Balloon-assisted tracking: A practical solution to avoid radial access failure due to difficult anatomical challenges.

AIM: The balloon assisted tracking (BAT) technique is utilised to overcome various anatomical difficulties during radial procedures when standard measures such as adequate sedation, pain relief, vasodilators and use of hydrophilic guidewires, fail. The aim of this study was to evaluate the success rates of the BAT technique in overcoming anatomical difficulties during radial coronary interventional procedures. METHODS: We retrospectively reviewed 1100 consecutive patients undergoing coronary procedures from the transradial approach (TRA) between May 2015 and May 2017. Anatomic variations and equipment used were recorded from procedure logs. RESULTS: Overall 30 patients (2.72%) required the use of BAT. Mean age was 66.7years, with a range from 48 to 90years (53.3% female). Out of these 30 cases, 86.7% patients underwent percutaneous coronary intervention (PCI) while the remaining patients underwent coronary angiography alone. Acute coronary syndrome cases represented 63.3% of the cases while the remaining patients were elective procedures. Anatomical difficulties included severe, non-resolving radial spasm (66.6%), catheter induced radial or brachial perforation (16.6%), small calibre and/or diseased radial artery (10.0%), severe radial, branchial and/or subclavian tortuosity (3.0%) and radial loops (3.0%). Anatomical difficulties were overcome in all cases (100%). Coronary angiography and/or PCI were successfully completed in all 30 cases without the need for obtaining alternative arterial access. Mean added procedural time was 131s. There were no procedure related complications. CONCLUSION: Balloon assisted tracking is a highly successful and safe technique for overcoming various anatomical difficulties at the level of the radial, brachial or subclavian arteries, which minimises the need for alternative arterial access.

Triple-vessel percutaneous coronary revascularization in situs inversus dextrocardia.

Dextrocardia with situs inversus occurs in approximately one in 10,000 individuals of whom 20% have primary ciliary dyskinesia inherited as an autosomal recessive trait. These patients have a high incidence of congenital cardiac disease but their risk of coronary artery disease is similar to that of the general population. We report what is, to our knowledge, the first case of total triple-vessel coronary revascularization by percutaneous stent implantation in a 79-year-old woman with situs inversus dextrocardia. We describe the successful use of standard diagnostic and interventional guide catheters with counter rotation and transversely inversed image acquisition techniques. The case also highlights that the right precordial pain may represent cardiac ischemia in this population.

Evaluation of carotid-femoral pulse wave velocity: influence of timing algorithm and heart rate.

Carotid-femoral pulse wave velocity (PWV), a measure of arterial stiffness, is determined from the time taken for the arterial pulse to propagate from the carotid to the femoral artery. Propagation time is measured variously from the foot of the waveform or point of maximum upslope. We investigated whether these methods give comparable values of PWV at rest, during beta-adrenergic stimulation, and pacing-induced tachycardia. In subjects at rest (n=43), values obtained using the foot-to-foot method (SphygmoCor system) were 1.7+/-0.75 m/s (mean+/-SD) greater than those obtained using the maximum slope (Complior system) at a mean value of 12 m/s. Isoprotenerol (0.5 to 1.5 microg/min; n=10), and pacing (in subjects with permanent pacemakers; n=11) increased heart rate but had differential effects on systolic blood pressure and pulse pressure. The increase in heart rate produced by isoprotenerol (18+/-3 bpm) and pacing (40 bpm) was associated with an increase in PWV measured using both systems (increases of 0.7+/-0.2 m/s and 0.9+/-0.2 m/s for SphygmoCor and Complior, respectively, during isoprotenerol and increases of 2.1+/-0.5 m/s and 1.1+/-0.2 m/s for SphygmoCor and Complior, respectively, during pacing, each P<0.001). Reanalysis of waveforms recorded from the Complior system using the foot-to-foot method produced similar values of PWV to those obtained with the SphygmoCor, confirming that the difference between these systems was attributable to the timing algorithm rather than other aspects of signal acquisition. Carotid-femoral PWV is critically dependent on the method used to determine propagation time, but this does not account for variation of PWV with heart rate.

Pressure wave reflection assessed from the peripheral pulse: is a transfer function necessary?

Synthesis of the aortic pressure waveform by application of a transfer function to the radial pulse allows the estimation of aortic systolic blood pressure and aortic augmentation index, an index of pressure wave reflection derived from the early systolic component of the waveform. The accuracy of this approach for determining the aortic augmentation index has been questioned, however, and it may be possible to derive similar information without using a transfer function. We compared aortic systolic blood pressure and the aortic augmentation index obtained from carotid and radial arteries with the use of transfer functions. We examined the correlation between the aortic augmentation index and a radial augmentation index obtained without use of a transfer function. Arterial tonometry (Sphygmocor) was performed in 84 subjects including healthy volunteers (n=30), subjects with essential hypertension (n=30), and patients with coronary artery disease (n=24). Effects of nitroglycerine and norepinephrine on aortic and radial augmentation index were examined in 12 healthy volunteers. Values of aortic systolic pressure obtained from radial and carotid arteries by using transfer functions were in acceptable agreement (R=0.98, difference=-0.9+/-4.6 mm Hg; mean+/-SD, n=84), but those of aortic augmentation index differed especially in control subjects (R=0.47, difference=-3.8+/-12.4%). Aortic augmentation index was, however, closely correlated with radial augmentation index (R=0.96, n=84). Nitroglycerine and norepinephrine produced parallel changes in the aortic and radial augmentation index. Our findings question the use of a transfer function to obtain the aortic augmentation index but suggest that similar information on central pressure wave reflection can be obtained directly from the radial pulse.