Stent graft implantation from distal radial access-A novel way to treat femoral access site complication during transcatheter aortic valve replacement: A case report.

In this paper, a case of an 82-year-old man who was admitted to our department with sever symptomatic degenerative aortic valve stenosis is presented and discussed. After all screening procedures, a successful transfemoral transcatheter aortic valve replacement was performed, but the closure of the femoral access was unsuccessful due to suture-based device failure. We decided to perform a prolonged balloon dilatation and external compression at the bleeding site, but the bleeding did not stop; therefore, an iCover stent graft was implanted from distal radial artery access using slender technique. Following that, the bleeding was stopped, and the patient had an uneventful outcome.

Combination of Laser Atherectomy and Super High-pressure Non-compliant Balloon to Treat Stent Under-expansion in Cases of Failed Interventional Options.

Patients with calcified, fibrotic native coronary vessels with prior suboptimal stenting outcomes are at major risk of stent thrombosis and could face serious consequences if untreated. In cases of multiple layers of under-expanded stents, the risk is multiplied. If conventional balloon post-dilatation is unsuccessful after stent implantation without proper lesion preparation, few interventional options remain. The authors report on a patient with prior numerous right coronary unsuccessful coronary interventions resulting in partially crushed multiple layers of stent material with critical lumen narrowing caused by stent under-expansion. Balloon angioplasty and stent rotational atherectomy (ROTA) had been attempted to overcome stent under-expansion but were unsuccessful. The authors investigated a new combination therapy of laser atherectomy (ELCA) and super high-pressure balloon (OPN non-compliant balloon) to treat single or multiple layers of stent with severe under-expansion due to fibrotic, calcified tissue surrounding the under-expanded stent structure.

Anatomical classification of chronic total occlusions in coronary bifurcations.

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) in coronary bifurcation lesions (CBL) is undergoing substantial technical progress and standardization, paralleling the evolution of dedicated devices, tools, and techniques. A standard consensus to classify CTO-CBL might be instrumental to homogenize data collection and description of procedures for scientific and educational purposes. The Medina-CTO classification replicates the classical three digits in Medina classification for bifurcations, representing the proximal main vessel, distal main vessel, and side branch, respectively. Each digit can take a value of 1 if it concerns atherosclerosis and is anatomically stenosed, or 0 if it is not. In addition, the occluded segment(s) of the bifurcation are noted by a subscript, which describes key interventional features of the cap: t (tapered), b (blunt), or a (ambiguous). This approach results in 56 basic categories that can be grouped by means of different elements, depending on the specific needs of each study. Medina-CTO classification, consisting of adding a subscript describing the basic cap characteristics to the totally occluded segment(s) of the standard Medina triplet, might be a useful methodological tool to standardize percutaneous intervention of bifurcational CTO lesions, with interesting scientific and educational applications.

Simultaneous Dual Distal Radial Balloon Aortic Valvuloplasty for Larger Aortic Annuli.

Dual distal mini-balloon aortic valvuloplasty stabilized an 85-year-old patient with severe aortic stenosis. Puncturing both radial arteries solves the issue of large diameters at the aortic ring, introducing a feasible strategy in selected cases of fragile octogenarian patients with a high hemorrhagic risk. Moving at the anatomical snuffbox offers better postprocedural occlusion rates and better workspace ergonomics during the procedure.

Distal Radial Secondary Access for Transcatheter Aortic Valve Implantation: The Minimalistic Approach.

