Preserving Radial Patency: Multiple Prior Radial Procedures and Now Large-Bore Access.

6 French percutaneous coronary intervention (PCI), has become widely adopted. We describe a case of successful 8 French transradial access (TRA) coronary intervention using state of the art hemostasis technique with preservation of radial patency after the procedure.

Comparison of radiation exposure associated with transradial and transfemoral access: An updated meta-analysis.

OBJECTIVES: To assess differences in radiation exposure between transradial access (TRA) and transfemoral access (TFA) for coronary procedures. BACKGROUND: TRA is associated with increased radiation exposure as compared to TFA. We compared radiation exposure between the two access sites. METHODS: Databases were searched from June 2014 to August 2021 for randomized controlled trials (RCTs) reporting coprimary outcomes of fluoroscopy time (FT) and/or dose area product (DAP) comparing TRA with TFA. Meta-regression was performed to assess the behavior of weighted mean difference (WMD) in FT from 1995 to 2021. Observational study data was used for corroborative evidence. RESULTS: Data from 8 RCTs (11,611 patients) showed the WMD of FT was 0.62 min (37 s) (95% confidence interval [CI]: [0.08-1.17], p = 0.023) in favor of TFA, WMD in DAP (9169 patients) was 1.94 Gy.cm2 (95% CI: [-2.1 to 5.9], p = 0.35) showing no significant difference. Pooled data from OBS and RCTs (83,990 patients) showed a similar trend. Studies from outside US between 1995 and 2021 showed WMD of FT between TRA and TFA of 0.88 min (52 s) (95% CI: [0.67-1.09], p = 0.005) versus 2.1 min (126 s) (95% CI: [1.38-2.8], p = 0.005) for US in favor of TFA. Meta-regression showed a declining WMD of FT between TRA and TFA from 1.6 min (96 s) in 1996 to 0.5 min (30 s) in 2020 with the lower limit of CI crossing the zero line in 2019. CONCLUSION: Radiation exposure between TRA and TFA continues to decrease overtime and is becoming clinically nonsignificant.

Evaluation of the incidence of radial artery occlusion using different introducer sheaths and hemostasis techniques.

BACKGROUND: Radial artery occlusion (RAO) remains one of the most important complications of transradial access (TRA). Despite the identification of multiple predictors, the interaction between these predictors on the occurrence of RAO has not been evaluated. METHODS: Consecutive patients undergoing TRA coronary angiography (CA) or percutaneous coronary intervention (PCI), were retrospectively analyzed to compare the effect of standard patent hemostasis using a one-bladder band versus two-bladder band with simultaneous ipsilateral ulnar artery compression and two introducer sizes on the primary endpoint of RAO. Access was obtained using 6-Fr slender introducer sheath or 7-Fr slender introducer sheath and hemostasis with either a one-bladder band or a two-bladder band. The radial artery was evaluated using ultrasound. RESULTS: Total of 2019 patients undergoing CA or PCI were included in the analysis. In the one-bladder band group, the incidence of RAO with a 6-Fr slender introducer sheath was 4.2%. In those receiving hemostasis with a two-bladder band, RAO occurred in 1% of patients receiving a 6-Fr slender introducer sheath versus 0.9% in those receiving a 7-Fr slender introducer sheath (p = 0.68). Larger radial artery diameter, larger body weight, and a two-bladder hemostasis band with ipsilateral ulnar compression were independently associated with a lower incidence of RAO. CONCLUSION: A two-bladder band with simultaneous ipsilateral ulnar artery compression when used for radial artery hemostasis, is associated with a lower incidence of RAO, and can mitigate the penalty for a larger catheter with reassuring implications for use of a 7-Fr capable system for complex transradial PCI.

Factors Affecting Image Resolution in a Modern Angiographic Suite: A Phantom-Based Study.

