Finding the optimal access for proximal upper limb artery (PULA) interventions: Lessons learned from the PULA multicenter registry.

OBJECTIVE: The multicenter proximal upper limb artery (PULA) Registry was created to study the optimal puncture sites for the interventions involving the subclavian, axillary, and innominate arteries. BACKGROUND: Little is known about the optimal vascular access for PULA interventions, despite the well-known technical complexity of these procedures. METHODS: We performed the retrospective analysis of consecutive patients treated for symptomatic steno-occlusive disease of the proximal upper limb arteries between January 2015 and December 2019 in three high-volume centers. Acute thrombotic occlusions were excluded from the study. RESULTS: Two hundred and seventy-two patients were treated for significant stenosis and 108 for total occlusion. The baseline patient's characteristics were similar, except for the higher median age of the stenotic patients: 68.5 years (31.1; 90.0) versus 64 years (38.0; 86.0) p = 0.0015. Successful revascularization rate was higher in the stenotic group 93.75% (255/272) versus 86.11% (93/108) p = 0.0230, while the procedure length 27 min (8; 133) versus 46 min (7; 140) p = 0.0001 and fluoroscopy times 439 s (92; 2993) versus 864 s (86; 4176) p = 0.0001 were higher in the occlusion group. The main adverse event rate was similarly low. Dual access was used more often to treat occlusions (60.19% (65/108) vs. 11.40% (31/272) p = 0.0001) without significantly increasing the complication rate. The safest access was ultrasound-guided distal radial artery puncture, significantly better than conventional radial access with 0% (0/31) versus 13.6% (18/131) p = 0.0253 complication. CONCLUSIONS: The percutaneous revascularization of proximal upper limb arteries is a safe and effective. Dual access can be applied to increase treatment efficacy, without significantly compromising safety.

Combined Transradial and Transpedal Approach for Femoral Artery Interventions.

OBJECTIVES: The purpose of this prospective study was to evaluate the acute success and complication rates of combined transradial and transpedal access for femoral artery intervention. BACKGROUND: Improved equipment and techniques have resulted in transition from transfemoral to transradial access for intervention of superficial femoral artery. METHODS: Between 2014 and 2016, clinical and angiographic data from 145 consecutive patients with symptomatic superficial femoral stenosis, treated via primary radial access using the 6-F SheathLess Eaucath PV guiding catheter were evaluated in a pilot study. Secondary access was achieved through the pedal or popliteal artery. The primary endpoints were major adverse events, target lesion revascularization, and rates of major and minor access-site complications. Secondary endpoints included angiographic outcome, procedural factors, crossover rate to femoral access site, and duration of hospitalization. RESULTS: Technical success was achieved in 138 patients (95.2%). Combined radial and pedal access was obtained in 22 patients (15.1%). The crossover rate to a femoral access site was 2%. Stent implantation was necessary in 23.4% of patients. Chronic total occlusion recanalization was performed in 63 patients, with a 90.4% technical success rate. The mean contrast consumption, radiation dose, and procedure time were 112.9 ml (101.8 to 123.9 ml), 21.84 Gy/cm2 (9.95 to 33.72 Gy/cm2), and 34.9 min (31.02 to 38.77 min), respectively. The cumulative rate of access-site complications was 4.8% (0% major, 4.8% minor). The cumulative incidence rates of major adverse events at 3 and 12 months follow-up was 8.3% and 19.2%. The cumulative incidence rates of death at 3- and 12-month follow-up were 2.8% and 5.6%. CONCLUSIONS: Femoral artery intervention can be safely and effectively performed using radial and pedal access with acceptable morbidity and a high technical success rate.

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.

OBJECTIVES: The 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. BACKGROUND: LRA 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. METHODS: The 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. RESULTS: Of 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). CONCLUSIONS: In 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.

Manual Versus Mechanical Compression of the Radial Artery After Transradial Coronary Angiography: The MEMORY Multicenter Randomized Trial.

OBJECTIVES: The aim of this study was to compare manual versus mechanical compression of the radial artery after coronary angiography via transradial access regarding radial artery occlusion (RAO), access-site bleeding complications, and duration of hemostasis. BACKGROUND: Hemostasis of the radial artery after sheath removal can be achieved either by manual compression at the puncture site or by using a mechanical hemostasis device. Because mechanical compression exerts a more stable, continuous pressure on the artery, it could be hypothesized that it is more effective compared with manual compression regarding hemostasis time, bleeding, and RAO risks. METHODS: A total of 589 patients undergoing diagnostic coronary angiography by transradial access with a 5-F sheath were randomized in a 1:1 ratio to receive either manual or mechanical patent hemostasis of the radial artery. Radial artery patency was evaluated by color duplex ultrasonography 24 h after the procedure. The primary endpoint was early RAO at 24 h. Secondary endpoints included access-site bleeding complications and duration of hemostasis. RESULTS: Thirty-six (12%) early RAOs occurred in the manual group, and 24 (8%) occurred in the mechanical group (p = 0.176). There were no significant differences between the 2 groups regarding access-site bleeding complications (hematoma, 52 [17%] vs. 50 [18%]; p = 0.749; bleedings, 8 [3%] vs. 9 [3%]; p = 1.000). Duration of hemostasis was significantly shorter in the manual group (22 ± 34 min vs. 119 ± 72 min with mechanical compression; p < 0.001). CONCLUSIONS: Manual and mechanical compression resulted in similar rates of early RAO, although the total duration of hemostasis was significantly shorter in the manual group.

In vitro and in vivo study of human amniotic fluid-derived stem cell differentiation into myogenic lineage.

Recent findings have shown that amniotic fluid (AF) could be a putative new source of multipotent stem cells (SC). We investigated whether these human SC could efficiently differentiate into myogenic lineage in vitro and integrate in vivo skeletal muscle in severe combined immunodeficiency (SCID) mice. C/kit immunomagnetic-sorted AF (AF c/kit+) SC were characterized by immunocytochemistry and Southern blotting for myogenic markers (desmin, MyoD). In vitro, AF c/kit+ SC phenotypic conversion into myogenic cells was assayed by myogenic-specific induction media. AF c/kit+ SC without ex vivo manipulation were transplanted into the tibialis anterior (TA) of (SCID) mice. Acquisition of a myogenic-like phenotype (desmin, MyoD) in AF c/kit+ SC was observed after culture in myogenic-specific induction media. In vivo, transplanted AF c/kit+ SC showed an engraftment in the skeletal muscle of SCID mice, but with unexpected tubular glandular tissue-like differentiation. Importantly, no immuno-rejection, inflammatory response or tumorigenicity of these cells was found. Within these experimental conditions, AF c/kit+ SC were able to differentiate into myogenic cells in vitro, but not in vivo after their transplantation into the skeletal muscle of SCID mice. Because AF c/kit+ SC survived and differentiated into tubular gland-like cells after their transplantation in the TA, an ex vivo engagement in myogenic pathway prior their transplantation could favor their differentiation into myogenic cells in vivo.