Safety and feasibility of a novel total percutaneous post-closure technique after bedside Impella decannulation in patients with cardiogenic shock.

OBJECTIVES: The Impella (Abiomed) is a widely used percutaneous mechanical circulatory support device for high-risk percutaneous coronary intervention in patients with cardiogenic shock. This study aimed to determine the safety and feasibility of a non-angio-guided post-closure approach using the Perclose ProGlide (Abbott) to decannulate the Impella in the intensive care unit. METHODS: This retrospective study included consecutive patients who were successfully weaned from mechanical circulatory support using the Impella device between April 2019 and April 2022 at Hamamatsu University School of Medicine. Fifteen patients underwent complete post-closure of the femoral artery access sites at the bedside. Technical success of the post-closure hemostasis technique was defined as no evidence of bleeding or additional medical procedures after manual compression. The safety endpoints comprised the Valve Academic Research Consortium-3 and Bleeding Academic Research Consortium criteria. RESULTS: All patients achieved successful hemostasis with this novel technique without surgical conversion. There was no significant bleeding; however, procedure-related vessel occlusion was observed in 1 patient who was recanalized with balloon angioplasty. CONCLUSIONS: Bedside post-closure using the Perclose ProGlide device is a safe and feasible alternative to manual compression and surgical removal of the Impella device with low bleeding or vascular complications rates.

Association of Malnutrition and High Bleeding Risk with Long-Term Prognosis in Patients with Acute Coronary Syndrome following Percutaneous Coronary Intervention.

BACKGROUND: Malnutrition in cardiovascular disease is associated with poor prognosis, especially in patients with heart failure and acute coronary syndrome (ACS). High bleeding risk is also linked to coronary artery disease prognosis, including ACS. However, whether the extent of malnutrition and high bleeding risk have a cumulative impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention remains unclear. METHODS: We analyzed 275 patients with ACS treated with percutaneous coronary intervention. The Controlling Nutritional Status score and Japanese version of the Academic Research Consortium for High Bleeding Risk criteria (J-HBR) were retrospectively evaluated. The primary and secondary outcomes were adjusted using the inverse probability treatment weighting method. RESULTS: The prevalence of moderate or severe malnutrition in this cohort was 16%. Kaplan-Meier analysis showed a significantly higher incidence of major adverse cardiovascular and cerebrovascular events in patients who were moderately or severely malnourished than in those who were not. Notably, the incidence of these major events was similar between severely malnourished patients with J-HBR and those without. CONCLUSION: Moderate or severe malnutrition has a significant impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention.

Prevalence and Characteristics of Inspiration-Induced Negative Left Atrial Pressure during Pulmonary Vein Isolation.

BACKGROUND: Atrial fibrillation (AF) ablation is performed under deep sedation, which may cause inspiration-induced negative left atrial pressure (INLAP) associated with deep inspiration. INLAP could be the cause of periprocedural complications. METHODS: We retrospectively enrolled 381 patients with AF (mean age, 63.9 ± 10.8 years; 76 women; 216 cases of paroxysmal AF) who underwent CA under deep sedation using an adaptive servo ventilator (ASV). Patients whose LAP was not obtained were excluded. INLAP was defined as <0 mmHg of mean LAP during inspiration immediately after the transseptal puncture. The primary and secondary endpoints were the presence of INLAP and the incidence of periprocedural complications. RESULTS: Among 381 patients, INLAP was observed in 133 (34.9%). Patients with INLAP had higher CHA2DS2-Vasc scores (2.3 ± 1.5 vs. 2.1 ± 1.6) and 3% oxygen desaturation indexes (median 18.6 (interquartile range 11.2-31.1) vs. 15.7 (8.1-25.3)), and higher prevalence of diabetes mellitus (23.3 vs. 13.3%) than patients without INLAP. Air embolism occurred in four patients with INLAP (3.0 vs. 0.0%). CONCLUSION: INLAP is not rare in patients undergoing CA for AF under deep sedation with ASV. Much attention should be paid to the possibility of air embolism in patients with INLAP.

[Efficacy of L-shaped Shielding in Interventional Radiology by Transradial Approach and Consideration of Methods for Appropriate Use].

