A randomized trial comparing left distal radial versus femoral approach for coronary artery bypass graft angiography: a pilot study.

BACKGROUND: Left distal transradial angiography (ldTRA) is a new technique for radial coronary angiography and may be an alternative to conventional transfemoral angiography (TFA) in patients who had previously undergone coronary artery bypass graft (CABG) surgery. In this study we compared ldTRA with TFA in patients who had undergone CABG surgery in terms of procedural details. METHODS: Fifty-seven consecutive patients with history of previous CABG among 459 patients who were admitted to coronary angiography unit (elective and acute coronary syndromes) in our center between October 2019 and February 2020 were included in the study. Consecutive patients were randomized to ldTRA (34 patients) and TFA (23 patients) group. The difference in total procedure times was defined as primary endpoint. The difference in sheat times, fluoroscopy times, contrast volume used and radiation exposure were designated as secondary endpoints. Post angiographic complications were compared between two groups. RESULTS: Out of 34 patients, successful distal radial access was obtained in 25 patients (74%). Baseline demographics, contrast use and radiation exposure were similar between groups. Sheath times in ldTRA was significantly longer (P<0.001), but total procedure times were not different (18.4±7.8 vs. 14.6±6.1, P=0.07). Non-standard angiographic equipment usage was significantly higher in ldTRA procedures (80% vs. 13%, P<0.001). There was no major bleeding in neither of groups, and three minor bleedings in FA group (0% vs.13%, P=0.10). CONCLUSIONS: ldTRA in patients with a palpable pulse and successful access might be used successfully for angiography in patient with previous CABG even early in an operator's experience.

A new method of arterial stiffness measurement in pseudoexfoliation syndrome: cardio-ankle vascular index.

PURPOSE: To investigate whether pseudoexfoliation syndrome affects arterial stiffness by using cardio-ankle vascular index measurement. METHODS: This cross-sectional case-control study included 55 patients with pseudoexfoliation syndrome and 106 age- and gender-matched healthy control subjects. All subjects underwent a complete ophthalmic exa mination of both eyes and cardio-ankle vascular index measu rements. Echocardiographic and body mass index measurements were performed in all patients, and the results were recorded. A binary regression model was used to determine the relationship between cardio-ankle vascular index and pseudoexfoliation. RESULTS: There were no significant differences between the pseudoexfoliation and control groups in baseline clinical and demographic characteristics, echocardiographic measurements of left ventricular ejection fraction, and body mass index. The mean cardio-ankle vascular index value was significantly higher in the pseudoexfoliation group than in the controls (9.47 ± 1.23 vs. 8.33 ± 1.50, p<0.001). Intraocular pressure was significantly higher in the pseudoexfoliation group than in the controls (18.31 ± 1.78 vs. 15.24 ± 2.42 mm Hg, p<0.05). Although the logistic regression analysis showed that mean cardio-ankle vascular index and IOP values were positively associated with pseudoexfoliation syndrome (Odds ratios (OR) = 1.973, 95% CI, 1.051-3.706, p=0.035; OR=3.322, 95% CI = 2.000-5.520, p<0.001, respectively), the Pearson correlation analysis revealed a borderline significant positive correlation between age and mean cardio-ankle vascular index and a significant positive correlation between dyslipidemia and intraocular pressure and mean cardio-ankle vascular index (r=0.265, p=0.050; r=0.337, p=0.012; r=0.433, p=0.001, respectively). CONCLUSION: Our findings demonstrated that cardio-ankle vascular index values increased in patients with pseudoexfoliation syndrome.

Relationship between door-to-balloon time and clinical experience level of emergency department physicians.

BACKGROUND: This study aimed to investigate the relationship between the experience level of physicians initially making the clinical diagnosis of ST-segment elevation myocardial infarction in the emergency department and door-to-balloon time (DBT). MATERIAL AND METHODS: The study group comprised 522 patients with ST-elevation myocardial infarction who were immediately treated in the catheter laboratory. Information about DBT, the experience level of the physicians who initially clinically diagnosed the patients and clinical benefit parameters were collected. The experience level of the physicians was divided into three groups: medical practitioner (no emergency training; n = 351), assistant physician (undergoing emergency medicine training; n = 111) and emergency medicine specialist (n = 60). DBT was compared among these groups. RESULTS: The average DBT was 80.3 ± 83.2 minutes for medical practitioners, 77.5 ± 74.7 minutes for assistant physicians and 53.6 ± 28.1 minutes for emergency medicine specialists. The difference in DBT between the emergency medicine specialist group and others was statistically significant (P = .046). CONCLUSIONS: DBT decreased as the experience level of the emergency physician increased, but randomisation is required to determine the clinical benefit of this effect.

