Distal arteriovenous fistula formation after percutaneous coronary intervention: An old complication of a new access site.

Dorsal or distal transradial artery access has recently gained popularity due to several perceived benefits that include favorable ergonomics, the potential for rapid hemostasis and lower rates of vascular complications. Still, no vascular access site is free of complications and reports of hematoma and pseudoaneurysm formation related to distal radial artery access have been reported in the literature. We present a case of a 71-year-old male who developed an arteriovenous fistula (AVF) involving the distal left radial artery following repeated access of the artery. This rare complication is likely avoidable with a comprehensive understanding of the surrounding anatomy and proper procedural technique, including the routine use of ultrasound for access.

Validation of the all-comers design: Results of the TARGET-AC substudy.

BACKGROUND: Results of clinical trials are often criticized by low inclusion rate and potential sampling bias in patient recruitment. The aim of this validation registry is to evaluate how far an all-comers design in the context of clinical research can ensure the representation of the true all-comers population. METHODS: This validation registry is a prospective international multicentre registry, conducted at 10 out of the total 21 centers, participating in TARGET-AC (registered under NCT02520180). During a predefined four-week period data were recorded prospectively on all PCIs performed in the participating centers, whether or not patients were enrolled in TARGET-AC. Data were collected on patient demographics, angiographic lesion- and procedural characteristics. For patients who were not enrolled in the study, operators were asked to declare the reason for not enrolling the patient, using a single-choice questionnaire. RESULTS: A total of 131 patients were enrolled in the TARGET-AC study during the investigated period (ER group), standing as 20% (range 4% and 54%) of all eligible cases per protocol. In the ER group more patients presented with stable angina (61% vs. 43%, respectively; P < .001). Whereas ST-elevation infarction was less common (5% vs. 26%, respectively; P < .001), there was no difference in non-ST elevation acute coronary syndrome (32% vs. 27%, respectively; P = .248). Risk factors and comorbidities did not show any difference between the ER and the non-enrolled (NER) groups, except for greater rate of significant valvular disease in the NER group (12% vs 19%, respectively; P = .037). The NER group presented more thrombotic stenoses than the ER group (20% vs 12%, respectively; P = .040). No difference was found in any other investigated angiographic parameters, like target vessels, bifurcation lesion, severe calcification or chronic total occlusions. Admission during regular working hours and availability of study nurse were associated with markedly higher recruitment rate. CONCLUSION: Results suggest that TARGET AC was outbalanced for stable patients over primary PCIs as compared to real world. However in terms of risk factors and comorbidities the trial managed to represent the collective of real world clinical practice. Fairly representative cases were included at an average inclusion-to-eligible rate of 20%.

Impact of sheath size and hemostasis time on radial artery patency after transradial coronary angiography and intervention in Japanese and non-Japanese patients: A substudy from RAP and BEAT (Radial Artery Patency and Bleeding, Efficacy, Adverse evenT) randomized multicenter trial.

BACKGROUND: During transradial (TR) access, it remains unclear whether differences in baseline patients characteristics and hemostasis care impact the rate of radial artery occlusion (RAO). We sought to compare the rate of RAO after TR access with the 6 French(Fr) Glidesheath Slender (GSS6Fr, Terumo, Japan) or a standard 5 Fr sheath in Japanese and non-Japanese patients. METHODS AND RESULTS: The Radial Artery Patency and Bleeding, Efficacy, Adverse evenT (RAP and BEAT) trial randomized 1,836 patients undergoing TR coronary angiography and/or interventions to receive the GSS6Fr or the standard 5 Fr Glidesheath (GS5Fr, Terumo, Japan). Out of this study population, 1,087 were Japanese patients and 751 non-Japanese patients. The overall incidence of RAO was significantly higher in Japanese patients (3.6% vs. 1.2%, P = 0.002). Use of GSS6Fr was associated with higher rates of RAO than GS5Fr in Japanese patients (5% vs. 2.2%, P = 0.02) and with similar RAO rates in non-Japanese patients (1.3 vs. 1.1%, P = 1). The mean hemostasis time was significantly longer in Japanese patients (378 ± 253 vs. 159 ± 136 min, P < 0.001) and more Japanese patients had a hemostasis time of more than 6 hr (16.2% vs. 4.9%, P < 0.0001). Longer hemostasis time was an independent predictor of RAO (OR per additional hour 1.070, 95% CI 1.008-1.136, P = 0.03). CONCLUSIONS: Use of GSS6Fr was associated with a higher rate of RAO than a standard 5 Fr sheath in Japanese patients but not in non-Japanese patients. Whether improvement in post-procedural care and reduced hemostasis time could impact the incidence of RAO in Japanese patients should be further assessed.

