and end-stage renal disease (ESRD) have been associated with worse outcomes after transcatheter aortic valve replacement (TAVR). With TAVR indications extending to a wider range of patient populations, it is important to understand the current implications of chronic renal insufficiency on clinical outcomes. We aim to determine the impact of CKD and ESRD on in-hospital outcomes after TAVR.MethodsWe queried the National Inpatient Sample for TAVR performed between 2016 and 2020 using International Classification of Diseases-10th Revision codes. We compared in-hospital mortality and clinical outcomes between three groups: normal renal function, CKD and ESRD. The association between CKD/ESRD and outcomes was tested with multivariable logistic regression analyses, using normal renal function as baseline.ResultsIn the five-year study period, 279,195 patients underwent TAVR (mean age 78.9 ± 8.5 years, 44.4% female). Of all patients, 67.1% had normal renal function, 29.2% had CKD, and 3.7% had ESRD. There were significant differences in age, sex, and prevalence of comorbidities across groups. In-hospital mortality was 1.3%. Compared to patients with normal renal function, patients with renal insufficiency had higher in-hospital mortality, with the highest risk found in patients with ESRD (adjusted odds ratio: 1.4 [95% confidence interval: 1.2–1.7] for CKD; adjusted odds ratio: 2.4 [95% confidence interval: 1.8–3.3] for ESRD). Patients with CKD or ESRD had a higher risk of cardiogenic shock, need for mechanical circulatory support, and vascular access complications, compared to those with normal renal function. In addition, patients with ESRD had a higher risk of cardiac arrest and periprocedural acute myocardial infarction. The incidence of conversion to open heart surgery was 0.3% and did not differ between groups. Post-procedural infectious and respiratory complications were more common among patients with CKD or ESRD.ConclusionPatients with CKD and ESRD are at higher risk of in-hospital mortality, cardiovascular, and non-cardiovascular complications after TAVR. The risk of complications is highest in patients with ESRD and does not result in more frequent conversion to open heart surgery. These results emphasize the importance of individualized patient selection for TAVR and procedural planning among patients with chronic renal insufficiency.

Streamlining same-day discharge for percutaneous coronary intervention: A single-center experience

Introduction and objectivesSame-day discharge (SDD) can be considered for patients who traditionally required overnight stay (ONS) after percutaneous coronary intervention (PCI). The authors aimed to evaluate viability of SDD-PCI. MethodsRetrospective single-center observational study of patients who underwent elective PCI. SDD patients were selected based on clinical, angiographic, and sociodemographic characteristics. Patient and procedure characteristics were collected from local databases, and SDD-PCI adverse events (all-cause mortality, acute coronary syndrome, stent thrombosis, reintervention, major bleeding, stroke, contrast-induced renal failure, vascular access complications) at 30-days were analyzed. ResultsThis study included 147 patients, 76% males with a mean age of 66±10, that underwent elective PCI during the first year after implementation of SDD protocol. Most patients undergoing elective PCI were discharged the same day (n=94, 64%). ONS group, when compared to SDD, had higher rates of acute coronary syndrome (38% vs 19%, P=.01) and left ventricular dysfunction (17% vs 6%, P=.04), higher Syntax I score (10 points [6–16] vs 8 points [5–12]; P=.01), more cases of multivessel PCI (24% vs 6%, P<.01) and a surrogate for longer procedures – fluoroscopy time (11min [7–15] vs 8min [5–13]; P=.02). There were no adverse events during the 30-day follow-up period of the patients treated in ambulatory regimen. ConclusionsSDD-PCI is a safe procedure. Protocol implementation is key to guide interventional cardiologists in low-risk patient selection. The potential role in decreasing bed-shortage, hospital overcrowding, and healthcare costs is pivotal.

The role of external iliac artery diameter indexed to BSA score in predicting vascular access complications after transfemoral transcatheter aortic valve implantation.

