Distal Radiation Access as an Alternative to Conventional Radial Access for Coronary Angiography and Percutaneous Coronary Interventions (According to TENDERA Trial).

The aim of this study was to assess the immediate and medium-term (3 months) results of the safety and efficacy of distal radial access (DRA) in coronary interventions compared with conventional transradial radial access (TRA). TRA is the recommended access for coronary procedures because of increased safety: fewer local complications, large and small bleeding. Recently, DRA has emerged as a promising alternative access to minimize radial artery occlusion (RAO) risk, as well as other complications. A large-scale, international, randomized trial comparing medium-term results with TRA and DRA is lacking. An analysis of 776 patients of the prospective randomized TENDERA trial was carried out: the distal artery access group (DRA) - 391, the transradial access group (TRA) - 385. Statistically more often the crossover access was in the DRA group (5.1% and 0.8%, P < 0.001). The primary endpoint was early or late thrombosis/occlusion of the radial artery (RA). Secondary endpoints: (1) composite complications from access vessels; (2) access parameters. Statistically significant differences were obtained for the primary endpoint: DRA 2.7% (n = 10), TRA 6.8% (n = 26), P = 0.008. Occlusion of the distal radial artery (DRAt), with patent RA: DRA 1.3% (n = 5), TRA 0 (0), P = 0.023. At the secondary composite endpoint, statistically significant differences were obtained for the following groups of complications: BARC type I bleeding (DRA: 3.8% (n = 14), TRA: 21.7% (n = 83), P < 0.001); hematoma larger than 5 cm on day 1 (DRA: 10% [n = 37], TRA: 25.9% [n = 98], P < 0.001); hematoma larger than 5 cm on day 7 (DRA: 12.4% [n = 45], TRA: 34.6% [n = 132], P < 0.001). Of the access parameters, the following statistically significantly differed: puncture time DRA 19.0 (8.0; 50), TRA 13.5 (5.0; 29), P < 0.001; insertion of introducer DRA 42.0 (26.0; 84.0), TRA 35.0 (23.0; 55.0), P < 0.001, access artery hemostasis duration (min.) DRA 180.0 (120.0; 480.0), TRA 155.0 (115.0; 195.0), P < 0.001. The duration of the procedure and fluoroscopy, radiation dose, RA spasm in both groups had no statistically significant differences. In the TENDERA trail, DRA demonstrated efficacy and safety in interventional coronary interventions compared with TRA in the medium-term follow-up period: a statistically significant lower incidence of RA occlusion and local complications.

Distal Radial Access: Is There a Clinical Benefit?

For decades, the femoral artery has been the most common vascular access for diagnostic and therapeutic endovascular procedures. However, over the past 20 years, radial access has been gaining popularity, as it is a safer and allows practical access with more benefits. Recently, the new distal radial access has proven to be an equal or perhaps even safer vascular access for diagnostic and therapeutic coronary and noncoronary interventions. Today, this access should be in the arsenal of every interventional surgeon.

[Coronary Angioplasty and Stenting in Patients Older Than 80 Years: Immediate and Long-Term Results].