BACKGROUND: Improvements in angiographic imaging systems technology provide options to decrease radiation exposure. The effect of these variations on image resolution is unknown. METHODS: Using an American National Standards Institution phantom, a high-contrast (line-pair) and low contrast (Gammex 151) phantoms, 5 second images were acquired using a Phillips Allure angiographic suite, using fluoroscopic capture (FC) as well as cineangiography (CA) in posterior anterior (PA) and left anterior oblique (LAO) projections as well as high and low table positions. Image resolutions were measured as ranked by three independent trained observers blinded to the purpose of the assessments. Comparative analyses were performed. Interobserver agreement was evaluated. RESULTS: High contrast image resolution was significantly lower with FC compared to CA (median [interquartile range], 1.69 [1.52-1.69] mm, vs 2.09 [1.88-2.09] mm, P < 0.001). No significant differences were observed in between PA and LAO projections as well as low and high table positions. Low contrast resolution was also lower with FC compared to CA (5 [6.5-5] vs 3 [5-3] mm, P < 0.001). No significant differences in high-contrast or low-contrast resolution were noted between PA and LAO projections, or high and low table positions. Both low and high-contrast image resolution improved with higher radiation exposure. Good interobserver agreement was noted (Fleiss-Kappa ranging from 0.69-0.74). CONCLUSION: Image resolution was perceived to be better with CA compared to FC, although not significantly affected by beam angulation or table height. Aligning resolution needs with imaging modality and maximizing table height may improve procedural efficacy and safety.

Assessment and comparison of distal radial artery diameter in anatomical snuff box with conventional radial artery before coronary catheterization.

BACKGROUND: The distal radial artery (dRA) approach at anatomical snuff box has gained attention of the interventional cardiologist in last few years. The procedural success rate by this novel approach depends on size of the radial artery and therefore the study was planned to study the size of distal radial artery. METHODS: Total of 1004 patients of >18 years of age undergoing coronary catheterization were included in the study. The vessel diameter was measured from media to media in the anatomical snuff box a day prior to coronary catheterization. RESULTS: The mean diameter of right radial artery at conventional access site was 2.56 ± 0.35 mm and at distal access site 2.23 ± 0.39 mm (p < 0.001). Females had significantly smaller radial artery diameter as compared to males at right conventional access site (2.42 ± 0.36 mm vs 2.60 ± 0.34 mm; p < 0.001) and distal access site (2.09 ± 0.38 mm vs 2.27 ± 0.39 mm; p < 0.001). The diameter of the right dRA was not significantly correlated with age (r2 linear = 0.002, p = 0.0475) but was positively correlated with height and weight (r2 linear = 0.076, p = <0.001 and r2 linear = 0.005, p = <0.001) and negatively correlated with BMI (r2 linear = 0.076, p = 0.519). CONCLUSIONS: This study has shown the size of right dRA 2.27 + 0.39 mm in males and 2.09 + 0.38 mm in females. Diabetes, hypertension, height and weight are important predictors of dRA diameter.

Safety and Efficacy of Robotic-Assisted PCI.

PURPOSE OF REVIEW: Robotics has been used in multiple areas of procedural medical intervention. Robotic percutaneous coronary intervention (PCI) has been available since 2004. Its adoption has been slow with initial application in simple cases. RECENT FINDINGS: With increasing adoption, robotic PCI has been applied to a broader variety of coronary substrates with demonstration of safety and efficacy. Improvements in the robotic console with future generation devices should add to the utility of this platform. Robotic PCI advances the innovations in endovascular space into a different dimension, removing the dependence of the procedure on patient-operator ergonomics and likely operator skill.

Simultaneous Measurement of Left Ventricular and Aortic Pressures Using a Dual-Catheter System With Single Arterial Access.

Although echocardiography remains the key tool for evaluation of aortic valve stenosis severity, in a fair minority of patients invasive evaluation is still needed. Dual-lumen catheters allow for simultaneous trans-aortic pressure measurements with single arterial access. We describe a technique where traditional hardware using non-dedicated catheters can be used to obtain simultaneous pressure measurements using a 6 French single arterial access.

Anatomical snuff box approach for percutaneous coronary interventions - Current status.