A novel approach to reduce radial artery occlusion after transradial catheterization: postprocedural/prehemostasis intra-arterial nitroglycerin.

OBJECTIVE: To evaluate whether administration of nitroglycerin through the sheath at the end of a transradial procedure might preserve the patency of the radial artery. BACKGROUND: Despite the increasing acceptance of transradial approach, radial artery occlusion (RAO) continues to be a vexing problem of transradial access and limits utility of the radial artery as an access site in the future. METHODS: We conducted a multicenter, prospective, randomized, placebo-controlled, operator-blinded trial and enrolled 1,706 patients who underwent transradial catheterization in three experienced radial centers. Patients were randomized to receive either 500 µg nitroglycerin (n=853) or placebo (n=853), given intra-arterially through the sheath at the end of the radial procedure. The primary outcome was the incidence of RAO as confirmed by absence of antegrade flow at one day after the transradial procedure evaluated by duplex ultrasound of the radial artery. RESULTS: The use of nitroglycerin, as compared with placebo, reduced the risk of the primary outcome [8.3% vs. 11.7%; odds ratio, 0.62; 95% confidence interval (CI), 0.44-0.87; P=0.006]. From a multivariable analysis, duration of hemostasis was a predictor of RAO (odds ratio, (odds ratio, 3.11; 95% CI, 1.66 to 5.82; P<0.001). There were no significant differences between the groups with respect to the sheath size (P=0.311), number of puncture attempts (P=0.941), duration of hemostasis (P=0.379) and procedural time (P=0.095). CONCLUSION: The administration of nitroglycerin at the end of a transradial catheterization, reduced the incidence of RAO, examined 1 day after the radial procedure by ultrasound. Postprocedural/prehemostasis pharmacologic regimens may represent a novel target for further investigation to reduce RAO.

Recurrent Myocardial Infarction After Primary Percutaneous Coronary Intervention in Multivessel Coronary Disease Is Primarily Related to Stent Failure: Post-Hoc Analysis of the PASSION Trial.

OBJECTIVES: Our aim was to investigate the risk of events related to non-culprit lesions after primary percutaneous coronary intervention (PCI) in patients with multivessel coronary disease (MVD). BACKGROUND: In patients undergoing primary PCI for ST-elevation myocardial infarction (STEMI) who are diagnosed with MVD, the optimal treatment strategy is currently under debate. Although observational data exposed an increased risk of multivessel PCI in the acute phase of STEMI, 2 recently published randomized controlled trials showed a reduction of death or recurrent myocardial infarction (MI) after preventive PCI of non-culprit lesions when compared with culprit-lesion PCI only. METHODS: We performed a post-hoc analysis of 279 patients with MVD included in the Paclitaxel-Eluting Stent versus Conventional Stent in Myocardial Infarction with ST-Segment Elevation (PASSION) trial. We analyzed the incidence and cause of recurrent MI. Recurrent MI due to stent failure was assumed in the event of definite or probable stent thrombosis. RESULTS: After 5 years, 14 patients (5.7%) with MVD had a recurrent MI versus 17 (5.4%) patients with 1-vessel disease (HR 1.06, 95%CI 0.52-2.15, P = 0.87). The majority of events was attributable to stent failure, while of the remaining 6 events, only 1 was proven to originate from a lesion that was judged significant at enrolment. CONCLUSIONS: In this post-hoc analysis of the PASSION trial, recurrent MI in patients with MVD was mainly related to stent failure rather than a new event originating from a significant stenosis in a non-culprit coronary artery.

Radial artery spasm associated with transradial cardiovascular procedures: results from the RAS registry.