Percutaneous angioplasty in the treatment of thrombosed hemodialysis fistulas: A single-center experience with 1 year of follow-up.

OBJECTIVE: Thrombosis of a hemodialysis arteriovenous fistula (AVF) is a serious complication that needs urgent treatment. Most cases are treated surgically, but recently, endovascular strategies have become a viable alternative. This study is an evaluation of the success and patency rate of percutaneous balloon angioplasty of thrombosed hemodialysis fistulas using a drug-coated balloon (DCB) contrasted with a standard balloon (SB). METHODS: The data of 33 patients with a thrombosed native hemodialysis AVF treated percutaneously in a tertiary care center were analyzed retrospectively. Success of the procedure was defined as restoration of flow with less than 30% residual stenosis and resumption of dialysis through the hemodialysis AVF. The success rate of the procedure and the patency rate at 1, 6, and 12 months were evaluated. The effect on patency of a DCB was compared to that of a SB. RESULTS: Twenty-five radiocephalic and 8 brachiocephalic thrombosed hemodialysis AVFs were treated during the study period. Flow was restored in 23 thrombosed fistulas, a success rate of 69.7%. The patency rate of successfully treated fistulas was 95.6% at 1 month, 76.1% at 6 months, and 57.9% at 12 months. Ten of the 23 re-established AVFs were treated with a DCB and the remainder were treated with a SB. The patency of the fistulas treated with a DCB was similar to that of a SB at 1 month (100% vs 92.3%, respectively; p=0.393). The patency rate of a DCB was greater than that of a SB at 6 months (88.9% vs 66.7%, respectively; p=0.258) and 12 months (75% vs 45.4%, respectively; p=0.219). CONCLUSION: Percutaneous intervention for thrombosed hemodialysis AVFs is a safe, minimally invasive, and effective procedure. There was a positive trend in the patency rate of patients treated with a DCB at 6 and 12 months compared with a SB.

Predictors and Clinical Outcomes of Crossover From Radial to Femoral Access During Primary Percutaneous Coronary Intervention.

Access site complications are more common with femoral access (FA) than radial access (RA). However, due to the higher rate of failure and crossover, door-to-balloon time (DBT) is prolonged by RA. Records of 3600 patients who underwent primary percutaneous coronary intervention (pPCI) between January 2016 and June 2019 were retrospectively reviewed. A total of 130 patients with crossover from RA to FA were identified and compared with the data of 501 patients who underwent pPCI with successful RA during 2018. Regression analysis was performed to determine the predictors of crossover. Crossover to the femoral approach occurred in 5.9% of our cases. Mean DBT was 17 minutes longer in the crossover group (61 ± 72 minutes vs 78 ± 79 minutes, P = .026). Female sex (odds ratio [OR]: 1.8; 95% CI, 0.99-3.46, P = .046) and anterior myocardial infarction (AntMI; OR: 0.52; 95% CI, 0.33-0.88, P = .007) were independent predictors of crossover. In-hospital mortality rates were significantly higher in the crossover group than in the radial success group (5.4% vs 1.8%, P = .020). Crossover to FA due to radial failure is associated with delayed DBT and increased rate of in-hospital mortality. Female sex and AntMI were primary predictors of crossover.

Increased cardio-ankle vascular index values in patients with acute branch retinal vein occlusion.

Purpose: Patients with retinal vein occlusions (RVOs) are at increased risk of cardiovascular disease. Arterial stiffness is an independent risk factor for cardiovascular events. Our aim is to evaluate the arterial stiffness in patients with acute branch retinal vein occlusion (BRVO) by using cardio-ankle vascular index (CAVI). Methods: This prospective study included 42 patients (18 male, mean age 57.5 ± 11.3) with acute BRVO and a matched control group (by age, sex, and presence of hypertension) with 70 (26 male, mean age 54.4 ± 9.4) patients. All patients and control subjects underwent complete ocular examination and CAVI measurement. BRVO was diagnosed based on clinical examination. Results: There were no significant differences between baseline clinical and demographic characteristics, echocardiographic measurements of left ventricular ejection fraction, systolic and diastolic blood pressure, and body mass index of the BRVO and control group. Both right and left CAVI values were found significantly higher in BRVO group (7.94 ± 1.53 vs 7.28 ± 1.25, P < 0.05 and 8.06 ± 1.41 vs 7.30 ± 1.26, P < 0.05, respectively). There were no significant difference in right and left ankle-brachial index values between the groups (1.05 ± 0.10 vs 1.06 ± 0.08, P = 0.46 and 1.04 ± 0.12 vs 1.05 ± 0.08, P = 0.46, respectively). Conclusion: Arterial stiffness is an important mediator of cardiovascular diseases. We found that CAVI which is a novel marker of the arterial stiffness is increased in patients with acute BRVO compared to controls.