Anatomical snuff box or distal radial artery approach for various percutaneous coronary angiograms and interventions has gained increased interest in recent years. The main advantage is the ergonomic comfort to the patient as it allows the patient's arm to be in more natural position. The safety and feasibility of this novel approach has been studied in past few years but still the data is limited and the distal radial artery approach has not been included in the guidelines. The present review focuses on the latest evidence, technique, advantages and disadvantages of this distal radial artery access.

Effects of previous coronary artery bypass graft surgery on in-hospital mortality in ST-segment elevation myocardial infarction: National dataset analysis.

BACKGROUND: Association of history of coronary artery bypass graft surgery (CABG) with clinical outcomes in patients presenting with ST-segment elevation myocardial infarction (STEMI) is unclear from current data. METHODS: Using Nationwide Inpatient Sample (NIS) data from 2003 to 2014, adult patients hospitalized with principal diagnosis of STEMI were extracted. The cohort was divided into patients with a history of CABG and those without a history of CABG. The primary outcome measure was in-hospital mortality (IHM). RESULTS: 2,710,375 STEMI patients were included in final analysis of which 110,066 had history of CABG. Patients with history of CABG had higher unadjusted (12.2% vs. 8.8%, P < 0.001) and adjusted (odds ratio [OR]1.16; 95% confidence interval [CI] 1.14 to1.19, P < 0.001) IHM compared to those without previous CABG. Compared to a trend of decreasing IHM in STEMI patients without previous CABG, a trend of increasing IHM was observed over the study period in those with a history of previous CABG. Although patients with previous CABG when treated with primary PCI (PPCI) had a higher unadjusted IHM compared to those without previous CABG, (4.8% vs 4.3%, P < 0.001), after adjusting for comorbidities and in-hospital complications no significant increase in IHM was observed in patients with previous CABG treated with PPCI. CONCLUSION: STEMI patients with previous CABG have a significantly higher IHM compared to those without previous CABG. PPCI improves IHM with no independent mortality disadvantage attributable to previous CABG.

Analysis of the 60/60 Sign and Other Right Ventricular Parameters by 2D Transthoracic Echocardiography as Adjuncts to Diagnosis of Acute Pulmonary Embolism.

Introduction The 60/60 sign in 2D transthoracic echocardiography (TTE) - a combination of pulmonary acceleration time (PAT) less than 60 milliseconds and tricuspid regurgitation (TR) jet gradient of less than 60 mmHg - has been found to be specific for the diagnosis of pulmonary embolism (PE). Materials and methods An observational prospective analysis was carried out on cases of suspected PE presenting to the emergency room (ER). TTE was performed on all cases with suspected PE prior to computed tomography pulmonary angiography (CTPA). Emphasis was placed on measurement of PAT and early systolic notching (ESN) on the pulsed wave (PW) Doppler of the pulmonary valve, TR jet gradient, right ventricle systolic excursion velocity (RV S') by tissue doppler imaging (TDI), tricuspid annular plane systolic excursion (TAPSE), and right ventricle to left ventricle end-diastolic dimension ratio (RV:LV EDD) in modified parasternal short-axis view. These signs were taken as screening tests and compared to CTPA as the standard test. Patients were followed up until hospital discharge or death. Observations Fifty-six cases of suspected PE were enrolled for the study. Of these, 24 cases of PE were confirmed by CTPA. Out of 24 cases of PE, 15 were high-risk PE, six were intermediate high-risk PE, and three were intermediate low-risk PE. The mean age was 53.07±9.79 years with a male-to-female ratio of 1.95:1. The 60/60 sign was present in 70.83% of cases of PE. RV:LV EDD in a modified short-axis view of more than 0.9 was present in 91.67% of cases of PE, and ESN on the PW Doppler of the pulmonary valve was present in 75% of cases of PE. The 60/60 sign, RV:LV EDD ratio more than 0.9, and ESN showed sensitivities of 70.83%, 91.67%, 75%, and specificities of 93.75%, 75%, and 100%, respectively for PE. For prediction of mortality, presence of the 60/60 sign (Odds Ratio=8.13, p-value=0.034) and ESN (Odds Ratio=17.50, p-value=0.02) were statistically significant. Conclusions 60/60 sign and ESN are specific for the diagnosis of PE but have poor sensitivity.