BACKGROUND: Although not yet recommended by the guidelines, distal radial access, a new site for cardiovascular interventions, has been rapidly acknowledged and adopted by many centers due to its high rate of success, safety and fewer complications. We present our experience using secondary distal radial access during transcatheter aortic valve implantation (TAVI), proposing a new, even more minimal approach. METHODS: As of November 2020, a systematic distal radial approach as secondary access site for TAVI was adopted in our center. Primary endpoints were technical success and major adverse events (MAEs). Secondary endpoints: the access site complication rate, hemodynamic and clinical results of the intervention, procedural related factors, crossover rate to the femoral access site, and hospitalization duration (in days). RESULTS: From November 2020, 41 patients underwent TAVI using this strategy. Patients had a mean age of 76 ± 11.2 years, 41% were male. Six (14.63%) patients received a balloon-expandable valve and 35 (85.37%) received a self-expandable valve. TAVI was successful in all cases. No complications occurred due to transradial access. Puncture success, defined as completed sheath placement was maximum (N = 41/41,100%) and emergent transfemoral secondary access was not required in any case. Primary transfemoral vascular access site complications occurred in 7 cases (17%) of which 4 (13.63%) were resolved through distal radial access: one occlusion, two flow-limiting stenoses and four perforations of the common femoral artery. There were no additional major vascular complications at 30 days. Overall MACE rate was 2.4%. CONCLUSION: The use of the distal radial approach for secondary access in TAVI is safe, feasible and has several advantages over old access sites.

The Role of Ultrasound in Accessing the Distal Radial Artery at the Anatomical Snuffbox for Cardiovascular Interventions.

In an effort to refine transcatheter vascular interventions, radial artery access has moved more distally at the anatomical snuffbox. Here, more challenges appear as the artery is smaller, more angulated, and more difficult to palpate. Including ultrasound guidance as a mandatory step during puncture may encourage more operators to switch to this approach. In the femoral approach, ultrasound guidance is strongly recommended because of bleeding complications, whereas in the proximal (conventional) radial approach, the role of ultrasound remains optional, and in current practice, almost all cases are performed by palpation of the pulse only. However, in distal radial access, the situation is different because the artery differs in caliber and position, and imaging can help the operator for a clean puncture, especially since repeated punctures are not only painful but also any hematoma formation leads to the complete compression of the artery and failure of access. The aim of this review is to investigate the rationale of vascular ultrasound during distal radial access and to establish some techniques and anatomical landmarks for the ultrasonographic exploration of the dorsal area of the hand.

Distal Radial Artery Access for Coronary and Peripheral Procedures: A Multicenter Experience.

INTRODUCTION: Distal radial access (dRA) has recently gained global popularity as an alternative access route for vascular procedures. Among the benefits of dRA are the low risk of entry site bleeding complications, the low rate of radial artery occlusion, and improved patient and operator comfort. The aim of this large multicenter registry was to demonstrate the feasibility and safety of dRA in a wide variety of routine procedures in the catheterization laboratory, ranging from coronary angiography and percutaneous coronary intervention to peripheral procedures. METHODS: The study comprised 1240 patients who underwent coronary angiography, PCI or noncoronary procedures through dRA in two Hungarian centers from January 2019 to April 2021. Baseline patient characteristics, number and duration of arterial punctures, procedural success rate, crossover rate, postoperative compression time, complications, hospitalization duration, and different learning curves were analyzed. RESULTS: The average patient age was 66.4 years, with 66.8% of patients being male. The majority of patients (74.04%) underwent a coronary procedure, whereas 25.96% were involved in noncoronary interventions. dRA was successfully punctured in 97% of all patients, in all cases with ultrasound guidance. Access site crossover was performed in 2.58% of the patients, mainly via the contralateral dRA. After experiencing 150 cases, the dRA success rate plateaued at >96%. Our dedicated dRA step-by step protocol resulted in high open radial artery (RA) rates: distal and proximal RA pulses were palpable in 99.68% of all patients at hospital discharge. The rate of minor vascular complications was low (1.5%). A threshold of 50 cases was sufficient for already skilled radial operators to establish a reliable procedural method of dRA access. CONCLUSION: The implementation of distal radial artery access in the everyday routine of a catheterization laboratory for coronary and noncoronary interventions is feasible and safe with an acceptable learning curve.

Double-kissing culotte technique for coronary bifurcation stenting.