The present study investigated how effective an L-shaped shield was, depending on its position, in reducing a doctor's exposure to radiation during catheterization to access the transradial approach (TRA). The shield's effectiveness was evaluated by measuring the air kerma where the doctor stood under four conditions: with and without the shield, and with and without the shield in conjunction with conventional protection. To enable the shield to be positioned correctly in clinical practice, an illustrated instruction decal affixable to the shield's doctor-facing surface was produced, and the effectiveness of the decal was verified by means of a crossover test in which, as subjects of the study, different nurses set up the shield with and without the decal affixed to it. In the test, in which a human body phantom was used, the C-arm set at the PA angle, and the shield positioned 10 cm from the axilla of the phantom, the shield's effectiveness at 100 cm, 130 cm, and 160 cm above the floor where the doctor stood was 55%, 77%, and 47%, respectively. The effectiveness increased when the shield was positioned closer to the axilla. A significant difference in the positioning of the shield by the subjects was observed depending on whether or not the decal was affixed ( p<0.05, Wilcoxon signed-rank test), indicating that the use of the decal improved the positioning. It was concluded that, positioned correctly, the shield could effectively reduce the doctor's exposure to radiation during TRA.

Association of an Increased Abnormal Mitochondria Ratio in Cardiomyocytes with a Prolonged Oxygen Uptake Time Constant during Cardiopulmonary Exercise Testing of Patients with Non-ischemic Cardiomyopathy.

Objective The cardiac function, blood distribution, and oxygen extraction in the muscles as well as the pulmonary function determine the oxygen uptake (VO2) kinetics at the onset of exercise. This factor is called the VO2 time constant, and its prolongation is associated with an unfavorable prognosis for heart failure (HF). The mitochondrial function of skeletal muscle is known to reflect exercise tolerance. Morphological changes and dysfunction in cardiac mitochondria are closely related to HF severity and its prognosis. Although mitochondria play an important role in generating energy in cardiomyocytes, the relationship between cardiac mitochondria and the VO2 time constant has not been elucidated. Methods We calculated the ratio of abnormal cardiac mitochondria in human myocardial biopsy samples using an electron microscope and measured the VO2 time constant during cardiopulmonary exercise testing. The VO2 time constant was normalized by the fat-free mass index (FFMI). Patients Fifteen patients with non-ischemic cardiomyopathy (NICM) were included. Patients were divided into two groups according to their median VO2 time constant/FFMI value. Results Patients with a low VO2 time constant/FFMI value had a lower abnormal mitochondria ratio than those with a high VO2 time constant/FFMI value. A multiple linear regression analysis revealed that the ratio of abnormal cardiac mitochondria was independently associated with a high VO2 time constant/FFMI. Conclusion An increased abnormal cardiac mitochondria ratio might be associated with a high VO2 time constant/FFMI value in patients with NICM.

Individualised left anterior oblique projection for lead implantation into interventricular septum.

OBJECTIVE: We sought to investigate whether it is possible to obtain individualised left anterior oblique (LAO) by preprocedural electrocardiographic parameters and, if so, whether these parameters can help to improve the success rate of right ventricular (RV) lead implantation into the interventricular septum. METHODS: In this observational study, we assessed the relationship between preoperative electrocardiographic parameters and the angle of the interventricular septum obtained using thoracic CT. The participants were divided into two groups: a retrospective derivation cohort to derive the optimal formula for the individual septum axis, and a prospective internal validation cohort to which we applied the optimal formula and implanted using the new method. RESULTS: In the retrospective derivation cohort (n=39), the mean angle of individualised LAO assessed by thoracic CT was 53.1°±8.9°, and the preoperative ECG QRS axis was strongly correlated with the interventricular septum axis (R2=0.490). LAO projection derived from the preoperative ECG QRS axis confirmed that the RV lead was placed in the interventricular septum during the pacemaker procedure in the prospective internal validation group (n=30). The success rate for placing the RV lead into the interventricular septum was significantly improved in the internal validation cohort (93% vs 64%, p<0.05). In addition, the N-terminal pro-brain natriuretic peptide level decreased significantly after surgery in the interventricular septal indwelling group. CONCLUSIONS: Individualised LAO angle derived from the preoperative ECG QRS axis is a new useful and simple method for RV lead implantation into the interventricular septum. TRIAL REGISTRATION NUMBER: UMIN000045741.

Safety of a Cardiac Resynchronization Therapy Device Implantation in a Patient with Unstable Heart Failure Who Require Impella-Device Assistance.