Association between insurance status and in-hospital outcomes in patients with out-of-hospital ventricular fibrillation arrest.

BACKGROUND: Lack of health insurance is associated with adverse clinical outcomes; however, the association between health insurance status and in-hospital outcomes after out-of-hospital ventricular fibrillation (OHVFA) arrest is unclear. HYPOTHESIS: Lack of health insurance is associated with worse in-hospital outcomes after out-of-hospital ventricular fibrillation arrest. METHODS: From January 2003 to December 2014, hospitalizations with a primary diagnosis of OHVFA in patients ≥18 years of age were extracted from the Nationwide Inpatient Sample. Patients were categorized into insured and uninsured groups based on their documented health insurance status. Study outcome measures were in-hospital mortality, utilization of implantable cardioverter defibrillator (ICD), and cost of hospitalization. Inverse probability weighting adjusted binary logistic regression was performed to identify independent predictors of in-hospital mortality and ICD utilization and linear regression was performed to identify independent predictors of cost of hospitalization. RESULTS: Of 188 946 patients included in the final analyses, 178 005 (94.2%) patients were insured and 10 941 (5.8%) patients were uninsured. Unadjusted in-hospital mortality was higher (61.7% vs. 54.7%, p < .001) and ICD utilization was lower (15.3% vs. 18.3%, p < .001) in the uninsured patients. Lack of health insurance was independently associated with higher in-hospital mortality (O.R = 1.53, 95% C.I. [1.46-1.61]; p < .001) and lower utilization of ICD (O.R = 0.84, 95% C.I [0.79-0.90], p < .001). Cost of hospitalization was significantly higher in uninsured patients (median [interquartile range], p-value) ($) (39 650 [18 034-93 399] vs. 35 965 [14 568.50-96 163], p < .001). CONCLUSION: Lack of health insurance is associated with higher in-hospital mortality, lower utilization of ICD and higher cost of hospitalization after OHVFA.

A Rare Case of an Unroofed Coronary Sinus With a Persistent Left Superior Vena Cava Diagnosed by Two-Dimensional Transthoracic Echocardiography.

An unroofed coronary sinus is a rare congenital anomaly in the roof of the coronary sinus causing a communication between the coronary sinus and the left atrium leading to a left to right shunt. It is often associated with a persistent left superior vena cava and other complex congenital lesions like anomalous pulmonary venous return and heterotaxy. Since it is a deep-seated defect, it is seldom diagnosed by transthoracic two-dimensional (2D) echocardiography and requires multimodal imaging for a diagnosis. Here, we present the case of a 27-year-old male in whom the defect was very apparent on standard 2D transthoracic echocardiography. Transthoracic 2D echocardiography revealed situs solitus, levocardia, and a dilated coronary sinus with unroofing which was most prominent in the standard parasternal long-axis view and the foreshortened apical four-chamber view. A color Doppler demonstrated a flow from the left atrium into the dilated coronary sinus. The right ventricle and atrium were dilated with mild pulmonary arterial hypertension. There was no right ventricular dysfunction. Examination with modified suprasternal views showed a left superior vena cava. All four pulmonary veins drained into the left atrium. Other chambers of the heart and great vessels were structurally normal without coarctation or patent ductus arteriosus. The interventricular septum was intact and atrioventricular and ventriculoatrial concordance was preserved. Detection of a dilated coronary sinus by transthoracic 2D echocardiography must be followed by multimodal imaging techniques like cardiac computed tomography and transesophageal echocardiography to detect and manage associated defects.

Trends, Outcomes, and Predictive Score For Emergency Coronary Artery Bypass Graft Surgery After Elective Percutaneous Coronary Intervention (from a Nationwide Dataset).