AIMS: The aim of this study was to assess whether the culotte technique could be improved by an additional kissing dilation prior to main branch (MB) stenting. METHODS AND RESULTS: Double-kissing (DK) culotte was compared to the culotte and DK-crush techniques in a bench model (n=24). Results were evaluated for stent apposition, luminal opening and flow dynamics. The total procedure duration of DK-culotte was 18.3±3.4 minutes, significantly lower than for DK-crush (24.3±5.7 min; p=0.015), but similar to culotte (21.6±5.9 min, p=0.104). In DK-culotte the overall rate of moderate (200-500 µm) and significant (>500 µm) malapposition was 2.1±1.9% and 0.4±0.2%, similar as compared to culotte (3.7±3.8%, p=0.459 and 1.0±1.0%, p=0.517, respectively), and lower as compared to DK-crush (8.1±2.5%, p<0.001 and 3.7±5.3%, p=0.002, respectively). The lower malapposition rate of DK-culotte as compared to DK-crush was due to less moderate and significant malapposition in the proximal MB (0.0±0.0% vs 14.0±7.6%, p<0.001 and 0.0±0.0% vs 4.2±9.1%, p=0.026, respectively). Micro-computed tomography did not show a difference in luminal opening at the proximal MB, distal MB or SB. There was no difference either in the maximum shear rate or in areas of high shear or recirculation. CONCLUSIONS: Bench test data suggest that the DK approach facilitates the culotte technique. The clinical validity and relevance remain to be confirmed in a larger in vivo population.

Management of a Balloon Shaft Fracture During Subintimal Retrograde Chronic Total Occlusion Percutaneous Coronary Intervention Due to In-stent Restenosis.

Balloon shaft fracture can be challenging to treat in the setting of retrograde CTO-PCI with guidewire externalization; withdrawal of the guide catheter may allow successful removal of the balloon shaft fragment.

Serum lipids and cardiac function correlate with nitrotyrosine and MMP activity in coronary artery disease patients.

AIMS: Peroxynitrite-matrix metalloproteinase (MMP) signalling has been shown to contribute to myocardial ischaemia/reperfusion injury and heart failure and to be influenced by hyperlipidaemia in preclinical models. Therefore, here we investigated the correlation between the markers of peroxynitrite-MMP signalling and hyperlipidaemia in patients with significant coronary stenosis. METHODS: Five minutes before percutaneous coronary intervention (PCI), arterial blood samples were collected from 36 consecutive patients with coronary artery disease (CAD) selected for elective PCI. RESULTS: Serum nitrotyrosine positively correlated with MMP-9 activity (r = 0·54, P = 0·01), but not with MMP-2 activity. Nitrotyrosine positively correlated with total (r = 0·58; P < 0·01) and LDL cholesterol (r = 0·55; P < 0·01), serum triglyceride (r = 0·47; P < 0·05), and creatinine (r = 0·42; P < 0·05) and negatively correlated with HDL cholesterol (r = -0·46; P < 0·05) and with left ventricular ejection fraction (LVEF; r = -0·55; P < 0·05), respectively. MMP-2 activity correlated positively with total (r = 0·55; P < 0·05) and LDL cholesterol (r = 0·45; P < 0·05). In statin-treated patients, a significantly reduced serum nitrotyrosine was found as compared to statin naives; however, MMP activities and serum cholesterol levels were not different. MMP-9 activity correlated with urea nitrogen (r = 0·42; P < 0·05) and LVEF (r = -0·73; P < 0·01). Serum creatinine correlated negatively with LVEF (r = -0·50, P < 0·01). CONCLUSIONS: This is the first demonstration that (i) serum nitrotyrosine correlates with MMP-9 activity, (ii) lipid parameters correlate with nitrotyrosine and MMP-2 activity, (iii) myocardial function correlates with creatinine, nitrotyrosine and MMP-9 activity, and (iv) creatinine correlates with nitrotyrosine and urea nitrogen with MMP-9 activity in patients with CAD. Studying the biomarkers of peroxynitrite-MMP pathway in large prospective trials may reveal their diagnostic avails.

Functional assessment of a left coronary-pulmonary artery fistula by coronary flow reserve.