Implantation of a cardiac resynchronization therapy (CRT) device is usually scheduled in the compensated phase of heart failure; however, procedural safety may be sometimes disturbed in the decompensated phase. We report a case of a successful semi-urgent implantation of a CRT device temporary assisted with Impella in a patient with the decompensated phase of severe heart failure dependent on inotropic agents and who cannot maintain the supine position. Impella assistance with left ventricular (LV) unloading and maintenance of end-organ perfusion contributed to early recovery from acute heart failure. Furthermore, an acute effect of mechanical resynchronization by biventricular pacing plays an important role in weaning from the mechanical support or inotropic dependence. These mutual effects of mechanical support and CRT might contribute to a decrease in LV end-diastolic pressure and to a remarkable early recovery from a severely decompensated condition.

Pre-procedural predictors of left atrial low-voltage zones in patients undergoing catheter ablation of atrial fibrillation.

Pulmonary vein isolation has become a cornerstone treatment for catheter ablation of atrial fibrillation (AF). Recent reports show that additional ablation targeting low-voltage zones reduces AF recurrence. However, the pre-procedural predictors of low-voltage zones remain elusive. We retrospectively enrolled 359 patients (mean age 63.7 ± 10.8 years; 73 females; and 149 had persistent atrial fibrillation) who underwent catheter ablation for AF and left atrial (LA) voltage mapping during sinus rhythm or atrial pacing. Low-voltage zones were defined as area of > 5 cm2 with a bipolar electrogram amplitude of < 0.50 mV. Overall, 51 (14.2%) patients had low-voltage zones. Patients with low-voltage zones were older (67.9 ± 9.9 vs. 63.0 ± 10.8 years; P = 0.003), predominantly female (33.3% vs. 18.2%; P = 0.013), had higher prevalence of dilated cardiomyopathy (DCM) (11.8% vs. 1.6%; P = 0.002) and hypertrophic cardiomyopathy (HCM) (9.8% vs. 2.6%; P = 0.025), and had larger LA volumes (153.6 ± 46.4 vs. 117.7 ± 67.8 mL; P < 0.001) than those without low-voltage zones. Multivariate logistic regression analysis revealed that age (OR 1.060; 95% CI 1.022-1.101, P = 0.002), female sex (OR 2.978; 95% CI 1.340-6.615, P = 0.007), DCM (OR 8.341; 95% CI 1.381-50.372, P = 0.021), HCM (OR 5.044; 95% CI 1.314-19.363, P = 0.018), persistent AF (OR 4.188; 95% CI 1.928-9.100, P < 0.001), and larger LA volume (OR 3.215; 95% CI 1.378-7.502, P = 0.007) were independently associated with the presence of low-voltage zones. Patient age, female sex, DCM, HCM, persistent AF and larger LA volume may predict the presence of low-voltage zones and could be useful in selecting the appropriate ablation strategy for AF.

Case Report: Structural Changes in the Coronary Vessel Wall in a Patient With Incomplete Kawasaki Disease.

Background: Kawasaki disease (KD) is an acute systemic vasculitis of infants and young children that affects medium-sized vessels. Conventional cardiac imaging techniques, such as cardiac catheterization, are useful for characterizing the coronary arterial lesion (CAL) size and luminal diameter of the diseased coronary artery segment in patients with KD, but there are limitations to the visualization of the detailed vascular anatomy. Optical coherence tomography (OCT) is a high-resolution intracoronary arterial imaging modality that can distinguish the three layers of the coronary arterial wall. Several studies have reported coronary artery wall abnormalities in KD patients with coronary arterial aneurysm or regressed aneurysm. However, there have been no reports on changes in the coronary artery wall in cases of incomplete KD without CAL. Case Presentation: We herein report an 11-year-old girl with a history of incomplete KD without coronary arterial aneurysms. She had been diagnosed with perimembranous ventricular septal defect (VSD) after birth and had experienced incomplete KD at 1 year old. During her hospitalization for KD, she did not receive intravenous immunoglobulin (IVIG), because she did not meet the Harada score or criteria for treatment in patients with incomplete KD established by the American Heart Association. No dilatation or coronary artery aneurysm were observed on transthoracic echocardiography in the acute or follow-up period. At 11 years old, she received cardiac catheterization and coronary angiography (CAG) for the evaluation of a VSD and follow-up of KD. CAG demonstrated no aneurysm, dilatation, or significant stenosis of the coronary arteries. We performed an OCT study, which revealed the presence of intimal thickening, disruption of the media, and neovascularization in the left anterior descending artery. Conclusion: OCT demonstrates the structural changes of CA even in the patient with incomplete KD who have not been treated with IVIG.