Aortic stenosis is the most common primary valve disease and requires invasive treatment. Transcatheter aortic valve implantation (TAVI) from a transfemoral access is a routine intervention worldwide. To investigate the correlation between external iliac artery diameter (EIAD) indexed to body surface area (BSA) (EIAD-BSA) and access site complications in patients undergoing TAVI via transfemoral access (TF) (TF-TAVI). Patients underwent TF-TAVI in 2017-2019 at the Upper-Silesian Medical Center in Katowice. Based on the preoperative multi-slice computed tomography (MSCT), pre-specified measurements of the ilio-femoral vessels were performed. The results were indexed to BSA and body mass index (BMI). Complications after TAVI were defined by Valve Academic Research Consortium 3 (VARC-3). The primary outcome regarding the adverse events after TAVI was the composite of access site complications requiring surgical intervention or blood transfusion. The registry included 193 unselected patients with severe symptomatic aortic stenosis. Vascular and access-related complications including bleeding occurred in 17.1% of patients. Major TAVI access site complications (VARC-3) were reported in 5.7% of patients, while minor complications (VARC-3) occurred in 2.6%. EIAD-BSA demonstrated a positive correlation with the access site complications primary endpoint. Patients with greater EIAD-BSA had a numerically higher number of access site adverse events requiring surgical intervention or blood transfusion: n = 12 (5%) vs. n = 4 (4%), p = 0.011. External iliac artery diameter indexed to BSA could be an underestimated indicator of unfavorable outcomes after TF-TAVI, predicting periprocedural access site complications.

Rate of Arteriovenous Fistula Stenosis and Access Recirculation among Individuals Receiving Maintenance Hemodialysis

Background: Arteriovenous fistula stenosis and access recirculation in hemodialysis represent critical challenges, influencing the efficiency of vascular access and dialysis treatment outcomes. Objective: The objective is to assess the prevalence of arteriovenous fistula (the AVF) stenosis as well as access recirculation (AR) in patients of hemodialysis. Study Design: Cross sectional study. Settings: Department of Nephrology, Bolan Medical Complex Hospital, Quetta. Duration: From 1st April 2022 to 1st September, 2022. Methods: Adult patients having age 18 years to 80 years receiving maintenance hemodialysis 3 times in a week were included in this study. Patients who were willing to provide informed consent participated in the study. Patients with active infections or sepsis, with a history of vascular access interventions within the last three months, pregnant or lactating women as well as patients with cognitive impairment were excluded from study. Outcome variables will be incidence of AVF Stenosis which was determined by regular ultrasound assessments and monitoring of clinical symptoms. Statistical analyses were performed using SPS version 22. Results: The study comprised 150 maintenance hemodialysis patients with a mean age of 55±10. Age distribution showed that 20% were between 18-40 years, 53.3% between 41-60 years, 23.3% between 61-80 years, and 3.3% were older than 80 years. Sixty percent (60%) of the participants were male, while 40% were female. The mean duration of AV fistula use was 3.21± 2.65 years, with 14.66% having duration of 6-12 months, 41.33% between 1-3 years, and 44% using AV fistulas for more than 3 years. Seventy-five point three percent (75.3%) of patients had hypertension, 40.0% had diabetes mellitus, and 28.0% had cardiovascular disease. Additionally, 16.7% of patients presented with other comorbidities. Out of total 25 (16.7%) patients were affected by arteriovenous fistula (AVF) stenosis, while access recirculation was observed in 20 patients (13.3%). Conclusion: In conclusion, our study reveals a notable incidence of arteriovenous fistula (AVF) stenosis and access recirculation among maintenance hemodialysis patients. The observed associations with age and AVF duration underscore the complexity of vascular access complications.

Posterior wall ablation by pulsed-field ablation: procedural safety, efficacy, and findings on redo procedures.

The left atrial posterior wall is a potential ablation target in patients with recurrent atrial fibrillation despite durable pulmonary vein isolation or in patients with roof-dependent atrial tachycardia (AT). Pulsed-field ablation (PFA) offers efficient and safe posterior wall ablation (PWA), but available data are scarce. Consecutive patients undergoing PWA using PFA were included. Posterior wall ablation was performed using a pentaspline PFA catheter and verified by 3D-electroanatomical mapping. Follow-up was performed using 7-day Holter ECGs 3, 6, and 12 months after ablation. Recurrence of any atrial arrhythmia lasting more than 30 s was defined as failure. Lesion durability was assessed during redo procedures. Posterior wall ablation was performed in 215 patients (70% males, median age 70 [IQR 61-75] years, 67% redo procedures) and was successful in all patients (100%) by applying a median of 36 (IQR 32-44) PFA lesions. Severe adverse events were cardiac tamponade and vascular access complication in one patient each (0.9%). Median follow-up was 7.3 (IQR 5.0-11.8) months. One-year arrhythmia-free outcome in Kaplan-Meier analysis was 53%. A redo procedure was performed in 26 patients (12%) after a median of 6.9 (IQR 2.4-11) months and showed durable PWA in 22 patients (85%) with only minor lesion regression. Among four patients with posterior wall reconnection, three (75%) presented with roof-dependent AT. Posterior wall ablation with this pentaspline PFA catheter can be safely and efficiently performed with a high durability observed during redo procedures. The added value of durable PWA for the treatment of atrial fibrillation remains to be evaluated.