The temporal trends and preprocedural predictors of emergency coronary artery bypass graft surgery (ECABG) after elective percutaneous coronary intervention (PCI) in the contemporary era are largely unknown. From January 2003 to December 2014 elective hospitalizations with PCI as the primary procedure were extracted from the Nationwide Inpatient Sample. ECABG was identified as CABG within 24 hours of elective PCI. Temporal trends of elective PCI, ECABG, comorbidities, and in-hospital mortality were analyzed. Logistic regression model was used to identify preprocedural independent predictors of ECABG and post-PCI ECABG risk score was developed using the regression coefficients from the logistic regression model in the development cohort. The score was then validated in the validation cohort. Of 1,605,641 elective PCI procedures included in the final analysis, 5,561 (0.3%) patients underwent ECABG. The incidence of ECABG, co-morbidities and overall in-hospital mortality increased over the study period, whereas the in-hospital mortality after ECABG remained unchanged. An increasing trend of elective PCI performed at facilities without on-site CABG was noted, with a higher unadjusted in-hospital mortality in this cohort. ECABG risk score, performed well with a significantly higher risk of ECABG in those patients with a score in the highest tertile compared with those with lower ECABG score (0.6% vs 0.3%, p = 0.0005). In conclusion, an increasing trend of adverse outcomes after elective PCI is observed. We describe an easy-to-use predictive score using preprocedural variables that may allow the operator to triage the patient to an appropriate setting in an effort to improve outcomes.

Comparison of Diagnostic Accuracy of Digital Plethysmography Versus Duplex Ultrasound in Detecting Radial Artery Occlusion After Transradial Access.

BACKGROUND: Duplex Doppler ultrasonography (USG) remains the gold standard for evaluation of radial artery occlusion (RAO) after transradial access (TRA). The diagnostic accuracy of digital plethysmography, which is cheaper and widely available, for evaluation of RAO after TRA is not known. METHODS: Patients undergoing TRA were prospectively studied. After undergoing TRA for diagnostic or interventional coronary procedure and obtaining radial artery hemostasis, the radial artery was evaluated for presence or absence of RAO using digital plethysmography of the ipsilateral index finger and the thumb using modified reverse Barbeau's test (MRBT) and USG. Sensitivity, specificity, predictive values, likelihood ratios and other metrics of evaluation of diagnostic performance of MRBT in reference to USG, the current gold standard, were evaluated. RESULTS: 503 patients who underwent TRA for coronary procedures were studied. MRBT demonstrated a sensitivity = 96.2%, specificity = 99.8%, positive predictive value = 96.1, negative predictive value = 99.8, likelihood ratio (+) = 481, likelihood ratio (-) = 0.38, diagnostic accuracy = 99.6, diagnostic odds ratio = 11,904, Youden's index = 0.96, receiver operator characteristic derived c-statistic = 0.98 and Cohen's k = 0.98 when compared to USG. MRBT performed using the ipsilateral index finger and the thumb was no different. Agreement between absence of ipsilateral radial artery pulsation and RAO was weak (Cohen's k = 0.69). CONCLUSIONS: MRBT using ipsilateral digital plethysmography performs comparably to USG for assessment of presence of RAO after TRA. There is no significant difference between MRBT performed using the ipsilateral thumb or the index finger.

Association between distance from the radiation source and radiation exposure: A phantom-based study.

OBJECTIVES: The study evaluated the association between distance from radiation source and radiation exposure. BACKGROUND: Radiation exposure during medical procedures is associated with increased risk of cancer and other adverse effects. METHODS: An American National Standards Institute phantom was used to study the relationship between measured entrance surface exposure (MESE) and distance from the X-ray source in postero-anterior, left anterior oblique, and right anterior oblique projections. Three distance settings for table height were evaluated with "low" defined as 52 cm, "mid" 66 cm, and "high" 80 cm from the focal point of the X-ray source. Air-kerma and dose-area product measurements were recorded. Operator exposure with each of these conditions was measured, in a short operator (150 cm) as well as in a tall operator (190 cm). RESULTS: Aggregate results for the three projections were as follows. MESE (µGy/frame) significantly decreased as table-height increases (median, interquartile range, p-value) (low table-height 192.5 [122.4-201.2], mid table-height 105.8 [82.7-115.8], and high table-height 71.7 [58.4-75], p < .0005). The operator exposure (µGy/frame), significantly increased as the table-height increased (low table-height 0.0943 [0.0598-0.1157], medium table-height 0.1128 [0.0919-0.1397], and high table-height 0.158 [0.1339-0.2165], p < .0005). A shorter operator received higher radiation exposure compared to a taller operator (short operator 0.1405 [0.1155-0.1758] and tall operator 0.0995 [0.0798-0.1212], p < .0005). CONCLUSIONS: Increasing table-height is associated with a significant decrease in MESE. Operator radiation exposure increases with increasing table-height and shorter operators receive greater radiation exposure compared to taller operators.