AIM: to assess immediate and long-term results of coronary angioplasty and stenting in patients older than 80 years - a high risk group in view of the severity of concomitant pathology and extent of coronary atherosclerosis. MATERIAL AND METHODS: We conducted retrospective analysis of data from 167 patients older than 80 years (mean age 81.43+/-2.14 years) subjected to percutaneous coronary intervention from 2006 to 2013 (3.2% from total number of patients). Multivessel involvement was present in 128 patients (76.6%) including 20 (12.4%) with stenosis in left main coronary artery. In 215 out of 270 stenotic lesions complicated stenoses type B2, C were detected . Number of chronic occlusions was 31 (10.3%) out of 301 treated lesions. There were 46 patients (27.5%) with diabetes, 16 (9.6%) with chronic anemia, 35 (21%) with chronic renal failure. Concomitant multifocal lesions in other arterial beds were found in 67 patients (40.1%). Radial, femoral, and combined femoral-radial accesses was used in 157 (94%), 5 (3%), and 5 (3%) patients, respectively. Results were studied with the help of automated system of digital computer angiography and intracoronary ultrasound. Long-term results were assessed with the help of questioning, control angiography, and echocardiography. RESULTS: Immediate angiographic and clinical success was achieved in 97 and 94% of cases, respectively. Revascularization was complete in 62.2% of cases. Hospital mortality was 0.7%. Major adverse cardiac events (MACE) were registered in 4.6 and 22.4% of patients during periods of 30 days and >24 months, respectively. Stent thrombosis was diagnosed in 3 cases (1.79%) in 6-18 months after intervention. Repeat revascularization in remote period was performed in 20 patients (12.8%), in 8 of them because of appearance of new lesion. Survival after 40 months was 91%, survival without MACE after 60 months was 74.8%. Complications related to access artery was 4.2% (1.9% in 157 transradial Interventions). According of logistic regression analysis, the following predictors of MACE in remote period were determined: initial depressed left ventricular function, diabetes mellitus, and lesion length >35 mm. CONCLUSION: Coronary angioplasty and stenting is an effective method of treatment of coronary atherosclerosis in patients older than 80 years with acceptable rate of MACE. Radial access lowers rate of access related vascular complications.

[Immediate and Long-term Results of the First in Russia of IntrocoronaryMetal Stent in the Coronary Artery].

The authors present immediate and long term results of the first in Russia implantation in coronary artery of Palmaz-Shatz metal stent. Indications for stenting were urgent after complicated dissection as a result of balloon dilation of discrete bifurcational stenosis of anterior interventricular artery (IVA). Immediate angiographic and clinical result was good. At control angiography after 13 years their was no restenosis in stented IVA. However novel narrowing was found in left main coronary artery (LMCA) in which drug eluting stent was implanted. Coronary angiography carried out after 7.5 years after stenting of LMCA and in 20 years after stent implantation in IVA revealed good patency of both stented segments without signs of restenosis. This case report demonstrates possibility of long term preservation of angiographic and clinical effect of staged endovascular treatment of coronary atherosclerosis.

[Multistage endovascular treatment of multifocal atherosclerosis].

We present a report of a clinical case of multistage endovascular treatment of multifocal atherosclerosis with involvement of coronary arteries, left renal artery, and arteries of lower extremities. A 54 year old patient with type 2 diabetes, impaired renal function, vasorenal hypertension, and lowered left ventricular contractility had history of stroke and myocardial infarction. Endovascular treatment was carried out in 6 stages with sequential angioplasty and stenting of coronary arteries, arteries of lower extremities, and left renal artery. Overall 20 stents were implanted (17 with drug covering): 10 in coronary vascular bed, 9 in arteries of lower extremities, 1 in renal artery. Control examination in 9 months showed good remote angiographic and clinical result.

[A case of spontaneous closure of left main coronary artery false aneurysm and stent thrombosis 11 years after coronary artery stenting].

This is the presentation of a case of formation of traumatic iatrogenic false aneurysm of left main coronary artery and its spontaneous closure combined with acute thrombosis of the stented segment of anterior interventricular artery (AIA) 11 years after initial procedure. False aneurysm was a consequence of dissection of arterial wall due to mechanical trauma by relatively stiff tip of guide wire and arterial wall hematoma extending to adventitia. Hematoma formation could be facilitated by thrombolytic therapy with streptokinase urgently carried out for acute AIA thrombosis after balloon angioplasty. Despite completion of processes of arterial wall repair at the implantation site confirmed by angiography 3.5 years after initial stenting development of novel atherosclerotic lesions and thromboses can occur in very remote period (after 11 years).

[Retrograde recanalization of coronary artery occlusions: novel method for increase of the rate of successful interventions].