OBJECTIVES: To report the incidence and predictors of moderate/severe radial artery spasm (RAS) in patients undergoing cardiovascular percutaneous procedures through a transradial approach (TRA) in centers with TRA expertise. BACKGROUND: Data regarding the actual rate of clinically meaningful RAS are limited due to difference in study designs and operator expertise. METHODS: The RAS registry, an international (14 centers from Argentina, Chile, India, Indonesia, Macedonia, The Netherlands and United States of America) registry that included 1,868 patients undergoing TRA cardiovascular procedures (63.5% diagnostic and 56.5% therapeutic).All selected centers used TRA as default strategy in the cardiac catheterization laboratory. Throughout 2012, each center included all consecutive TRA cases (during a 2-month period) into a dedicated database covering clinical characteristics as well as procedural topics related to TRA patterns and RAS occurrence. RESULTS: The incidence of moderate/severe RAS was 2.7%. Only 0.7% of patients required crossover (8 to transfemoral and 5 to contralateral TRA). Patients with moderately/severe spasm were more frequently females, had a history of dyslipidemia, received more often a 7F sheath and more puncture attempts than patients without spasm. By multivariate analysis, the need for more than one attempt and the use of a 7 F sheath were independent predictors of the development of moderate/severe RAS. CONCLUSIONS: The incidence of moderate/severe RAS is low in centers with a default TRA. Its development appears to be strongly related to the numbers of puncture attempts and the use of large sheaths.

Lack of long-term clinical benefit of thrombus aspiration during primary percutaneous coronary intervention with paclitaxel-eluting stents or bare-metal stents: post-hoc analysis of the PASSION-trial.

BACKGROUND: Although current clinical guidelines recommend the use of thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI), previous studies evaluating TA demonstrated contradictory results. The aim of this study was to evaluate long-term clinical outcome after TA in adjunct to PPCI for acute ST-segment myocardial infarction (STEMI), as compared with conventional treatment, with the use of paclitaxel-eluting stents or bare-metal stents. METHODS: We analyzed data of the PASSION trial, in which 619 patients with STEMI were randomly assigned to a paclitaxel-eluting stent or a bare-metal stent. TA was performed in 311 patients (50.2%). Clinical endpoints at 2 years were compared between patients who received TA during PPCI with patients who underwent conventional PPCI. The primary outcome of interest was a composite of cardiac death, recurrent myocardial infarction (MI), or target-lesion revascularization (TLR). A propensity score model was made to account for baseline differences that could have affected the probability of performing TA. RESULTS: Complete follow-up was available for 598 patients (96.6%). The cumulative incidence of the combined outcome measure of cardiac death, recurrent MI, or TLR was 40 (13.0%) in the TA group and 41 (13.5%) in the conventional PPCI group (HR 0.96; 95% CI 0.62-1.47; P = 0.84). Also after adjusting for propensity score, no significant difference in event rate was observed between both treatment groups. CONCLUSIONS: In this post-hoc analysis of the PASSION trial, TA in adjunct to PPCI did not affect rates of major adverse cardiac events at 2 years follow-up, as compared with conventional PPCI.

Primary percutaneous coronary intervention by magnetic navigation compared with conventional wire technique.

Aims Comparison of magnetic guidewire navigation in percutaneous coronary intervention (MPCI) vs. conventional percutaneous coronary intervention (CPCI) for the treatment of acute myocardial infarction. Methods and results We compared 65 sequential patients (mean age 61 ± 15 years) undergoing primary MPCI with those of 405 patients undergoing CPCI (mean age 61 ± 13 years). The major endpoint was contrast media use. Technical success and procedural outcomes were evaluated. Clinical demographics and angiographic characteristics of the two groups were similar, except for fewer patients with previous coronary artery bypass grafting (CABG) and hypertension in the CPCI group and fewer patients with diabetes in the MPCI group. The technical success rate was high in both the MPCI and CPCI groups (95.4 vs. 98%). There was significantly less contrast media usage in the MPCI compared with the CPCI group, median reduction of contrast media of 30 mL with an OR = 0.41 (0.21-0.81). Fluoroscopy times were significantly reduced for MPCI compared with CPCI, median reduction of 7.2 min with an OR = 0.42 (0.20-0.79). Conclusion This comparison indicates the feasibility and non-inferiority of magnetic navigation in performing primary PCI and suggests the possibility of reductions in contrast media use and fluoroscopy time compared with CPCI.

International Hand Function Study Following Distal Radial Access: The RATATOUILLE Study.

