Percutaneous Left Ventricular Unloading During High-Risk Coronary Intervention: Rationale and Design of the CHIP-BCIS3 Randomized Controlled Trial.

INTRODUCTION: Percutaneous coronary intervention for complex coronary disease is associated with a high risk of cardiogenic shock. This can cause harm and limit the quality of revascularization achieved, especially when left ventricular function is impaired at the outset. Elective percutaneous left ventricular unloading is increasingly used to mitigate adverse events in patients undergoing high-risk percutaneous coronary intervention, but this strategy has fiscal and clinical costs and is not supported by robust evidence. METHODS: CHIP-BCIS3 (Controlled Trial of High-Risk Coronary Intervention With Percutaneous Left Ventricular Unloading) is a prospective, multicenter, open-label randomized controlled trial that aims to determine whether a strategy of elective percutaneous left ventricular unloading is superior to standard care (no planned mechanical circulatory support) in patients undergoing nonemergent high-risk percutaneous coronary intervention. Patients are eligible for recruitment if they have severe left ventricular systolic dysfunction, extensive coronary artery disease, and are due to undergo complex percutaneous coronary intervention (to the left main stem with calcium modification or to a chronic total occlusion with a retrograde approach). Cardiogenic shock and acute ST-segment-elevation myocardial infarction are exclusions. The primary outcome is a hierarchical composite of all-cause death, stroke, spontaneous myocardial infarction, cardiovascular hospitalization, and periprocedural myocardial infarction, analyzed using the win ratio. Secondary outcomes include completeness of revascularization, major bleeding, vascular complications, health economic analyses, and health-related quality of life. A sample size of 250 patients will have in excess of 80% power to detect a hazard ratio of 0.62 at a minimum of 12 months, assuming 150 patients experience an event across all follow-up. CONCLUSIONS: To date, 169 patients have been recruited from 21 National Health Service hospitals in the United Kingdom, with recruitment expected to complete in 2024. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05003817.

Giant left sinus of Valsalva aneurysm as a rare cause of acute myocardial infarction: a case report.

Background: Sinus of Valsalva aneurysm (SVA) is a rare but potentially life-threatening condition. Acute myocardial infarction (MI) is a rare consequence of aneurysmal dilatation of one or more sinuses of Valsalva. We present a case of an unruptured and partially thrombosed left SVA, presenting as anterior MI and congestive heart failure. Case summary: A 55-year-old gentleman was admitted with pulmonary oedema and a late presenting ST-elevation MI with Q wave. After initial treatment on furosemide infusion, a coronary angiography showed significant stenosis in both his left main stem (LMS) and left anterior descending artery (LAD). This is likely a result of external compression, potentially from the enlarged left sinus of Valsalva. A subsequent transthoracic echocardiogram and transoesophageal echocardiogram (TOE) confirmed large SVA involving the left coronary cusp measured 9.9 cm compressing both LMS and LAD. Discussion: Left SVAs are rare and frequently asymptomatic, typically being identified incidentally. Due to the close proximity of the left coronary system, they can present with myocardial ischaemia due to extrinsic compression of the coronary system. We were able to perform a comprehensive multi-modality assessment of left SVA, which helped establish this unusual diagnosis and guide management. Transthoracic echocardiogram and TOE helped assess the SVA and demonstrated the thrombus in situ, aortic valve insufficiency, and cardiac function. The computed tomography scan aided in accurately defining the extent of the aneurysm and the extent of compression of the left coronary system and cardiac magnetic resonance scan was able to demonstrate viability in LAD and circumflex territory.

Very early invasive strategy in higher risk non-ST-elevation acute coronary syndrome: the RAPID NSTEMI trial.