Accurate assessment of coronary blood flow by continuous thermodilution technique: Validation in a swine model.

OBJECTIVE: To assess the accuracy of coronary thermodilution measurements made with the RayFlow® infusion catheter. BACKGROUND: Measurements of absolute coronary blood flow (ABF) and absolute microvascular resistance (Rµ ) by continuous coronary thermodilution can be obtained in humans but their accuracy using a novel dedicated infusion catheter has not yet been validated. We compared ABF values obtained at different infusion rates to coronary blood flow (CBF) values obtained using flow probes, in swine. METHODS: Twelve domestic swine were instrumented with coronary flow probes placed around the left anterior descending and circumflex coronary arteries. ABF was assessed with the RayFlow® infusion catheter during continuous saline infusion at fixed rates of 5 (n = 14), 10 (n = 15), 15 (n = 19), and 20 (n = 12) ml/min. RESULTS: In the 60 measurements, ABF measured using thermodilution averaged 41 ± 17 ml/min (range from 17 to 90) and CBF values obtained with the coronary flow probes averaged 37 ± 18 ml/min (range from 8 to 87). The corresponding Rµ values were 1532 ± 791 (range from 323 to 5103) and 1903 ± 1162 (range from 287 to 6000) Woods units using thermodilution and coronary flow probe assessments, respectively. ABF and Rµ values measured using thermodilution were significantly correlated with the corresponding measurements obtained using coronary flow probes (R = 0.84 [0.73-0.95] and R = 0.80 [0.69-0.88], respectively). CONCLUSIONS: ABF and Rµ assessed by continuous saline infusion through a RayFlow® catheter closely correlate with measurements obtained with the gold standard coronary flow probes in a swine model.

Association between plasma xanthine oxidoreductase activity and in-hospital outcomes in patients with stable coronary artery disease after percutaneous coronary intervention.

OBJECTIVES: Reactive oxygen species generated by xanthine oxidoreductase (XOR) are associated with the progression of atherosclerosis. However, changes in plasma XOR (pXOR) activity after percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) remains unknown. METHODS: Herein, we compared the change in the pXOR activity in patients undergoing PCI with that in patients undergoing coronary angiography (CAG) and further evaluated the relation between changes in pXOR activity and in-hospital and long-term outcomes of patients undergoing PCI. The pXOR activity of 80 consecutive patients who underwent PCI and 25 patients who underwent CAG during the hospitalization was analyzed daily. The percentage changes from baseline regulated time interval was evaluated. RESULTS: We found that although pXOR activity decreased after PCI, and remained low until discharge, no significant changes were observed in patients undergoing CAG. Furthermore, among the patients undergoing PCI, those who experienced in-hospital adverse events, had a higher percentage of pXOR reduction 3 days after PCI. There was no association between these changes and long-term events. CONCLUSIONS: A significant change in pXOR activity was observed in patients undergoing PCI than in patients undergoing CAG, and there seems to be a correlation between the in-hospital outcomes and the percentage reduction from baseline in pXOR activity.

Comparison of Side-Branch Dilation Techniques After Resorbable Magnesium Scaffold Implantation: A Bench Study.

BACKGROUND: The resorbable magnesium scaffold (RMS) has demonstrated a good safety profile to treat de novo lesions. Nevertheless, bifurcation lesions involving a side branch (SB) >2.0 mm in diameter were excluded from these studies, and such lesions remain technically challenging due to concerns of scaffold deformation or fracture. We sought to evaluate different SB dilation strategies after provisional T-stenting strategy with RMS using silicon bifurcation phantoms. METHODS AND RESULTS: Three different strategies were compared: proximal optimization technique (POT)-side-rePOT (rePOT), kissing-balloon inflation (KBI), and mini kissing-balloon inflation (MKBI) strategies. Strut and connector fractures were evaluated by micro computed tomography and apposition by optical coherence tomography (OCT). Twelve Magmaris scaffolds (Biotronik) were successfully implanted (4 in each group). There was no difference in strut and connector fractures among the three techniques, as no fracture was visualized. OCT demonstrated that MKBI significantly decreased global malapposition following SB inflation as compared with rePOT or KBI strategies (95.3% vs 88.3% of perfectly apposed struts [P<.001] and 93.6% [P<.01], respectively, for MKBI vs rePOT and KBI). After step-by-step over-expansion of 6 RMS devices with 3.75 mm, 4.0 mm, and 4.5 mm NC balloons at 16 atm (ie, +1.5 mm from the initial 3.0 mm RMS), no strut or connector fracture could be visualized. CONCLUSION: Provisional single-stent technique with the Magmaris RMS on a bifurcation lesion is technically feasible with these three different strategies without scaffold fracture. MKBI strategy resulted in better apposition rates as compared with KBI or rePOT strategies. Nevertheless, Magmaris use in bifurcation lesions should not be advised before similar results are confirmed by in vivo studies.

