RESUMO
Arterial access in coronary angiography has always been an important issue. Convincing prognostic data from large randomized controlled trials (RCTs) in the first place but also safe performance of same-day-discharge after diagnostic and interventional procedures, improved patient comfort and cost-effectiveness led to a paradigm shift from the transfemoral approach (TFA) to the transradial approach (TRA) in several clinical situations. Consequently, today's relevant guidelines recommend a radial-first strategy as default approach. However, there is still strong controversy among interventional cardiologists resulting in delayed spread of the TRA causing significant regional differences. One major critics point is the rate of postprocedural radial artery occlusion (RAO) after using the traditional puncture site at the proximal radial artery (pTRA) which was registered too high in certain centers. A new access using the distal radial artery (dTRA) in the area of the snuff box (SB) and the dorsal box (DB) has been proven to minimize RAO and enabling even complex interventions using 7F guiding catheters. Although, dTRA seems to be an advantageous option, this approach is still not widely used. This review-addressed to beginners and even advanced interventionalists-presents all arterial access routes in interventional cardiology. It focusses on those to be routinely preferred and also on the possibility to guide the puncture with ultrasound. Thereby, the various approaches, including the transulnar (TRU) but also the still relevant TFA approach, are discussed in detail. Thereby, we introduce our philosophy of "radial freedom" and a new classification for TRA.
RESUMO
AIM: To determine the effectiveness of functional stress testing and computed tomography angiography (CTA) for diagnosis of obstructive coronary artery disease (CAD). METHODS AND RESULTS: Two-thousand nine-hundred twenty symptomatic stable chest pain patients were included in the international Collaborative Meta-Analysis of Cardiac CT consortium to compare CTA with exercise electrocardiography (exercise-ECG) and single-photon emission computed tomography (SPECT) for diagnosis of CAD defined as ≥ 50% diameter stenosis by invasive coronary angiography (ICA) as reference standard. Generalised linear mixed models were used for calculating the diagnostic accuracy of each diagnostic test including non-diagnostic results as dependent variables in a logistic regression model with random intercepts and slopes. Covariates were the reference standard ICA, the type of diagnostic method, and their interactions. CTA showed significantly better diagnostic performance (p < 0.0001) with a sensitivity of 94.6% (95% CI 92.7-96) and a specificity of 76.3% (72.2-80) compared to exercise-ECG with 54.9% (47.9-61.7) and 60.9% (53.4-66.3), SPECT with 72.9% (65-79.6) and 44.9% (36.8-53.4), respectively. The positive predictive value of CTA was ≥ 50% in patients with a clinical pretest probability of 10% or more while this was the case for ECG and SPECT at pretest probabilities of ≥ 40 and 28%. CTA reliably excluded obstructive CAD with a post-test probability of below 15% in patients with a pretest probability of up to 74%. CONCLUSION: In patients with stable chest pain, CTA is more effective than functional testing for the diagnosis as well as for reliable exclusion of obstructive CAD. CTA should become widely adopted in patients with intermediate pretest probability. SYSTEMATIC REVIEW REGISTRATION: PROSPERO Database for Systematic Reviews-CRD42012002780. CRITICAL RELEVANCE STATEMENT: In symptomatic stable chest pain patients, coronary CTA is more effective than functional testing for diagnosis and reliable exclusion of obstructive CAD in intermediate pretest probability of CAD. KEY POINTS: Coronary computed tomography angiography showed significantly better diagnostic performance (p < 0.0001) for diagnosis of coronary artery disease compared to exercise-ECG and SPECT. The positive predictive value of coronary computed tomography angiography was ≥ 50% in patients with a clinical pretest probability of at least 10%, for ECG ≥ 40%, and for SPECT 28%. Coronary computed tomography angiography reliably excluded obstructive coronary artery disease with a post-test probability of below 15% in patients with a pretest probability of up to 74%.