OBJECTIVE: To investigate whether a very early invasive strategy (IS)±revascularisation improves clinical outcomes compared with standard care IS in higher risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS: Multicentre, randomised, controlled, pragmatic strategy trial of higher risk patients with NSTE-ACS, defined by Global Registry of Acute Coronary Events 2.0 score of ≥118, or ≥90 with at least one additional high-risk feature. Participants were randomly assigned to very early IS±revascularisation (<90 min from randomisation) or standard care IS±revascularisation (<72 hours). The primary outcome was a composite of all-cause mortality, new myocardial infarction or hospitalisation for heart failure at 12 months. RESULTS: The trial was discontinued early by the funder due to slow recruitment during the COVID-19 pandemic. 425 patients were randomised, of whom 413 underwent an IS: 204 to very early IS (median time from randomisation: 1.5 hours (IQR: 0.9-2.0)) and 209 to standard care IS (median: 44.0 hours (IQR: 22.9-72.6)). At 12 months, there was no significant difference in the primary outcome between the early IS (5.9%) and standard IS (6.7%) groups (OR 0.93, 95% CI 0.42 to 2.09; p=0.86). The incidence of stroke and major bleeding was similar. The length of hospital stay was reduced with a very early IS (3.9 days (SD 6.5) vs 6.3 days (SD 7.6), p<0.01). CONCLUSIONS: A strategy of very early IS did not improve clinical outcomes compared with a standard care IS in higher risk patients with NSTE-ACS. However, the primary outcome rate was low and the trial was underpowered to detect such a difference. TRIAL REGISTRATION NUMBER: NCT03707314.

Role of Optical Coherence Tomography in Chronic Spontaneous Coronary Artery Dissection-Diagnosis and Management.

Spontaneous coronary artery dissection is an underdiagnosed cause of acute coronary syndrome, often occurring in younger females. Such a diagnosis should always be considered in this demographic. In this case report, we focus on the importance of optical coherence tomography in the diagnosis and management of this condition in the elective setting.

Aortic cusp perforation during rotational atherectomy: a case report.

Background: Rotational atherectomy has become increasingly utilised over the past decade. Although a relatively safe procedure in appropriately trained physicians' hands, there are a number of recognised complications. Case summary: We describe the case of a 64-year-old female who presented with chest pain and was diagnosed with non-ST-segment elevation acute coronary syndrome. A transthoracic echocardiogram (TTE) showed normal biventricular function and no valve disease. Invasive coronary angiogram was performed which revealed a severely calcified ostial right coronary artery (RCA) disease which was felt to be the culprit of the presentation. Balloon dilatation was unsuccessful, therefore, rotational atherectomy with an Amplatz left 0.75 guide and a 1.5 mm rota-burr was utilised and improved calcium burden. This was complicated by ostial dissection, treated with stenting. A TTE following the procedure revealed moderate aortic regurgitation (AR). The patient was discharged as she remained asymptomatic. An outpatient transoesophageal echocardiogram performed eight months later showed evidence of severe eccentric AR. Cardiac magnetic resonance imaging confirmed severe AR with left ventricular dilatation. Repeat angiogram 10 months after index procedure revealed in-stent restenosis, and the patient was accepted by heart multidisciplinary team for aortic valve replacement and grafting of RCA. Discussion: As the field of rotational atherectomy continues to expand, we propose that novel complications such as reported in this case may become recognised. Finally, we stress the importance of multi-modality imaging in the investigation and timely planning of interventions in the management of these patients.

Routine Pressure Wire Assessment Versus Conventional Angiography in the Management of Patients With Coronary Artery Disease: The RIPCORD 2 Trial.

BACKGROUND: Measurement of fractional flow reserve (FFR) has an established role in guiding percutaneous coronary intervention. We tested the hypothesis that, at the stage of diagnostic invasive coronary angiography, systematic FFR-guided assessment of coronary artery disease would be superior, in terms of resource use and quality of life, to assessment by angiography alone. METHODS: We performed an open-label, randomized, controlled trial in 17 UK centers, recruiting 1100 patients undergoing invasive coronary angiography for the investigation of stable angina or non-ST-segment-elevation myocardial infarction. Patients were randomized to either angiography alone (angiography) or angiography with systematic pressure wire assessment of all epicardial vessels >2.25 mm in diameter (angiography+FFR). The coprimary outcomes assessed at 1 year were National Health Service hospital costs and quality of life. Prespecified secondary outcomes included clinical events. RESULTS: In the angiography+FFR arm, the median number of vessels examined was 4 (interquartile range, 3-5). The median hospital costs were similar: angiography, £4136 (interquartile range, £2613-£7015); and angiography+FFR, £4510 (£2721-£7415; P=0.137). There was no difference in median quality of life using the visual analog scale of the EuroQol EQ-5D-5L: angiography, 75 (interquartile range, 60-87); and angiography+FFR, 75 (interquartile range, 60-90; P=0.88). The number of clinical events was as follows: deaths, 5 versus 8; strokes, 3 versus 4; myocardial infarctions, 23 versus 22; and unplanned revascularizations, 26 versus 33, with a composite hierarchical event rate of 8.7% (48 of 552) for angiography versus 9.5% (52 of 548) for angiography+FFR (P=0.64). CONCLUSIONS: A strategy of systematic FFR assessment compared with angiography alone did not result in a significant reduction in cost or improvement in quality of life. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT01070771.