BACKGROUND: Distal radial access (DRA) has been proposed to improve procedure ergonomics and favor radial artery patency. Although promising data, nothing is known on evolving hand function after DRA. OBJECTIVES: This study sought to comprehensively evaluate hand function in patients undergoing DRA. METHODS: Real-world patients undergoing DRA undertook a thorough multimodality assessment of hand function implementing multidomain questionnaires (Disabilities of the Arm, Shoulder and Hand and Levine-Katz), and motor (pinch grip test) and sensory (Semmes-Weinstein monofilaments test) examinations of both hands. All assessments were performed at preprocedural baseline and planned at 1-, 6-, and 12-month follow-up (FU). Adverse clinical and procedural events were documented too. RESULTS: Data of 313 patients (220 men, age 66 ± 10 years) from 9 international centers were analyzed. The Disabilities of the Arm, Shoulder and Hand and the Levine-Katz scores slightly improved from baseline to FU (P = 0.008 and P = 0.029, respectively). Pinch strength mildly improved from baseline to FU (P < 0.001 for both the left and right hands). Similarly, touch pressure threshold appeared to faintly improve in both the left and right hands (P < 0.012 for all the sites). For both motor and sensory function tests, comparable findings were found for the DRA hand and the contralateral one, with no significant differences between them. Repeated assessment of all tests over all FU time points similarly showed lack of worsening hand function. Access-related adverse events included 19 harmless bleedings and 3 forearm radial artery and 3 distal radial artery occlusions. None affected hand function at FU. CONCLUSIONS: In a systematic multidimensional assessment, DRA was not associated with hand function impairment. Moreover, DRA emerges as a safe alternative vascular access.

A randomized comparison of manual versus mechanical thrombus removal in primary percutaneous coronary intervention in the treatment of ST-segment elevation myocardial infarction (TREAT-MI).

OBJECTIVES: The objective of this study was to compare the efficacy and long-term clinical outcome of manual thrombus aspiration with the Export catheter (Medtronic, Minneapolis, MN) versus mechanical thrombus cutting/aspiration with the X-sizer system (eV3, White Bear Lake, MN) in primary percutaneous coronary intervention (PPCI). BACKGROUND: In PPCI for acute ST-segment elevation myocardial infarction (STEMI), markers of myocardial reperfusion are improved with adjunctive thrombectomy. Previous studies of different devices showed a variability in performance, suitability, and short-term clinical outcome. In current literature, no direct comparison is available. METHODS: We prospectively randomized 201 patients admitted for PPCI for STEMI to either the Export catheter or the X-sizer prior to stent deployment. Technical success in advancing to and across the lesion, improvement of flow, reduction of thrombus, and the effect on ST-segment resolution were examined. The primary endpoint of the follow-up study was the combined endpoint of cardiac death, recurrent myocardial infarction (MI), or target-vessel revascularization (TVR) at 3 years. RESULTS: Although the Export catheter was more successfully deployed, other procedural parameters were similar with a trend toward better ST-segment resolution (56.6% vs. 44%; P = 0.06) as compared to the X-sizer system. The occurrence of the primary clinical endpoint at 3 years was 22.2% and 18.6%, respectively (HR 1.20; 95% CI 0.65-2.22; P = 0.35). CONCLUSION: Despite shorter procedural times, better lesion crossing, and fewer complications, both surrogate endpoints as well as 3-year clinical follow-up were similar with the use of the Export catheter as compared to the X-sizer system.

Ultrasound-guided access to the distal radial artery at the anatomical snuffbox for catheter-based vascular interventions: a technical guide.

Conventional radial access has been shown to have many advantages over the transfemoral approach. The risk of potential radial artery occlusion and subsequent hand ischaemia can be reduced further by accessing the vessel distally at the anatomical snuffbox, allowing maintenance of antegrade flow to the hand by the superficial palmar arch branch. Additional potential advantages of distal radial access in comparison to the conventional radial approach at the wrist include fewer puncture-site complications and faster post-procedural haemostasis as the vessel is very superficial. Furthermore, it provides another safe, non-femoral option for vascular access. The use of ultrasound guidance enables the operator to identify important anatomical landmarks and avoid injuring adjacent structures. We provide a detailed step-by-step guide for performing distal radial access using sonographic and anatomical correlation, thereby facilitating safe access and optimising technical success.

Distal Versus Conventional Transradial Artery Access for Coronary Angiography and Intervention: A Meta-Analysis.