Association between Cardio-ankle Vascular Index and Contrast-induced Nephropathy.

OBJECTIVE: To investigate the relationship between cardio-ankle vascular index (CAVI), which is a marker of arteriosclerosis and the development of contrast-induced nephropathy (CIN). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Department of Cardiology, Sakarya University Medical Faculty, from May to December 2019. METHODOLOGY: Between May and December 2019, demographic characteristics, CAVI measurements, and in-hospital clinical outcomes were compared among 66 patients, who developed CIN after coronary angiography (CAG) and an acute coronary syndrome (ACS) diagnosis, and 60 ACS patients without CIN. RESULTS: The frequency of CIN development in the study was 5.5%. In the CIN group, EF was lower (44.5 ± 10.6% vs. 49.3 ± 9.8%, p = 0.011) and GFR (mL/min/1.73 m2) at admission, was lower (60.3 ± 23.3 vs. 87.0 ± 21.5, p <0.001) than in the non-CIN group. CAVI values indicative of arterial stiffness (AS) were significantly higher in the CIN group. Mortality was not significantly higher in the CIN group (p = 0.099). CONCLUSION: AS is more common in ACS patients, who developed CIN after CAG. Older patients with low EF and low GFR, in whom AS is more common, should be intravenously hydrated and more closely monitored to prevent CIN development. Key Words: Contrast-induced nephropathy, Acute coronary syndrome, Cardio-ankle vascular index, Arterial stiffness.

Comparison of effects of thrombolytic therapy and primary percutaneous coronary intervention in elderly patients with acute ST-segment elevation myocardial infarction on in-hospital, six-month, and one-year mortality.

INTRODUCTION: This study aims to evaluate the effect of primary percutaneous coronary intervention (PCI) and thrombolytic therapy (TT) on the in-hospital adverse events, in-hospital and long-term mortality in patients over 65 years of age with acute ST-segment elevation myocardial infarction (STEMI). MATERIAL AND METHODS: A total of 111 retrospectively screened patients (73 males, mean age: 73.4 ±5.9 years) over 65 years of age with STEMI, who underwent TT or primary PCI, were included in the study. Patients' characteristics, in-hospital outcomes, and 6-month and 1-year mortalities were recorded. RESULTS: Our study was conducted with 111 patients over 65 years of age with STEMI (73 males, 38 females). Of the patients, 66 (59.5%) were treated with thrombolytics, and 45 (40.5%) patients underwent primary PCI. Door-to-needle time was 25.9 ±7.8 min in the TT group, whereas door-to-balloon time was 84.4 ±20.0 min in the PCI group. Time from symptom onset to hospital admission was 213.6 ±158.4 min in the thrombolytic group, and 166.8 ±112.8 min in the PCI group. Rescue PCI was performed in 7 (10.6%) patients in the TT group due to lack of reperfusion. Recurrent infarction was observed in 5 (7.6%) patients in the TT group and in 2 (4.4%) patients in the PCI group. Non-haemorrhagic stroke was observed in 1 (1.5%) patient in the thrombolytic-administered group and in 4 (8.9%) patients in the PCI group. No intracranial haemorrhage was observed in any patient. Major haemorrhage was observed in 4 (6.1%) patients in the TT group and in 4 (8.9%) patients in the PCI group. Six-month and 1-year mortalities were present in 15 (22.7%) patients and 19 patients in thrombolytic group, and 8 (17.8%) and 8 (17.8%) patients in the PCI group, respectively. Binary logistic regression analysis indicated that the patient's age was the only predictor for 1-year mortality (odds ratio (OR) = 1.1, 95% confidence interval (CI): 1.019-1.188, p = 0.015). CONCLUSIONS: Considering the in-hospital adverse outcomes, in-hospital mortality, and 6-month mortality rates, TT and primary PCI have similar effects in STEMI patients aged 65 years and over according to the results of our study. Although 1-year mortality was higher in the TT group, it was not statistically significant.

The Trends in Utilizing Nonvitamin K Antagonist Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation: A Real-Life Experience.