Changing trends in the incidence, management and outcomes of coronary artery perforation over an 11-year period: single-centre experience.

INTRODUCTION: Coronary artery perforation (CP) is a rare but life-threatening complication of percutaneous coronary intervention (PCI). This study aimed to assess the incidence, management and outcomes of CP over time. METHODS: A single-centre retrospective cohort study of all PCIs performed between January 2010 and December 2020. Patients with CP were divided into two cohorts (A+B), representing the two halves of the 11-year study. RESULTS: The incidence of CP was 68 of 9701 (0.7%), with an increasing trend over the two 5.5-year periods studied (24 of 4661 (0.5%) vs 44 of 5040 (0.9%); p=0.035). Factors associated with CP included chronic total occlusions (CTOs) (16 of 68 (24%) vs 993 of 9633 (10%); p<0.001), type C lesions (44 of 68 (65%) vs 4280 of 9633 (44%); p<0.001), use of intravascular ultrasound (IVUS) (12 of 68 (18%) vs 541 of 9633 (6%); p<0.001), cutting balloon angioplasty (3 of 68 (4%) vs 98 of 9633 (1%); p<0.001) and hydrophilic wires (24 of 68 (35%) vs 1454 of 9633 (15%); p<0.001). Cohorts A and B were well matched with respect to age (69±11 vs 70±12 years; p=0.843), sex (males: 13 of 24 (54%) vs 31 of 44 (70%); p=0.179) and renal function (chronic kidney disease: 1 of 24 (4%) vs 4 of 44 (9%); p=0.457). In cohort A, CP was most frequently caused by post-dilatation with non-compliant balloons (10 of 24 (42%); p=0.009); whereas in cohort B, common causes included guidewire exits (23 of 44 (52%)), followed by stent implantation (10 of 44 (23%)). The most common treatment modality in cohorts A and B was balloon inflation, which accounted for 16 of 24 (67%) and 13 of 44 (30%), respectively. The use of covered stents (16%) and coronary coils (18%) during cohort B study period did not impact all-cause mortality, which occurred in 2 of 24 (8%) and 7 of 44 (16%) (p=0.378) in cohorts A and B, respectively. CONCLUSION: The incidence of CP is increasing as more complex PCI is performed. Factors associated with perforation include CTO or type C lesions and use of IVUS, cutting balloon angioplasty or hydrophilic wires.

ST-segment elevation myocardial infarction with plaque erosion, to stent or not to stent: utility of intracoronary optical coherence tomography (OCT) imaging-a case report.

Background: Treating acute myocardial infarction in the setting of insignificant coronary obstruction is an emerging challenge especially with the application of intracoronary imaging like intravascular ultrasound and optical coherence tomography (OCT). The cardiologists dealing with such patients may consider not to stent if there is intracoronary imaging evidence of minimal thrombus without plaque rupture and the vessel appears patent with settling of chest pain and electrocardiogram (ECG) changes. Case summary: A 47-year-old gentleman presented direct to the emergency department after experiencing retrosternal chest pain with an ECG showing hyperacute anterior T waves. He had ongoing chest pain and was therefore brought to the cardiac cath lab on the primary percutaneous coronary intervention (PCI) pathway. The first picture showed that the proximal left anterior descending (LAD) was occluded (TIMI 0 flow) with evidence of large thrombus burden. Pre-dilating with a 2.5 × 15 mm balloon did not change flow. Aspiration with an Export catheter was carried out for several runs. Most of the thrombus was successfully removed; however, some of it did go into the distal LAD but was successfully retrieved with aspiration catheter. The diagonal branch was occluded with thrombus which was wired followed by thrombus aspiration establishing TIMI II flow. The procedure was covered with Eptifibatide boluses and heparin. After thrombectomy, angiographically there was no obvious lesion present within the LAD. Optical coherence tomography confirmed only mild atheroma with a small amount of plaque and minimal thrombus. There was OCT evidence of plaque erosion without any plaque rupture. The area was above 9 mm2 and we decided not to treat that with a stent. The right coronary artery had an anterior take-off and was unobstructed. In conclusion, the patient had successful primary PCI to LAD with thrombus aspiration and balloon angioplasty only. He was placed on 12 months of dual antiplatelets therapy with Aspirin and Prasugrel. Discussion: This case highlights the rare presentation of patients with acute myocardial infarction with plaque erosion and the usefulness of OCT in formulating a management plan.