Randomized COmparison of Isolated Radial Artery ComPrEssioN Versus Radial and Ipsilateral Ulnar Artery Compression in Achieving Radial Artery Patency: The OPEN-Radial Trial.

BACKGROUND: Radial artery occlusion (RAO) occurs after transradial access (TRA), limiting future ipsilateral access. Pragmatic RAO-lowering strategies need to be developed. METHODS: Patients undergoing transradial cardiac catheterization were randomized to receive postprocedural hemostasis with either a single-bladder radial compression band (group 1) or a double-balloon band capable of simultaneous ipsilateral ulnar artery compression (group 2). Hemostatic compression was performed for 120 minutes. Patients in group 2 received ipsilateral ulnar artery compression for the first 60 minutes of radial hemostasis. The primary endpoint of the study was achievement of patent hemostasis, defined as radial artery patency at 15 minutes after onset of hemostatic compression. Radial artery patency was measured at 15 minutes, 60 minutes, 90 minutes, and 120 minutes after onset of compression and 1 hour after removal of the compression bands. RESULTS: A total of 253 patients were randomized (127 in group 1 and 126 in group 2). Patent hemostasis was achieved significantly more frequently in group 2 vs group 1 (96.8% vs 74.8%, respectively; P<.001). RAO at 1 hour post band removal was significantly lower in group 2 vs group 1 (1.6% vs 10.2%, respectively; P<.001). Rebound bleeding occurred less frequently in group 2 vs group 1 (1.6% vs 7.9%, respectively; P=.03). CONCLUSION: Ipsilateral ulnar compression performed for the initial 1 hour during the radial hemostatic process after TRA using a dedicated double-balloon device is associated with higher rates of patent hemostasis and lower incidence of RAO compared with a single-balloon band.

Comparison of Robotic Percutaneous Coronary Intervention With Traditional Percutaneous Coronary Intervention: A Propensity Score-Matched Analysis of a Large Cohort.

BACKGROUND: Robotic percutaneous coronary intervention (R-PCI) has been shown to benefit the operator but has not shown any significant benefit to the patient. We sought to compare a large cohort of R-PCI to traditional percutaneous coronary intervention (PCI) procedures performed at a tertiary care center in the same time frame. METHODS: A total of 996 consecutive patients referred for PCI between December 2017 and March 2019 were studied, of which 310 (31.1%) patients were selected to undergo R-PCI and 686 (68.9%) patients underwent traditional PCI. The coprimary study outcome measures were air kerma, dose-area product, fluoroscopy time, volume of contrast, and total procedural time. Caliper propensity-matching technique was used (caliper, 0.05) to match each R-PCI patient to the nearest traditional PCI patient without replacement. RESULTS: Air kerma (mGy; median [interquartile range]; P; 884 [537-1398] versus 1110 [699-1498]; P=0.002) and dose-area product (cGycm2; 4734 [2695-7746] versus 5746 [3751-7833]; P=0.003) were significantly lower in the R-PCI group. There was no difference in fluoroscopy time (minutes; 5.51 [3.53-8.31] versus 5.48 [3.31-9.37]; P=0.936) and contrast volume (mL; 130 [103-170] versus 140 [100-180]; P=0.905). Total procedural time (minutes) was significantly higher in the R-PCI group (27 [21-40] versus 37 [27-50]; P<0.0005). CONCLUSIONS: R-PCI is associated with a significant decrease in radiation exposure to the patient with no increase in fluoroscopy time, as well as contrast utilization, and a minor increase in procedure duration compared with traditional PCI.