First results of the use of a novel method of percutaneous coronary angioplasty of chronic occlusions of coronary arteries are presented. In 8 patients (men aged 54 - 75 years, mean age 60,4 +/- 7.1 years, mean duration of occlusion 45.5 +/- 7.9 months) retrograde recanalization was carried out through collateral branches of right coronary artery (RCA, 6 patients) or left anterior interventricular artery (LAIA, 2 patients). In all cases the procedure was preceded by unsuccessful attempts of antegrade recanalization of occlusion. Retrograde intervention was successful in 6 of 8 cases (5 RCA, 1 - LAIA). Technique of retrograde recanalization is described, criteria of selection of collateral branch, and instrumentation for optimization of the method are presented. As collateral branch in 6 cases we used septal branches either from LAIA (in case of recanalization of RCA) or from posterior interventricular branch of RCA (intervention on LAIA). In 2 cases retrograde recanalization of RCA was performed through posterior-lateral collateral branch of the circumflex artery.

[Efficacy of the use of sirolimus covered stents in the treatment of diffuse atherosclerotic lesions of coronary arteries].

Aim of the study was to compare efficacy of sirolimus covered (116 patients, group 1) and bare (117 patients, group 2) stents. Groups were comparable according to main characteristics. Proportion of patients with diabetes was 19 and 13.7%, with multivessel lesions--87.1 and 80.4%, with arterial diameter <2.75 mm--46.5 and 23.9% in group 1 and 2, respectively. Lesion length was 25.9+/-6.6 mm (28-93 mm) in group 1 and 22.1+/-7.8 mm (26-102 mm) in group 2. Overall 473 stents were implanted into 232 arteries (2.1 per artery). In group 1 184 stents were implanted in 116 arteries, in group 2--289 stents in 117 arteries. Immediate success rate was 97.4 and 99.1% in groups 1 and 2, respectively (p=0.74). There were no cases of acute stent thrombosis. Subacute thrombosis (after 1-3 weeks) occurred in 2 patients (1.7%) of group 1 and in 1 patient (0.85%) of group 2 (p=0.47). Angiographic restenosis was observed in 12 (10.6%) and 66 (56.9%) patients in groups 1 and 2, respectively (p<0.0025). In 47 of 66 patients (71.2%) in group 2 restenosis was diffuse. There was no case of diffuse restenosis in group 1. Twelve months survival without angina and major coronary events was 79.8% in group 1 and 31%--in group 2.

[13-year result after implantation of intracoronary stent (treatment of progressing atherosclerosis of coronary arteries with the help of endovascular methods)].

Clinical case of implantation in anterior interventricular artery (AIA ) of the first coronary stent in Russia is presented. Control angiogram obtained 7 years after stenting showed stent patency without restenosis with maximal 15.68% in-stent stenosis. Angiogram obtained after 13 years revealed good patency of previously stented segment of AIA. However a new stenosis appeared in left main coronary artery as a result of natural progression of atherosclerotic process. A drug eluting stent (Cypher) was implanted into left main coronary artery with good immediate result. This clinical observation demonstrates possibility of maintenance of effect of coronary artery stenting for long period of time as well as possibility of repetitive use of endovascular methods of treatment of ischemic heart disease despite newly developed complex lesions.

[The treatment of coronary atherosclerosis: effect of the use of stents on immediate and long term results of coronary angioplasty]. / Lechenie koronarnogo ateroskleroza: vliianie massovogo primeneniia stentov na blizhaishie i otdalennye rezul'taty koronarnoi angioplastiki.

Immediate and long term results of 2 methods of coronary angioplasty (balloon dilatation and stenting) were analyzed retrospectively. During 10 years proportion of stent implantations increased 30-fold reaching 95-97% of coronary interventions. This was associated with improvement of immediate results of angioplasty: lowered rates of myocardial infarctions, urgent coronary artery bypass graftings and acute coronary artery occlusions (from 2.7% after balloon angioplasty to 0.6% after stenting). Improved long-term prognosis after stenting manifested in lower frequency of cardiovascular events. Five year survival was 98,8 and 92.7% after stenting and balloon angioplasty, respectively (p=0.004). However effect of stenting on rates of angiographic restenosis and repeat revascularizations was less pronounced (27.1 and 30.4%, respectively, after stenting vs. 30.1 and 34.5%, respectively, after balloon angioplasty).

[Reparation of the vascular wall after laser recanalization of the artery (characteristics of changes in the vascular wall at a late period after laser recanalization)]. / Reparatsiia sosudistoi stenki lazernoi rekanalizatsii arterii (kharakteristika izmenenii v stenke sosuda v otdalennye sroki posle lazernoi rekanalizatsii).