BACKGROUND: Distal transradial artery access (dTRA) through the anatomical snuffbox is a novel approach for performing coronary angiography and interventions. However, the safety and efficacy of dTRA as compared to conventional TRA (cTRA) remains unknown. We aim to evaluate the outcomes of dTRA versus cTRA for coronary angiography and intervention. METHODS: Electronic search of the National Library of Medicine PubMed and Cochrane Library databases was performed until April 2019 for studies comparing the clinical outcomes of dTRA approach versus conventional TRA (cTRA) approach in coronary angiography and interventions. Random-effects DerSimonian-Laird risk ratios (RR) were calculated. The main outcome was failure of access site utilization. Other outcomes included access site hematoma, radial artery spasm, dissection, and occlusion. RESULTS: Five studies (4 observational and 1 randomized controlled) with a total of 6746 patients (dTRA n = 3209 and cTRA n = 3537) were available for analysis. The failure rate was similar in dTRA and cTRA groups (5.26% versus 3.75%; RR = 1.36; 95%CI 0.41-4.48; p = 0.62). Similarly, no difference was observed between dTRA and cTRA in regards to access site hematoma (1.20% versus 1.24%, RR = 1.01; 95%CI 0.49-2.07; p = 0.99), radial artery spasm (1.42 versus 3.84%, RR = 0.91; 95%CI 0.32-2.62; p = 0.86), or radial artery dissection (0.11 versus 0.20%, RR = 0.63; 95%CI 0.18-2.16; p = 0.46). The rate of radial artery occlusion was lower with dTRA (2.30 versus 4.86%, RR = 0.51; 95%CI 0.32-0.81; p = 0.004) as compared to cTRA. CONCLUSION: Distal TRA appears to be a safe and effective alternative to conventional TRA. The outcomes of this novel technique warrant further randomized studies.

Paclitaxel-eluting versus uncoated stents in primary percutaneous coronary intervention.

BACKGROUND: Drug-eluting coronary-artery stents have been shown to decrease restenosis and therefore the likelihood that additional procedures will be required after percutaneous coronary intervention (PCI). We evaluated the use of a drug-eluting stent in patients undergoing PCI for acute myocardial infarction with ST-segment elevation. METHODS: We randomly assigned 619 patients presenting with an acute myocardial infarction with ST-segment elevation to receive either a paclitaxel-eluting stent or an uncoated stent. The primary end point was a composite of death from cardiac causes, recurrent myocardial infarction, or target-lesion revascularization at 1 year. RESULTS: Baseline clinical and angiographic characteristics in both groups were well matched. There was a trend toward a lower rate of serious adverse events in the paclitaxel-stent group than in the uncoated-stent group (8.8% vs. 12.8%; adjusted relative risk, 0.63; 95% confidence interval, 0.37 to 1.07; P=0.09). A nonsignificant trend was also detected in favor of the paclitaxel-stent group, as compared with the uncoated-stent group, in the rate of death from cardiac causes or recurrent myocardial infarction (5.5% vs. 7.2%, P=0.40) and in the rate of target-lesion revascularization (5.3% vs. 7.8%, P=0.23). The incidence of stent thrombosis during 1 year of follow-up was the same in both groups (1.0%). CONCLUSIONS: Although the use of paclitaxel-eluting stents in acute myocardial infarction with ST-segment elevation reduced the incidence of serious adverse cardiac events at 1 year by 4.0 percentage points, as compared with uncoated stents, the difference was not statistically significant. (Current Controlled Trials number, ISRCTN65027270 [controlled-trials.com].).

Comparison of magnetically navigated and conventional wire percutaneous coronary intervention of a single discrete stenosis.