Dabigatran and rivaroxaban are novel nonvitamin K antagonist oral anticoagulants (NOACs) approved for thromboprophylaxis in atrial fibrillation (AF). In Turkey, like other countries, the efficacy of translation of the clinical trial results and current guideline recommendations into daily clinical practice is yet to be discovered. Using data from medical records of three tertiary care cardiology centers, we identified patients with nonvalvular AF on dabigatran or rivaroxaban treatment. Baseline characteristics and utilization trends were compared between dabigatran and rivaroxaban groups. Secondarily, clinical events including ischemic stroke and/or transient ischemic attack, systemic embolism, and bleeding were evaluated. Among 294 patients with AF included, dabigatran was utilized in 177 (60.2%) and rivaroxaban in 117 (39.8%). Overall, 76% of patients had received long-term warfarin therapy. The use of 110 mg twice a day (55.4%) was the prevailing strategy in dabigatran group, whereas in rivaroxaban group 20 mg every day (67.5%) was the preferred option. Of the patients, 37.3% had severe valvular disease in which mitral regurgitation was the predominant valve abnormality. Scores of CHADS2, CHA2DS2VASc, and HAS-BLED were similar in both the groups. Of the patients, 24% in dabigatran group and 13.7% in rivaroxaban group were prescribed the lower dose inappropriately. The two NOACs did not differ significantly in terms of clinical events. The results of this study indicate that in daily practice, the physicians' behavior in utilizing the NOACs is shaped by the clinical trials and the guideline recommendations. On the other hand, in dose selection, this adherence is not of high quality.

Spontaneous rectus sheath hematoma during rivaroxaban therapy.

Rivaroxaban is an oral anticoagulant agent that directly inhibits Factor Xa and interrupts both the intrinsic and extrinsic pathway of the coagulation cascade and is currently indicated for use in patients for atrial fibrillation and prophylaxis of deep venous thrombosis. The present case reports of spontaneous rectus sheath hematoma during rivaroxaban therapy for atrial fibrillation in a 75-year-old woman.

Relation between the GRACE score and severity of atherosclerosis in acute coronary syndrome.

BACKGROUND: Patients with non-ST-elevation acute coronary syndrome are heterogeneous in terms of clinical presentation and immediate- and long-term risk of death or non-fatal ischemic events. The aim of the present study was to evaluate the relationship between the Global Registry of Acute Coronary Events (GRACE) score and severity of coronary artery disease angiographically evaluated by Gensini score in patients with non-ST-elevation acute coronary syndrome. METHODS: A total of 245 patients with non-ST-elevation acute coronary syndrome were enrolled to the study. Based on the GRACE risk score classification system, the patients were divided into low- (n=97, 39.6%), intermediate- (n=84, 34.3%), and high- (n=64, 26.1%) risk groups. All patients underwent coronary angiography within five days after admission. RESULTS: The Gensini scores were 26±29 in the low-risk group, 29±19 in the intermediate-risk group, and 38±23 in the high-risk group (p=0.016). The low-risk group was significantly different from the high-risk group (p=0.013), and the difference from the intermediate-risk group almost reached significance. Normal, noncritical, one and two, or multivessel disease were identified in 15 (6.1%), 31 (12.7%), 75 (30.6%), and 124 (50.6%) patients, respectively. The prevalence of multivessel disease was 28% in the low-risk group, 30% in the intermediate-risk group, and 42% in the high-risk group. The high-risk group was significantly different from the low-risk group (p<0.01). CONCLUSION: Our study demonstrates that the GRACE score has significant value for assessing the severity and extent of coronary artery stenosis in patients with non-ST-elevation acute coronary syndrome.

Acute Coronary Syndrome During Pregnancy: A Case Report and Literature Review.

A 32-year-old multiparous woman who presented with chest pain at seven weeks gestation was admitted to our hospital 35 minutes after the onset of symptoms. Sudden cardiac arrest developed while the patient was waiting in the triage room. Cardiopulmonary resuscitation was performed, and the patient was immediately intubated. Electrocardiography revealed an inferior myocardial infarction. The patient underwent coronary angiography, which revealed slow coronary flow of the circumflex and left anterior descending coronary arteries. For treatment, the combination of aspirin with clopidogrel and unfractionated heparin was initiated. She had previously had three healthy children and hadn't had any problems during her previous pregnancies. She had a history of family and smoking, but no history of other coronary risk factors such as diabetes mellitus, hypertension, or dyslipidemia. She was discharged home on day five after admission with clopidogrel, aspirin and a beta-blocker with close outpatient follow-up. Elective abortion was planned for two weeks after the myocardial infarction.

Successfully treated bilateral renal artery stenosis in a patient with coronary artery disease.

Renal artery stenosis (RAS) is the most common cause of secondary hypertension and accounts for approximately 1-3% of all causes of hypertension. Over 90% of RASs are caused by atherosclerosis; atherosclerotic RAS is increasingly common in aging populations, particularly elderly people with diabetes, hyperlipidaemia, aortoiliac occlusive disease, coronary artery disease or hypertension. Three therapeutic options are currently available for patients with renovascular hypertension: medical antihypertensive therapy, surgical revascularisation and transluminal angioplasty including stent implantation. We present in this report a male patient with bilateral severe ostial stenosis and coronary artery disease, and who was successfully treated with renal stent implantation in one session.