Filter Lifespan, Treatment Effect, and Influencing Factors of Continuous Renal Replacement Therapy for Severe Burn Patients.

Continuous renal replacement therapy (CRRT) is often disrupted due to various factors, such as patient-related issues, vascular access complications, treatment plans, and medical staff factors. This unexpected interruption is referred to as non-selective filter stoppage and can result in additional treatment expenses. This study conducted a retrospectively analyzed 501 CRRT filters used in 62 patients with severe burns, lifespan and therapeutic effect of all filters were mainly analyzed, used logistic regression analysis was performed to identify risk factors associated with non-selective cessation filters. Out of 493 filters, 279 cases received heparin (56.60%), the median lifespan of the filter was 14.08 h (25th, 75th quantile: 7.30, 21.50); 128 cases were treated with nafamostat mesylate (26.00%), and the median lifespan of the filter was 16.42 h (10.49, 22.76); 86 cases were treated with sodium citrate (17.40%), and the median lifespan of the filter was 31.06 h (19.25, 48.75). In addition, significant differences were observed in the electrolyte index, renal function index, and procalcitonin levels before and after treatment with a single filter (P < .001). Multivariate logistic regression showed that the risk of non-selective cessation of sodium citrate anticoagulants was lower than that of heparin anticoagulation. Overall, CRRT is progressively becoming more prevalent in the treatment of patients with severe burns. The lifespan of individual filters and total patient treatment duration showed a consistent upward trend. The filter's lifespan was notably greater during sodium citrate anticoagulation when compared to nafamostat mesylate and heparin, meanwhile notably reducing the risk of non-selective cessation. Therefore, we recommend sodium citrate for anticoagulation in patients without any contraindications.

Emergency transvenous temporary pacing during rotational atherectomy.

Rotational atherectomy (RA) during percutaneous coronary intervention may cause transient bradycardia or a higher-degree heart block. Traditionally, some operators use prophylactic transvenous pacing wire (TPW) to avoid haemodynamic complications associated with bradycardia. We sought to establish the frequency of bail-out need for emergency TPW insertion in patients undergoing RA that have received no upfront TPW insertion. We performed a single-centre retrospective study of all patients undergoing RA between October 2009 and October 2022. Patient characteristics, procedural variables, and in-hospital complications were registered. A total of 331 patients who underwent RA procedure were analysed. No patients underwent prophylactic TPW insertion. The mean age was 73.3 ± 9.1 years, 71.6% (n = 237) were male, while nearly half of the patients were diabetic [N = 158 (47.7%)]. The right coronary artery was the most common target for RA (40.8%), followed by the left anterior descending (34.1%), left circumflex (14.8%), and left main stem artery (10.3%). Altogether 20 (6%) patients required intraprocedural atropine therapy. Emergency TPW insertion was needed in one (0.3%) patient only. Eight (2.4%) patients died, although only one (0.3%) was adjudicated as being possibly related to RA-induced bradycardia. Five patients (1.5%) had ventricular fibrillation arrest, while nine (2.7%) required cardiopulmonary resuscitation. Six (1.8%) procedures were complicated by coronary perforation, two (0.6%) were complicated by tamponade, while 17 (5.1%) patients experienced vascular access complications. Bail-out transvenous temporary pacing is very rarely required during RA. A standby temporary pacing strategy seems reasonable and may avoid unnecessary TPW complications compared with routine use.

Same day discharge after large bore vascular access in percutaneous coronary intervention of chronic total coronary occlusions