In vitro test-retest repeatability of invasive physiological indices to assess coronary flow.

AIMS: Several invasive techniques are available in clinical practice to assess coronary flow. Nevertheless, the test-retest repeatability of these techniques in a controlled setting has not been reported. Therefore, we sought to evaluate fractional flow reserve (FFR), coronary flow reserve (CFR), index of microvascular resistance (IMR), and absolute coronary blood flow (ABF) with absolute microvascular resistance (AMR) test-retest repeatability using a coronary flow simulator. METHODS AND RESULTS: Using a coronary flow simulator (FFR WetLab version 2.0; Abbott Vascular, Santa Clara, CA), we created stenoses ranging from 0% to 70%, with 10% increments. Three different flows were established with their hyperemic phases, and two consecutive measurements were obtained, evaluating the following indices: FFR, CFR, IMR, ABF, and AMR, using a pressure/temperature wire and an infusion catheter. One hundred and thirty-eight pairs of measurements were performed. Test-retest reliability was compared in 48 FFR, 18 CFR, 24 IMR, 24 ABF, and 24 AMR. Test-retest repeatability showed excellent reproducibility for FFR, ABF, and AMR; respectively 0.98 (0.97-0.99), 0.92 (0.81-0.97) and 0.91 (0.79-0.96) (P < 0.0001 for all). However, test-retest repeatability was weaker for IMR and poor for CFR; respectively 0.53 (0.16-0.77) (P = 0.006) and 0.27 (-0.26-0.67) (P = 0.30). CONCLUSIONS: Using a coronary flow simulator, FFR and ABF with AMR had excellent test-retest reliability. IMR and CFR demonstrated weaker test-retest reliability.

In vitro flow and optical coherence tomography comparison of two bailout techniques after failed provisional stenting for bifurcation percutaneous coronary interventions.

OBJECTIVES: To evaluate, in vitro, SB stenting techniques after failed provisional stenting. We aimed to compare flows and stent strut apposition of T and protrusion (TAP) versus Reversed String (RS) techniques using a flow simulator, optical coherence tomography (OCT) using silicon bifurcation phantoms with different bifurcation angulations. BACKGROUND: While bifurcation coronary artery stenoses are preferably treated with provisional T-stenting strategy, the preferred bailout two stents technique to treat the side branch remains unclear. METHODS AND RESULTS: Eleven 30°-angle and ten 60°-angle bifurcation phantoms were used. After performing provisional stenting, TAP and RS techniques were compared in six phantoms with 30° and five with 60° angles. Flow measurement was performed using absolute coronary flow and particle image velocimetry techniques. Strut apposition was evaluated using OCT. Flow analyses showed that disturbed flow regions were observed in the vicinity of floating struts protruded into the lumen both regardless of TAP and RS techniques. OCT analysis showed a higher proportion of floating struts protruding into the main branch with TAP compared to RS, respectively (13% vs. 1%; P <0.001) in both angles. CONCLUSIONS: RS reduces the proportion of floating struts protruding into the main branch compared to TAP, at comparable flow rates. Clinical studies are needed to evaluate feasibility and potential clinical benefit of this technique.

Retroperitoneal Bleeding and Arteriovenous Fistula after Percutaneous Coronary Intervention Successfully Treated with Intravascular Ultrasound-guided Covered Stent Implantation.

The major puncture-site complications of the transfemoral approach are retroperitoneal bleeding (RPB), arteriovenous (AV) fistula, and arterial pseudoaneurysm. Although the management of RPB and AV fistula depends on individual cases, our experience shows that the use of a covered stent with intravascular ultrasound (IVUS) guidance can successfully manage percutaneous coronary intervention-associated RPB and AV fistula. IVUS guidance can therefore make it easy to use an optimal-size covered stent.