Retrieval of Entrapped Catheter-Mounted Axial Flow Pump From Mitral Subvalvular Apparatus Using a Snare Catheter.

Axial-flow ventricular assist devices are being increasingly used to support hemodynamically compromised patients undergoing percutaneous coronary intervention. Periprocedural valvular complications have been recognized in a few case reports. We present a unique case of entanglement of the Impella within he mitral subvalvular apparatus, retrieved successfully using a snare under fluoroscopic guidance. (Level of Difficulty: Advanced.).

Contemporary use of excimer laser in percutaneous coronary intervention with indications, procedural characteristics, complications and outcomes in a university teaching hospital.

BACKGROUND: Excimer laser coronary atherectomy (ELCA) can be used as an adjunctive percutaneous coronary intervention treatment for challenging, heavily calcified lesions. Although previous studies have documented high rates of complication and restenosis, these predate the introduction of the smaller 0.9 mm laser catheter. As the coronary complexity has increased, there has been a renewed interest in the ELCA. This study investigates the indications, procedural characteristics, complications and outcomes of ELCA in a contemporary coronary interventional practice. METHODS: This single-centre study retrospectively analysed 50 patients treated with ELCA between January 2013 and January 2019. RESULTS: Patients had a mean age of 67.9±11.4 years with a male predominance (65.3%). 25 (50%) cases were performed in patients with stable angina. Failure to deliver the smallest available balloon/microcatheter was the most frequent indication in 32 (64%) cases for ELCA use. 30 (60%) of the procedures were performed via radial access. The 0.9 mm X-80 catheter was used in 41 (82%) of cases, delivering on average 9000±3929 pulses. ELCA-related complications included 2 coronary dissections and 1 perforation, all of which were covered with stents. No major complications could be directly attributed to the use of ELCA. There was one death and one case of stent thrombosis within 30 days of the procedure. CONCLUSION: ELCA can be performed safely via the radial approach with a 0.9 mm catheter with a high success rate by suitably trained operators. The low procedure-related complications with contemporary techniques make this a very useful tool for complex coronary interventions, especially for difficult to dilate lesions and chronic total occlusion vessels.

Successful rotational atherectomy of left main stem with double kiss crush stenting using double guiding catheter: a case report.

BACKGROUND: Coronary artery bypass grafting is the preferred revascularization procedure for patients with multivessel disease, and those with complex left main disease, as it is associated with a survival advantage in this group of patients. Sometimes however surgical management is not the treatment of choice due to many factors including ongoing chest pain, haemodynamic instability, or patient preference. In these situations, percutaneous coronary intervention (PCI) offers an alternative revascularization strategy. In this case study, we present a successful PCI with rotational atherectomy (RA) for distal left main stem (LMS), left anterior descending (LAD), and circumflex artery (CX) using a double guide catheter technique in a patient with severe calcific disease. CASE SUMMARY: A 63-year-old female was diagnosed with a non-ST-elevation myocardial infarction. Coronary angiography showed significant distal LMS disease with a severe proximal/ostial calcified lesion of the LAD and a possible thrombotic lesion at the ostium of the CX. She had ongoing haemodynamic instability with chest pain however could not be offered immediate surgical revascularization. We therefore elected to proceed to complex bifurcation LMS coronary intervention using RA under intravascular ultrasound (IVUS) guidance achieving an excellent final result with TIMI III flow. DISCUSSION: This case demonstrates that RA using the double catheter technique (also known as Ping-Pong) can be safely performed with minimal complication rates and with very favourable angiographic and IVUS results. The clinical outcome was excellent with early discharge.