Abstract Background Same day discharge (SDD) in patients undergoing percutaneous coronary intervention (PCI) of a chronic total coronary occlusion (CTO) appears feasible, safe, and carries economic advantage. However, SDD may be hampered by the application of large bore dual arterial access, due to its association with vascular complications. Nevertheless, increasing French size augments therapeutic options and is therefore considered fundamental in complex CTO PCI. Purpose The present study investigated the feasibility of SDD in patients undergoing CTO PCI with large bore dual arterial access. Methods Between 2013 and 2018, a total of 683 patients were prospectively enrolled in a single-center CTO registry and underwent single-vessel CTO PCI. Large bore arterial access was defined as the application of 7 and/or 8 French sheaths in at least one access site. Technical success was defined as Thrombolysis in Myocardial Infarction flow grade 3 and residual stenosis &amp;lt;30%. Vascular access complications were defined as a composite of clinically significant bleeding and/or hematoma, urgent transfusion, dissection, pseudoaneurysm, arteriovenous fistula formation, and thrombosis. Results Mean age was 66 ± 11 years; 83% were male. Large bore arterial access was applied in 87%; the most common set-up was radial-femoral (68%) and bifemoral (23%) access. In 432 (62%) patients, SDD was achieved. Patients within the SDD group were younger and had lower rates of prior MI, prior CABG, renal insufficiency, and peripheral artery disease. A high Japanese CTO score (≥2) was less common in patients with versus without SDD (58% vs. 72%, p&amp;lt;0.001). In addition, technical success rate was higher in the SDD group (96% vs. 89%, p&amp;lt;0.001). Vascular access complications were found in 22 (3,2%) cases, with 17 (77,2%) occurring in the non-SDD group. Local access site bleeding was found to be the most common complication (82,4% of total vascular access complications). Finally, multivariable analysis showed that female gender (OR 2.22, 95% CI: 1.30 – 3.78) and local access site bleeding (OR 12.0, 95% CI: 4.37 – 33.21) were significantly associated with a lower probability of SDD. Conclusions Our study demonstrates the feasibility of SDD in the majority of patients undergoing CTO PCI with large bore dual arterial access, with high rates of technical CTO PCI success and acceptable vascular access complication rates. Care should be taken to avoid local access site bleeding since this hinders SDD.

Five-year outcomes of coarctoplasty with stent in the paediatric population, results from a retrospective single-centre cohort with centrally-adjudicated outcomes

Abstract Background Stenting is being increasingly used as a therapeutic option for coarctation of aorta (CoA) in paediatric patients. Although the short and mid-term outcomes are well-documented, data on long-term results are scant. Purpose The current study aimed to determine the long-term safety and efficacy of aortic coarctation stenting via centrally-adjudicated outcomes. Methods The present study is a retrospective cohort conducted at a large tertiary cardiovascular centre. All patients aged up to 15 years who had undergone de novo stenting for CoA between 2006 and 2017 were recruited. Both immediate and 5-year outcomes were investigated. Immediate outcomes, including procedural and in-hospital, were retrieved from electronic medical records, re-analysed, and finally adjudicated by the clinical event committee (CEC). The rates of five-year recoarctation, stent fracture, aneurysmal/pseudoaneurysmal formation, and all-cause mortality were reported as the main long-term outcomes. The first three mentioned outcomes were adjudicated only in patients with available predefined appropriate imaging follow-up tests (Figure 1). Patients who had available recorded 5-year clinical visits and those who answered the phone interview were evaluated for the 5-year mortality. Results A total of 274 patients (98 [35.8%] were female with median [interquartile range] age of 9 [6-12] years) who underwent de novo coarctoplasty with stent were included. Procedural success was achieved in 251 (91.6%) of the patients. Immediate complications were observed in a total of 24 (8.75%) as follows: There were 1 (0.3%) stent migration, 3 (1.1%) small, non-expanding non-flow-limiting aortic wall injuries, and 2 (0.7%) ischemic strokes. Also, there were 18 (6.6%) major vascular access complications, the most common of which was acute limb ischemia in 8 (2.9%) patients, followed by 5 (1.8%) pseudoaneurysms, 3 (1.1%) retroperitoneal haemorrhages, 1 (0.3%) arteriovenous fistula, and 1 (0.3%) large hematoma. A total of 4 (1.4%) in-hospital mortality occurred. The 5-year cumulative incidence of stent fracture, recoarctation of the aorta, and aneurysm/pseudoaneurysm of the aorta were 17/100 (17%), 73/154 (48%), and 8/101 (7.92%), respectively. Five-year all-cause mortality occurred in 4/251 (1.6%) (Table 1). Conclusion In our study, coarctoplasty with stent was safe and effective in the paediatric population during long-term follow-up. Developmental changes in childhood resulting in stent-size mismatch are suggested as a potential aetiology for a high re-intervention rate. Of note, re-intervention was safe and effective.Figure 1Table 1

Incremental versus conventional haemodialysis in end-stage kidney disease: a systematic review and meta-analysis.