OBJECTIVE: The objective of this study is to compare magnetic guidewire navigation in percutaneous coronary intervention (MPCI) to conventional percutaneous coronary intervention (CPCI) for the elective treatment of a single discrete stenosis. BACKGROUND: Magnetic navigation actively steers an angioplasty wire-tip and may improve PCI procedures, but it is not known whether the intricacy and increased preparation necessary for using the system negatively influences the performance of simple procedures in terms of time and contrast use. METHODS: The procedures of 44 patients (mean age 65 +/- 10 year) undergoing elective single vessel MPCI of a single discrete stenosis were matched for age, gender, and lesion location with 44 concurrent patients (mean age 65 +/- 10 year) undergoing CPCI. The major endpoint was procedural time. RESULTS: Technical success was defined as an intraluminal wire position distal to the stenosis. Procedural outcome, contrast use, and costs were evaluated. Clinical demographics and angiographic characteristics of the two groups were similar, except for a higher incidence of previous MI and class III angina pectoris in the conventional group. The technical success rate was high and identical in both groups (97.7%). Procedural and fluoroscopy times were not significantly different for MPCI compared to CPCI (21.0 +/- 14.5 min vs. 24.7 +/- 14.0 min; 4.9 +/- 4.8 min vs. 7.3 +/- 10.3 min, P = NS). There was a significant reduction in median contrast use [60 ml/patient (41-100) vs. 100 ml/patient (64-130); P = 0.006]. CONCLUSION: Magnetic navigation does not increase procedural time, irradiation, equipment use, or cost compared to conventional PCI of a single discrete stenosis. It proved feasible, yielding high rates of procedural success with less contrast use.

Bare metal or drug-eluting stent implantation in last remaining vessel PCI? A serious dilemma.

This case report describes the treatment of an old male diabetic patient with last remaining vessel coronary artery disease and poor left ventricular function. In presence of an old occlusion of the left main coronary artery, a subtotal stenosis of a dominant right coronary artery required angioplasty. After ample consideration it was decided to implant a bare metal stent (BMS) instead of a drug-eluting stent (DES). The major reason was the fear for early discontinuation of clopidogrel in case a drug-eluting stent was placed. The procedure and follow-up are described followed by an overview of current literature concerning similar pathology.

Distal transradial access as default approach for coronary angiography and interventions.

BACKGROUND: Distal transradial access (dTRA) as a refinement of the conventional transradial access has advantages in terms of patient and operator comfort and risk of radial artery (RA) occlusion. RA preservation with this new technique could be a relevant issue in patients requiring its future use. In turn, one relevant drawback is the more challenging puncture of a smaller artery. In order to evaluate the real world feasibility and safety of both right (rdTRA) and left (ldTRA) distal transradial access as default access site for routine coronary angiography (CAG) and percutaneous coronary intervention (PCI), this prospective observational registry was conducted. METHODS: From February to July 2019, 435 consecutive patients underwent CAG and/or PCI (620 procedures at all, by two experienced transradial operators) through rdTRA or ldTRA. RESULTS: Mean patient age was 62.4 years old. Most were male (66.0%). The majority (49.4%) of patients had an acute coronary syndrome; overall, 15.2% with ST-elevation acute myocardial infarction (STEMI). Distal RA was successfully punctured in all patients, always without ultrasound guidance, with puncture and sheath insertion at until 2 attempts in the vast majority of patients. We had only 3.0% access site crossovers (successful arterial puncture but failed sheath insertion), mainly performed via the contralateral dTRA (53.8%). Successful dTRA sheath insertion was then achieved in 98.6% of all 435 patients. Redo ipsilateral dTRA was performed in 2.5% of patients. Distal and proximal RA pulses were palpable in all patients at hospital discharge. No major adverse cardiac and cerebrovascular events and no major complications were recorded. CONCLUSIONS: dTRA as default approach for routine CAG and/or PCI by experienced transradial operators appears to be safe and feasible. Further randomized and larger trials are still needed to assure the clinical benefits and the safety of this new technique.

ACRA Perfusion Study.

BACKGROUND: Transradial intervention (TRI) may impair digital perfusion with hand dysfunction as a result. However, the effect of TRI on digital perfusion has never been investigated, including the influence of variations of the collateral arterial network and the effect on hand dysfunction. METHODS AND RESULTS: We investigated the effect of TRI on digital perfusion by laser Doppler perfusion imaging. Laser Doppler perfusion imaging was performed at baseline, during radial access, TR band application, and at discharge. We compared tissue perfusion of the homolateral thumb (access site) with the contralateral thumb (comparator) during radial access as primary outcome. The hand circulation was assessed with angiography. Upper extremity function was evaluated with the validated QuickDASH questionnaire at baseline and follow-up. A significant reduction of tissue perfusion was observed during radial access and TR band application in the homolateral thumb (-32%, -32%, respectively) and contralateral thumb (-34%, -21%, respectively). We detected no perfusion difference between the homolateral and contralateral thumb during radial access (217; interquartile range, 112-364 versus 209; interquartile range, 99-369 arbitrary flux units; P=0.59). Reduced perfusion of the thumb during radial access was not associated with incompleteness of the superficial palmar arch ( P=0.13). Digital perfusion improved at discharge, though it remained below baseline levels (homolateral -11% and contralateral -14%). Hand dysfunction at 18 months was not associated with TRI-induced perfusion reduction ( P=0.54). CONCLUSIONS: TRI is safe. Digital perfusion is reduced in both hands during radial access and TR band application but is not associated with future loss of hand function and variations of the arterial hand supply.