Macrophage infiltrates in coronary plaque erosion and cardiovascular outcome in patients with acute coronary syndrome.

BACKGROUND AND AIMS: Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS), and inflammation plays a key role in plaque instability. We assessed the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value. METHODS: ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target-vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03-2.58) years]. RESULTS: We included 153 patients [median age (IQR) 64 (53-75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p = 0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression, PE with MØI was an independent predictor of MACEs [HR = 2.95, 95% CI (1.09-8.02), p = 0.034]. CONCLUSIONS: Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up.

Management of acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura, the value of optical coherence tomography: a case report.

BACKGROUND: Treating myocardial infarction in the setting of immune thrombocytopenic purpura (ITP) is always a challenge especially if the platelet count is labile. Cardiologists dealing with such patients should keep a delicate balance between thrombotic and bleeding complications. CASE SUMMARY: A 50-year-old gentleman with treatment-challenging ITP presented with acute inferior ST elevation myocardial infarction after receiving recent intravenous immunoglobulin. Using optical coherence tomography (OCT) guidance, it was decided to treat him with percutaneous old balloon angioplasty especially with the labile nature of his platelet count. Subsequently, dual antiplatelet therapy was a challenge and he remained on clopidogrel for a period of only 10 weeks. CONCLUSION: This case highlights the rare presentation of patients with ITP with thrombotic complications and the usefulness of OCT in formulating a management plan.

Comparison of Routine Versus Selective Glycoprotein IIb/IIIa Inhibitors Usage in Primary Percutaneous Coronary Intervention (from the British Cardiovascular Interventional Society).

The role of glycoprotein IIb/IIIa inhibitors (GPI) in primary percutaneous coronary intervention (PPCI) remains uncertain. Previous analyses compare PPCI outcomes with clopidogrel plus GPI, versus without GPI. This does not reflect modern contemporary PPCI practice with ticagrelor or prasugrel. Nor does it answer the important question faced daily by PPCI operators: should GPI be used routinely or selectively? We aim to determine whether a strategy of routine use of GPI in contemporary PPCI practice is superior to selective GPI use. A total of 110,327 consecutive PPCIs performed in England were prospectively recorded in the British Cardiovascular Intervention Society Database (2009 to 2015). The cohort was divided into routine and selective GPI usage groups based on the PPCI operator's strategy, defined as GPI used in >75% and <25% PPCIs, respectively. Overall, GPI use declined from 73.1% to 43.3% of PPCIs. Routine compared with selective GPI usage was associated with lower all-cause 1-year mortality: 9.7% versus 11.0%, p < 0.001. There was a consistent survival benefit for routine GPI usage as compared with selective GPI usage: univariable analysis (hazard ratio = 0.88 [95% confidence interval 0.83 to 0.93], p < 0.001), multivariable analysis (hazard ratio = 0.82 [0.77 to 0.88], p < 0.001). For survival, there was no interaction between GPI usage and the type of P2Y12-inhibitor used. In conclusion, a strategy of routine GPI usage in patients who underwent PPCI was associated with lower all-cause mortality as compared with selective GPI usage. This benefit was maintained despite 44.3% of patients receiving prasugrel or ticagrelor.

Successful treatment of a spontaneous right coronary artery dissection with a 4-mm diameter cutting balloon: a case report.

BACKGROUND: Guidelines recommend conservative management for a spontaneous coronary artery dissection (SCAD) in the absence of ongoing ischaemia, haemodynamic instability, or left main dissection. Conventional percutaneous coronary intervention methods for SCAD are associated with an unfavourable prognosis due to difficulties wiring the lesion, dissection propagation, and potential 'milking' of the intramural haematoma along the vessel or into other vessels. These factors promote implantation of multiple stents which are often undersized, increasing the risk of in-stent restenosis significantly. There have been several case reports demonstrating the novel use of small diameter cutting balloons in the left anterior descending artery system. Here, we describe the successful use of a larger 4 mm cutting balloon to treat a spontaneous right coronary artery (RCA) dissection. CASE SUMMARY: A 53-year-old woman with troponin negative chest pain and was diagnosed with unstable angina due to ischaemic electrocardiographic features. Coronary angiography revealed a tight discrete lesion in the RCA. Intravascular imaging confirmed SCAD and a 4 mm cutting balloon was used to dissect the tunica intima to allow complete resorption of the intramural haematoma and resolution of symptoms. DISCUSSION: This case demonstrates the safe use of a larger 4 mm cutting balloon to treat an RCA SCAD, resulting in complete resolution of the haematoma.