We report a 71-year-old man who presented with atypical chest pain. Coronary angiography did not reveal left main or proximal left anterior descending coronary artery stenosis, but a fistulous communication with a stronger tube-like fistula was present originating from the proximal left anterior descending coronary artery and emptying into the main pulmonary artery. Fractional flow reserve and coronary flow reserve measurements were performed to gain more data on the potential functional aspects of this fistula. With the present case, the importance of functional evaluation of these fistulas is demonstrated.

[Relationship between early myocardial reperfusion assessed by videodensitometry and late left ventricular function. Results following invasive treatment of acute myocardial infarction]. / A videodenzitometriával vizsgált korai myocardialis reperfúzió és a kései balkamra-funkció összefüggései. Eredmények acut myocardialis infarctus invazív ellátását követoen.

INTRODUCTION: It is known that there is a relationship between myocardial perfusion and left ventricular function. AIM: The aim of the current study was to examine the relationship between myocardial reperfusion as assessed by videodensitometry on coronary angiograms following invasive treatment of ST elevation myocardial infarction and magnetic resonance imaging-derived late left ventricular function. METHOD: The study included 25 patients with ST elevation myocardial infarction. A quantitative parameter of myocardial (re)perfusion was calculated by the ratio of maximal density (Gmax) and the time to reach maximum density (Tmax) following invasive treatment. Magnetic resonance imaging was performed 387±262 days after ST elevation myocardial infarction for the evaluation of left ventricular function in all cases. RESULTS: Significant correlations were demonstrated between left ventricular ejection fraction and Gmax (r = 0.40, p = 0.05) and Gmax/Tmax (r = 0.41, p = 0.04) following vessel masking. CONCLUSIONS: The results demonstrate significant relationship between densitometric Gmax/Tmax and late left ventricular function following ST elevation myocardial infarction. Orv. Hetil., 2014. 155(5), 187-193.

[Aortic valve stenosis is associated with reduced myocardial perfusion as assessed by videodensitometry in coronary angiograms]. / Az aortabillentyu szukülete együtt jár a koronarográfiás felvételeken videodenzitometria során meghatározott myocardialis perfúzió csökkenésével.

UNLABELLED: Aortic valve stenosis may be accompanied by angina despite coronary arteries free of significant stenosis due to microvascular abnormalities. AIMS: The aim of the current study was to test whether densitometry-derived myocardial perfusion on coronary angiogram is reduced in patients with aortic valve stenosis. METHODS: The study comprised 20 patients with aortic valve stenosis (mean transvalvular gradient: 47.4±15.2 mm Hg) and 30 control subjects without significant epicardial coronary artery stenosis. A quantitative parameter of myocardial perfusion was calculated by the ratio of maximal density (Gmax) and time to reach maximum density (Tmax) on time-density curves in regions of interest of each coronary artery on coronary angiograms. RESULTS: Mean three-vessel Gmax/Tmax proved to be significantly lower in patients with aortic valve stenosis compared to control subjects (2.55±1.02 1/sec vs. 3.39±1.09 1/sec, p<0.01). CONCLUSIONS: Reduced Gmax/Tmax values indicative of myocardial perfusion abnormalities as measured by densitometry on coronary angiograms could be demonstrated in patients with aortic valve stenosis compared to controls.

Multiple coronary fistulas originating from all major coronary arteries.

Coronary fistulas to one of the cardiac chambers are infrequent anomalies and usually are found unexpectedly. Fistulas communicating between coronary artery and left heart chambers are extremely rare, especially those emptying into the left ventricle. We report a case in which all three major coronary arteries emptied into the left ventricle through multiple microfistulas.

Comparison of two visual angiographic perfusion grades in acute myocardial infarction.