Validation of brachial artery pressure reconstruction from finger arterial pressure.

OBJECTIVE: Measurement of finger artery pressure with Finapres offers noninvasive continuous blood pressure, which, however, differs from brachial artery pressure. Generalized waveform filtering and level correction may convert the finger artery pressure waveform to a brachial waveform. An upper-arm cuff return-to-flow measurement may be used to calibrate the blood pressure on an individual basis. We tested these corrective methods as implemented in the Finometer device. METHODS: Intrabrachial artery pressure (BAP) and finger artery pressures were recorded simultaneously in 37 cardiac patients, aged 41-83 years, who underwent a cardiac catheterization procedure. Finger artery pressures were compared after waveform filtering and level correction and after an additional return-to-flow calibration. Measurements were performed in supine and sitting positions. Accuracy and precision were considered clinically acceptable if the mean and standard deviation of the return-to-flow intrabrachial artery pressure (reBAP)-BAP differences were smaller than 5 +/- 8 mmHg (Association for the Advancement of Medical Instrumentation requirements). RESULTS: Finger artery systolic, diastolic and mean pressures for the group differed from that of intrabrachial artery pressure by -10 +/- 13, -12 +/- 8 and -16 +/- 8 mmHg, respectively. After waveform filtering and level correction the filtered level corrected arterial pressure differed by -1 +/- 11, -0 +/- 7 and -2 +/- 7 mmHg. After individual calibration, reBAP differed by 3 +/- 8, 4 +/- 6 and 3 +/- 5 mmHg. Comparable results were found in the sitting position but only when the supine return-to-flow calibration was used. CONCLUSION: Reconstruction of intrabrachial artery pressure from finger artery pressure with waveform filtering and level correction reduces the pressure differences substantially, with diastolic and mean within Association for the Advancement of Medical Instrumentation requirements. After one supine return-to-flow calibration, all pressure differences meet the requirements. Return-to-flow calibration should not be repeated in sitting position.

Transradial approach for coronary angiography and interventions in patients with coronary bypass grafts: tips and tricks.

Among patients undergoing coronary procedures, patients with coronary artery bypass grafts represent an important, high risk subgroup. Routine transradial approach may be successfully adopted in these patients to reduce access-site complications. However, transradial cannulation of the grafts may result technically demanding. In this article we discuss the specific technical issues and we present a series of tips and tricks which may facilitate angiography and interventions on both internal mammary and aorto-coronary grafts.

Use of the Stereotaxis Niobe magnetic navigation system for percutaneous coronary intervention: results from 350 consecutive patients.

INTRODUCTION: The Stereotaxis Niobe magnetic navigation system (MNS; Stereotaxis, St. Louis, MO) facilitates precise vector based navigation of magnetically-enabled guidewires for percutaneous coronary intervention (PCI) by using two permanent magnets located on opposite sides of the patient table to produce a controllable magnetic field. The objective of this study is to describe the results of a large patient series using this system, to compare the results with a historical control group, and to detail the MNS learning curve. METHODS: We prospectively collected data on 439 lesions in 350 consecutive PCI patients using the MNS predominantly using the radial approach. All data were entered into a customized database to capture the key parameters and then compared with a previously collected stent registry from the same center. RESULTS: In 410/439 lesions (93%) the wire crossed the lesion successfully using the MNS. Twenty-five of the 35 failures were chronic total occlusions. No wire perforations or dissections occurred in this population. Lesion crossing time was 81 +/- 168 sec (mean +/- SD), and fluoroscopy time was 64 +/- 123 sec. A clear learning curve was evident after the first 80 patients. Contrast use was reduced when compared with a historical control group. Procedural and fluoroscopy times were similar. CONCLUSIONS: Use of the MNS may enable the successful performance of more complex procedures in the cardiac catheterization laboratory with an improvement in time efficiency.