Chronic experimental studies were carried out on 9 mongrel dogs. To study the reparation processes in the arterial wall after laser intervention, arteries of different anatomic zones were irradiated with laser: descending and abdominal aorta, iliac, femoral and axillary arteries. To make a laser trauma, two types of laser catheters were used: a) with the light guide with diameter of 400 and 600 microns; and b) with a quartz tip at the end. The laser light source was a laser of Cu vapors, and ND; YAG laser. Laser energy was transmitted in the form of individual impulses with the duration of 2-5 sec, and power of 8-10 watt. Histological studies of the preparations of the irradiated arterial wall were performed at periods: 1-3-7-16-28 days, and 2-8 months. Characteristic signs of the vascular wall reparations are given. The analysis of the experimental results showed that by the 28-th day after laser trauma, on the site of laser irradiation a connective tissue scar was formed substituting the defect in the vascular wall and covered from the lumen side with a thin continuous layer of endothelium without any signs of inflammatory infiltration. The development of intimal hyperplasia is not excluded, as well as of inflammatory reaction with the following thrombotic occlusion of the artery lumen. The study results can be used in clinical practice in order to determine the optimum tactics and performance of laser recanalization of the artery, as well as the treatment after the laser intervention.

[Transcutaneous transcatheter use of laser recanalization of coronary arteries in patients with ischemic heart disease]. / Chrezkozhnoe chrezkateternoe primenenie lazernoi rekanalizatsii koronarnykh arterii u bol'nykh ishimicheskoi bolezn'iu serdtsa.

The paper discusses the potential possibility and effectiveness of X-ray endovascular laser recanalization (ELR) of the coronary arteries in order to treat coronary atherosclerosis in patients with coronary heart disease. The intervention was performed in 4 patients (into the anterior interventricular artery in 3 and into the right coronary artery in 1). In 3 of 4 cases, X-ray ELR proved to be successful, in one case the intervention failed due to technological reasons. Recanalization of a completely occluded segment of the coronary artery with a residual stenosis of no more than 40% was observed in two cases. Laser recanalization of profound local coronary stenosis was made in the mid-third of the vessel in one case. It can be stated that X-ray ELR of the coronary artery may extend the scope of X-ray surgical therapeutical tools of the treatment of coronary atherosclerosis. At the same time, accumulation of clinical experience and further improvement of laser and laser catheter engineering are essential in defining the value and possible scope for the application of this method.

[Association of aortocoronary bypass and intraoperative laser recanalization of the coronary arteries in ischemic heart disease. Initial clinical results]. / Sochetanie aortokoronarnogo shuntirovaniia i intraoperatsionnoi lazernoi rekanalizatsii koronarnykh arterii pri ishemicheskoi bolezni serdtsa. Pervye klinicheskie rezul'taty.

The work discusses the results of intraoperative laser recanalization (LR) of the coronary arteries (CA). It is shown that the method facilitates increase of the degree of myocardial revascularization after a combined operation--aortocoronary shunting and intraoperative CA LR. The intervention was carried out on 10 patients, in 9 of them retrograde CA LR was conducted for recanalization of proximal affection of the CA and one patient underwent retrograde LR of a distally occurring stenosis of the anterior interventricular artery. Among the 10 interventions 7 were successful: in 5 patients the narrowed CA lumen was completely restored without residual stenosis, in 2 patients the stenosis reduced by 50-60% with a residual stenosis of no more than 30-40%. Perforation of the CA wall occurred in 2 cases and was repaired surgically. Still in another case an attempt to perform laser recanalization of the right CA failed because of technical reasons. Reocclusion of the recanalized CA segment was encountered in the late-term period in 2 of 4 patients. The conclusion may be drawn that CA LR is an effective auxiliary method in the formation of an aortocoronary shunt. The presence of diffuse, multiple lesions of the shunted CA and occlusion of the vascular lumen, affection of the distal arterial channel of the CA are the main indications for the use of intraoperative CA LR.