INTRODUCTION: Prognosis after opening the obstructed coronary artery in acute myocardial infarction (AMI) is influenced by several factors. In routine clinical practice, revascularization is considered to be successful when the restoration of epicardial blood-flow is complete. However, the patent epicardial artery does not always provide functional recovery in the myocardium. There are two visual angiographic grades to assess myocardial perfusion: myocardial blush grade (MBG) and TIMI myocardial perfusion grade (TMP). The aim of our study was to compare these two parameters, how they correlate with short-term indicators of myocardial damage. PATIENTS AND METHODS: The two visual grades were assessed along with enzymatic infarct size as creatine kinase release (CK), echocardiographic left ventricular ejection fraction (LVEF), and ST-segment resolution (STR) in 62 patients with acute myocardial infarction and successful revascularization. RESULTS: Better correlation was found with TMP in case of all clinical parameters (CK: R= - 0.687, P<0.001; LVEF: R=0.586, P<0.001; STR: R=0.574, P<0.001). MBG also showed significant correlations with clinical measurements, except for enzymatic infarct size (CK: R=- 0.062, P=0.626; LVEF: R=0.389, P=0.002; STR: R=0.348, P=0.006). CONCLUSION: Our findings suggest that the clearance of the dye (described by TMP) is more characteristic to myocardial recovery after AMI, than maximal contrast density (described by MBG) in the clinical practice.

Five-year experience with transradial coronary angioplasty in ST-segment-elevation myocardial infarction.

BACKGROUND AND PURPOSE: Percutaneous coronary intervention (PCI) via radial approach has been shown to be an alternative to femoral approach in emergency cases; however, its feasibility has been questioned. This single-center study was performed to compare the outcomes and complication rates between transradial (TR) and transfemoral (TF) PCI in ST-segment-elevation myocardial infarction (STEMI). METHODS AND MATERIALS: The clinical and angiographic data of 582 consecutive STEMI patients treated with PCI between 2001 and 2006 were evaluated in a retrospective study. Forty-three patients were excluded from the present study due to cardiogenic shock or rescue PCI. Patients (n=539) were categorized into the TR group (n=167) or the TF group (n=372), and several parameters were evaluated to assess the advantages and drawbacks of TR access: access-site crossover, rate of access-site complications, procedure time, fluoroscopy time, X-ray area dose, major adverse cardiac events (MACE) at 1 month, and consumption of angioplasty equipment. RESULTS: In the TR group, the crossover rate to femoral access was 5%, while in the TF group, it was 0.8% (P<.05). There was a significant difference, in both major and minor access-site complications, between the TR group and the TF group (0% vs. 5%, P<.05, and 4% vs. 9%, P<.05, respectively). Consumption of angioplasty equipment proved to be the same for the two groups. The MACE rate was 4% in the TR group and 11% in the TF group (P<.05). CONCLUSIONS: Our results suggest that the TR approach is a safe and effective way to treat STEMI; furthermore, site-related complications are less common with this approach.

Myocardium selective densitometric perfusion assessment after acute myocardial infarction.

BACKGROUND: Myocardial perfusion is an important prognostic factor after recanalisation in acute myocardial infarction patients. We present a computerized, densitometric measurement method to assess myocardial perfusion on phase-matched digitally subtracted coronary angiograms. METHODS AND MATERIALS: Quantitative myocardial perfusion was assessed by the G(max)/T(max) parameter of the time-density curves (TDCs) in infarct-related myocardial regions on X-ray coronary angiograms. Arteries were masked out from regions of measurement. This novel method has been compared with enzymatic infarct size, ST-segment resolution, and ejection fraction after successful revascularization of 62 patients with acute myocardial infarction. RESULTS: Significant correlations were found between G(max)/T(max) and enzymatic infarct size (R=-0.445, P<.001), ST-segment resolution (R=0.364, P=.004), and ejection fraction (R=0.278, P=.029). Bland and Altman plot of G(max)/T(max) reveals good interobserver agreement. CONCLUSIONS: G(max)/T(max) of the TDC measured in the infarct-related myocardial area is a reliable parameter to assess clinical indicators of myocardial reperfusion. Therefore, results suggest that it could be used to immediately assess the success of recanalisation at the tissue perfusion level during coronary intervention, and as an objective end point in clinical trials of new interventional devices and drugs.