Appropriate dialysis prescription in the transitional setting from chronic kidney disease to end-stage kidney disease is still challenging. Conventional thrice-weekly haemodialysis (HD) might be associated with rapid loss of residual kidney function (RKF) and high mortality. The benefits and risks of incremental HD compared with conventional HD were explored in this systematic review and meta-analysis. We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials up to April 2023 for studies that compared the impacts of incremental (once- or twice-weekly HD) and conventional thrice-weekly HD on cardiovascular events, RKF, vascular access complications, quality of life, hospitalization and mortality. A total of 36 articles (138939 participants) were included in this meta-analysis. The mortality rate and cardiovascular events were similar between incremental and conventional HD {odds ratio [OR] 0.87 [95% confidence interval (CI)] 0.72-1.04 and OR 0.67 [95% CI 0.43-1.05], respectively}. However, hospitalization and loss of RKF were significantly lower in patients treated with incremental HD [OR 0.44 (95% CI 0.27-0.72) and OR 0.31 (95% CI 0.25-0.39), respectively]. In a sensitivity analysis that included studies restricted to those with RKF or urine output criteria, incremental HD had significantly lower cardiovascular events [OR 0.22 (95% CI 0.08-0.63)] and mortality [OR 0.54 (95% CI 0.37-0.79)]. Vascular access complications, hyperkalaemia and volume overload were not statistically different between groups. Incremental HD has been shown to be safe and may provide superior benefits in clinical outcomes, particularly in appropriately selected patients. Large-scale randomized controlled trials are required to confirm these potential advantages.

Abstract 16030: Efficacy and Safety of Catheter Directed Thrombolysis in Intermediate to High-Risk Pulmonary Embolism: A Meta-Analysis of Randomized Trials

Background: Systemic anticoagulation (SA) is the standard treatment for acute pulmonary embolism (PE). The role of catheter directed thrombolysis (CDT) in addition to SA in intermediate-high risk PE remains unclear. Methods: Three randomized controlled trials comparing CDT+SA versus SA alone in intermediate-high risk PE were included in the analysis using databases including Embase, PubMed and Cochrane databases (inception June 01, 2023). The primary outcome was 90-day all-cause mortality. The secondary outcomes were major bleeding, number of patients with RV/LV ratio &gt;0.9 at 3 months, and vascular access complication. The outcomes were reported as relative risk (RR) with a 95% confidence interval (CI) using random effects model. Results: The analysis comprised of 179 patients with 88 in the CDT group and 79 in the SA group. There was no significant difference in 90-day all-cause mortality (RR: 0.19, 95% CI, 0.02-1.64, p=0.30) among both the groups. Similarly there was no significant difference in major bleeding (RR: 1.20, 95% CI, 0.03-46.18 p= 0.92), RV/LV ratio &gt;0.9 at 3 months (RR: 0.70, 95% CI, 0.41-1.21p=0.2) and vascular access complications (RR: 2.51, 95% CI, 0.44-14.35 p= 0.30). Conclusions: Our study found no significant advantage of CDT+SA versus SA alone in patients with intermediate-high risk PE. Given the scarcity of randomized data, we emphasize the need for a large-scale randomized trial to investigate the long-term effects of CDT in this population.

Abstract 18727: Outcomes of Utilization of Transesophageal Echocardiogram (TEE) vs Intracardiac Echocardiogram (ICE) for Atrial Fibrillation Ablations in the Real-AF Registry

Introduction: Transesophageal (TEE) and intracardiac (ICE) echocardiogram are widely used strategies to rule out LAA thrombus prior to atrial fibrillation (AF) ablation. We compare the utilization of TEE and ICE, outcomes and complications of each strategy. Methods: The Real-world Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal (PAF) and Persistent (PsAF) Atrial Fibrillation registry (Real-AF) is a multicenter prospective registry that is enrolling patients undergoing AF ablation at high-volume centers. We compared complications rates (Table 1) between TEE and ICE in patients with AF underdoing index ablation for AF in the REAL-AF registry. Patients who underwent both TEE and ICE were excluded from the analysis. Bleeding complication was defined as bleeding that occurs within the first 72 hours of the procedure requiring transfusion or resulting in &gt;20% drop in hemoglobin. Vascular access complications included AV fistula or pseudo-aneurysm needing intervention. Results: A total of 1628 patients were included in the analysis.The mean age was 64.78 (SD=11.43) years, 45.7% were women, mean BMI was 30.36 (SD=6.71) and mean CHAD2DS2VASc score was 2.49 (SD=1.51). TEE was used in 911 patients (58.5%) and ICE was used in 717 (46.1%) ] prior to ablation. There were 0% strokes reported in the TEE group vs 0.1% in the ICE group (p = 0.095). Among other complications reported there was no statistical difference between the two groups (Table 1). There was no significant difference between the two groups on recurrence of arrhythmias at 12 months (HR: = 0.983, CI: 0.79,1.3 , p &lt; 0.894) Conclusion: Both TEE and ICE are acceptable strategies for pre-ablation assessment of left atrium and LAA. There are no significant differences in stroke rates between the two groups. Other reported complications are also similar between the two groups. Choice of either TEE vs ICE depend on patient specific characteristics, hospital resources and operator preference.