What is the cause of hypotension? A rare complication of percutaneous coronary intervention of a chronic total occlusion: a case report.

BACKGROUND: In the last few years, complex techniques and advanced equipment became available to treat chronically occluded coronary arteries. Such procedures portend a series of possible complications that operators should be ready to quickly recognize and deal with. CASE SUMMARY: A 75-year-old lady with uncontrolled stable angina underwent percutaneous treatment of a chronically occluded right coronary artery. After balloon angioplasty and stenting, she developed a severe hypotension, refractory to fluid resuscitation and vasopressors. Computerized tomography scan demonstrated an intramural haematoma (IMH) of the right atrioventricular groove resulting in life-threatening pseudotamponade (or dry tamponade), as further confirmed by cardiac magnetic resonance imaging (MRI). The decision was for conservative management and haemodynamic support by intra-aortic balloon pump. Clinically, the patient improved and was discharged a few days later. Follow-up MRI confirmed resolution of the IMH. DISCUSSION: Severe hypotension during percutaneous treatment of chronically occluded coronary arteries may be related to various causes. Differential diagnosis is thus important in this setting and should include IMH, a rare but potentially fatal complication as it may cause compression of cardiac chambers and lead to pseudotamponade. A high index of suspicion is required to diagnose IMH but there are no clear guidelines for management of such cases.

Retrieval of a stuck Rotablator burr ("Kokeshi phenomenon") and successful percutaneous coronary intervention.

We report the case of a 74-year-old man having angioplasty following admission with a troponin positive acute coronary syndrome. Due to heavy coronary artery calcification, rotablation was used. The procedure was complicated by a stuck burr ("Kokeshi phenomenon"). We employed a novel method to safely remove the burr and complete the procedure. .

Successful treatment of a radial artery pseudoaneurysm in an octogenarian.

The transradial approach for coronary catheterisation has gained rising popularity owing to its fewer access site complications compared with the transfemoral approach. A rare but recognisable complication of the procedure is radial artery pseudoaneurysm (PSA). We report a case of radial PSA occurring 2 h following percutaneous coronary intervention in an 85-year-old woman, which was successfully treated by ultrasound-guided thrombin injection. This non-surgical technique has recently gained rising popularity as a relatively novel modality of managing radial PSA.

Rotational atherectomy through the radial artery is associated with similar procedural success when compared with the transfemoral route.

OBJECTIVES: Rotational atherectomy (RA) has traditionally been carried out using 7 or 8 Fr guides through a transfemoral approach to allow for passage of 2.0 mm burrs or larger. With transradial percutaneous coronary intervention becoming more common, our aim was to investigate whether transradial RA would offer equivalent rates of procedural success when compared with transfemoral RA. METHODS: Using a prospective percutaneous coronary intervention registry, we identified all patients who had undergone RA at the University Health Network between January 2001 and December 2012 and compared those in whom the transfemoral approach had been used with those in whom the transradial approach had been used. RESULTS: A total of 119 patients were analyzed (67 femoral, 52 radial). Larger guides were used in the femoral group compared with the radial group (6.79 vs. 6.31 Fr, P<0.001), but there was no significant difference in the number of burrs used or the average size of the burrs. There was no significant difference in the procedural success rate (91 vs. 96%, P=0.46), fluoroscopy time (40.5 vs. 43.8 min, P=0.37), radiation dose (27743 vs. 29939 cGy cm, P=0.50), or contrast use (429 vs. 384 ml, P=0.19) between the two groups. Patients in the femoral group were more likely to have a transvenous pacing wire inserted (25 vs. 6%, P=0.006). Access site crossover tended to occur more frequently in the radial group (6 vs. 0%, P=0.08). CONCLUSION: We have shown that RA through the transradial route is associated with outcomes similar to those achieved through the transfemoral route. Keeping in mind the single-center context and the small number of operators, our data do not suggest an increased rate of failure of RA through the radial route despite the use of smaller guiding catheters.