Battery collection in municipal waste management in Japan: challenges for hazardous substance control and safety.

To clarify current collection rules of waste batteries in municipal waste management in Japan and to examine future challenges for hazardous substance control and safety, we reviewed collection rules of waste batteries in the Tokyo Metropolitan Area. We also conducted a field survey of waste batteries collected at various battery and small waste electric and electronic equipment (WEEE) collection sites in Tokyo. The different types of batteries are not collected in a uniform way in the Tokyo area, so consumers need to pay attention to the specific collection rules for each type of battery in each municipality. In areas where small WEEE recycling schemes are being operated after the enforcement of the Act on Promotion of Recycling of Small Waste Electrical and Electronic Equipment in Japan in 2013, consumers may be confused about the need for separating batteries from small WEEE (especially mobile phones). Our field survey of collected waste batteries indicated that 6-10% of zinc carbon and alkaline batteries discarded in Japan currently could be regarded as containing mercury. More than 26% of zinc carbon dry batteries currently being discarded may have a lead content above the labelling threshold of the EU Batteries Directive (2006/66/EC). In terms of safety, despite announcements by producers and municipalities about using insulation (tape) on waste batteries to prevent fires, only 2.0% of discarded cylindrical dry batteries were insulated. Our field study of small WEEE showed that batteries made up an average of 4.6% of the total collected small WEEE on a weight basis. Exchangeable batteries were used in almost all of mobile phones, digital cameras, radios, and remote controls, but the removal rate was as low as 22% for mobile phones. Given the safety issues and the rapid changes occurring with mobile phones or other types of small WEEE, discussion is needed among stakeholders to determine how to safely collect and recycle WEEE and waste batteries.

Prognostic implications of optimal medical therapy in patients undergoing percutaneous coronary intervention for acute coronary syndrome in octogenarians.

The proportion of elderly acute coronary syndrome (ACS) patients who receive optimal medical therapy (OMT) after percutaneous coronary intervention (PCI) and whether OMT affects their long-term outcomes remain unclear. We retrospectively investigated 405 ACS patients who underwent stent implantation between 2005 and 2009, and compared the outcomes between patients <80 years of age vs. ≥80 years of age. The prescription rate of the recommended medical agents for ACS in both groups during hospitalization and 2 years after admission was also retrieved. Among the enrolled study population, 75 patients (19%) were aged ≥80 years. These elderly patients had a higher 2-year mortality compared with patients aged <80 years group. The prescription rate of beta-blockers, angiotensin-blocking drugs, and statins tended to be lower in patients aged ≥80 years than in those aged <80 years. Furthermore, among patients ≥80 years of age, those who received OMT had better clinical outcome of 2-year mortality compared to those without OMT. Elderly patients with ACS treated by PCI are at substantially higher risk of adverse events than younger patients. However, they are less likely to receive OMT. PCI with OMT might improve the clinical outcomes of elderly ACS patients.

Aortic aneurysm: an independent predictor of a looped brachiocephalic trunk in patients undergoing transradial coronary angiography.

BACKGROUND: A looped brachiocephalic trunk may cause transradial coronary angiography (TRA) failure with a right radial approach. The prevalences of aortic aneurysm (AA) and a looped brachiocephalic trunk are closely related to increased age. OBJECTIVE: The aim of this study was to clarify the relationship between AA and a looped brachiocephalic trunk. PATIENTS AND METHODS: A total of 1306 consecutive patients who underwent TRA through the right radial artery at Keio University Hospital between January 2007 and December 2011 were examined retrospectively. A looped brachiocephalic trunk was defined as the presence of a full 360° loop in the 45° left anterior oblique view requiring a change in the access site to the left radial or femoral artery. RESULTS: Of the 1306 patients who underwent TRA at Keio University Hospital between January 2007 and December 2011, 137 had AA. The patients were divided into two groups: patients with a looped brachiocephalic trunk and those without it. Patients in the looped brachiocephalic group were older and had a higher BMI. The prevalence of hypertension was higher in the looped brachiocephalic trunk group. Creatinine clearance was lower in patients with a looped brachiocephalic trunk than in those without a looped brachiocephalic trunk. Multivariate analysis showed that AA was an independent predictor of a looped brachiocephalic trunk. CONCLUSION: AA is a predictor of a looped brachiocephalic trunk that should be considered in patients undergoing TRA.