Efficacy and safety of patients with chronic kidney disease undergoing left atrial appendage closure for atrial fibrillation.

The relative safety and efficacy of left atrial appendage closure (LAAC) for atrial fibrillation (AF) in patients with chronic kidney disease (CKD) have not been well defined. To evaluate the results in this cohort, we conducted a systematic review and meta-analysis of observational studies. We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception to January 2023 for all relevant studies. Our inclusion criteria were met by twelve observational studies that included 61324 patients altogether. Compared with no CKD group, in-hospital mortality (OR: 2.84, 95% CI: 2.12-3.81, p<0.01, I2 = 0%), acute kidney injury (AKI) (OR: 4.39,95% CI:4.00-4.83, P<0.01, I2 = 3%), major bleeding events (OR: 1.44, 95% CI: 1.29-1.60, p<0.01 I2 = 0%), and pericardial effusion/tamponade (OR 1.30; 95% CI 1.13-1.51, p < 0.01; I2 = 0%) were more common in the CKD group, especially in patients with end-stage renal disease (ESRD). No significant difference was observed in the occurrence of stroke (OR: 1.24, 95% CI: 0.86-1.78, P = 0.25, I2 = 0%), LAAC success rates (OR: 1.02, 95% CI: 0.33-3.16, p = 0.97, I2 = 58%) and vascular access complications (OR: 1.13, 95% CI: 0.91-1.39, p = 0.28, I2 = 0%) between the two groups. During the follow-up, there was no difference in the risk of stroke between the two groups. CKD patients who receive LAAC have a greater risk of in-hospital mortality, AKI, pericardial effusion/tamponade, and major bleeding events than those without CKD, especially in patients with ESRD. No significant difference in the risk of stroke was found in the long-term follow-up after LAAC between the two groups, demonstrating a similar efficacy of LAAC to prevent stroke in CKD patients.

Comparison of Transradial Access and Transfemoral Access for Diagnostic Cerebral Angiography in the Elderly Population

Evaluate the efficacy, safety, and patient satisfaction of transradial access (TRA) compared with conventional transfemoral access (TFA) for diagnostic cerebral angiography in elderly patients (≥65 years of age). We performed a retrospective review of patients receiving cerebral angiography via TRA or TFA between October 2020 and December 2021 at 3 institutions. Basic patient characteristics, angiographic data, postoperative complications, and patient satisfaction were collected for analysis. Of the 357 enrolled elderly patients, 175 were performed through TRA and 182 were performed through TFA. There was no significant difference in mean fluoroscopy time (8.6 ± 3.8 minutes vs. 9.1 ± 3.1 minutes; P= 0.103) and radiation exposure (47.7 ± 10.8 Gy-cm2 vs. 49.8 ± 11.3 Gy-cm2; P= 0.068) between the TRA and TFA groups. However, the TRA group had a shorter procedural time (54.7 ± 6.2 minutes vs. 61.1 ± 5.6 minutes; P < 0.001) and less contrast agent (83.2 ± 28.1 mL vs. 100.1 ± 26.2 mL; P < 0.001) than the TFA group. In terms of safety, the incidence of minor vascular access complications in the TRA group was lower than that in the TFA group (1.7% vs. 8.8%; P= 0.003). The incidence of serious complications and neurologic complications in the TRA group was also lower, although the difference was not statistically significant. Overall patient satisfaction was higher in the TRA group than that in the TFA group. TRA was an efficient and safe alternative to conventional TFA in elderly patients who underwent diagnostic cerebral angiography and who underwent TRA were more satisfied. Findings supported the radial-first strategy for cerebral angiography in elderly populations.