Distal Forearm Arteriovenous Fistula Maturation in Diabetic Hemodialysis Patients.

PURPOSE: Atherosclerotic disease of the forearm arteries can impede the maturation of distal fistulas in diabetic patients. The goal of this study was to look at the maturity of diabetic hemodialysis patients' distal forearm (radiocephalic snuffbox or distal forearm) arteriovenous fistulas. MATERIALS AND METHODS: Patients with chronic renal failure who were candidates for distal forearm radiocephalic arteriovenous fistula implantation were evaluated in this cross-sectional study. Patients' demographic details, underlying disorders, laboratory measurements, vital signs, and information on their surgery were all noted. Patients were checked for fistula development 1 week, 1 month, 2 months, and then monthly until 6 months after surgery. Arteriovenous fistula maturation characterized by optimal blood flow, vessel dilation, and structural adaptations. RESULTS: Among 343 patients (56% male, 44% female, mean age: 57.32 ± 12.48 years), hypertension prevailed (81.9%), followed by hyperlipidemia (42.3%) and coronary artery disease history (25.9%). AVFs achieved 58.3% maturation in 64.98 ± 11.05 days; higher BP during creation correlated with successful maturation (17.02 ± 1.46 mmHg vs 13.90 ± 1.93 mmHg, P < .05). No significant statistical difference found in distal forearm arteriovenous fistula maturation between males (57.8%) and females (58.9%) (P > .005). However, 41.7% of AVFs failed in 18.83 ± 17.89 days. Failed AVFs exhibited lower BP during operation and failure (11.75 ± 1.86 mmHg). Kaplan-Meier analysis depicted maturation probabilities over 90 days post-surgery. CONCLUSION: Diabetes and patient sex did not affect the maturation time of distal forearm AVFs in hemodialysis patients. Increased blood pressure during and after surgery correlated with shorter maturation time.

Routine preprocedural ultrasound in palpation versus ultrasound guided radial access for cardiac catheterization.

BACKGROUND: The radial first approach in cardiac catheterization is preferred for its benefits in patient comfort and recovery time. Yet, challenges persist due to characteristics like small, deep, calcified, and mobile radial arteries. Utilizing ultrasound before and during procedures can improve success rates. However, the adoption of its use is still limited and subject to debate. AIM: To utilize routine preprocedural ultrasound (US) and compare US guided with palpation guided radial access, focusing on operator efficiency and outcomes. METHODS AND RESULTS: Consenting adult patients undergoing elective radial cardiac catheterization were divided into palpation and US groups. Routine preprocedural assessment of radial artery characteristics was performed using handheld US. Baseline data, US findings, procedural outcomes, and clinical outcomes were compared in 182 participants (91 in each group). US guided radial access had significantly higher first pass success rates (76.92% vs. 49.45%, p 0.0001), fewer number of attempts (1.46 ± 1 vs. 1.99 ± 1.46, p 0.004), and shorter amount of time (93.62 ± 44.04 vs. 120.44 ± 67.1, p 0.002) compared with palpation guidance. The palpation group had significantly higher incidence of spasm (15.38% vs. 3.3%, p 0.0052). Subgroup analysis indicated consistent benefits of US guidance, especially in calcified radial arteries. CONCLUSION: This prospective, nonrandomized, single-center study demonstrated that real-time procedural US improved the operator's time and effort and enhanced patient comfort compared with palpation. US guidance use was particularly favorable in the presence of calcifications observed on baseline preoperative US.

Intraoperative transit time flow measurement predicts maturation of radiocephalic arteriovenous fistulas.

OBJECTIVE: The arteriovenous fistula (AVF) is the first choice for gaining vascular access for hemodialysis. However, 20% to 50% of AVFs fail within 4 months after creation. Although demographic risk factors have been described, there is little evidence on the intraoperative predictors of AVF maturation failure. The aim of this study was to assess the predictive value of intraoperative transit time flow measurements (TTFMs) on AVF maturation failure. METHODS: In this retrospective cohort study, intraoperative blood flow, measured using TTFM, was compared with AVF maturation after 6 weeks in 55 patients. Owing to its significantly higher prevalence and risk of nonmaturation, the radiocephalic AVF (RCAVF) was the main focus of this study. A recommended cutoff point for high vs low intraoperative blood flow was determined for RCAVFs, using a receiver operating characteristic curve. RESULTS: The average intraoperative blood flow in RCAVFs was 156 mL/min. Patients with an intraoperative blood flow equal or lower than the determined cutoff point of 160 mL/min, showed a 3.03 times increased risk of AVF maturation failure after 6 weeks, compared with patients with a higher intraoperative blood flow (P < .001). CONCLUSIONS: The intraoperative blood flow in RCAVFs measured by TTFM provides an adequate means of predicting AVF nonmaturation 6 weeks after surgery. For RCAVFs, a cutoff point for intraoperative blood flow of 160 mL/min is recommended for maximum sensitivity and specificity to predict AVF maturation failure after 6 weeks.

Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters.

OBJECTIVE: Systemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient, and the radial artery is the most common site of catheter placement. The present study compared 3 different arterial line procedures. It is hypothesized that a 20-G 12.7- cm catheter inserted into the radial artery will be equal to a 20-G 12.7- cm angiocath placed in the brachial artery, and superior to a 20-G 5.00 cm angiocath placed in the radial artery. DESIGN: A prospective randomized control study was performed. SETTING: Single academic university hospital. PARTICIPANTS: Adult patients ≥18 years old undergoing nonemergent cardiac surgery using cardiopulmonary bypass (CPB). INTERVENTIONS: After approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate 3 different peripheral intraarterial catheter systems was performed: (1) Radial Short (RS): 20-G 5- cm catheter; (2) Radial Long (RL): 20-G 12- cm catheter; and (3) Brachial Long (BL): 20-G 12- cm catheter. MEASUREMENTS AND RESULTS: Gradients between central aortic and peripheral catheters (CA-P) were compared and analyzed before CPB and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines and administration of vasoactive medications were recorded. After exclusions, 67 BL, 61 RL, and 66 RS patients were compared. Before CPB, CA-P SAP and MAP gradients were not significant among the 3 groups. Two minutes after CPB, the CA-P SAP gradient was significant for the RS group (p = 0.005) and insignificant for BL (p = 0.47) and RL (p = 0.39). Two-group analysis revealed that CA-P SAP gradients are similar between BL and RL (p = 0.84), both of which were superior to RS (p = 0.02 and p = 0.04, respectively). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p = 0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p = 0.13) and RL (p = 0.06). Two minutes after CPB, the CA-P MAP gradients were significant for the BL (p = 0.003), RL (p < 0.0001), and RS (p < 0.0001) groups. Two-group analysis revealed that the CA-P MAP gradients were lower for the BL group compared with the RL (p = 0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p < 0.0001) and both greater than the BL group (p = 0.002). A femoral arterial line was placed more frequently in the RS group (8/66 = 12.1%) than in the RL group (3/61 = 4.9%) and the BL group (2/67 = 3.0%). Vasopressin was administered significantly more frequently in the RS group. CONCLUSION: Regarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients, BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration were fewer for the BL and RL groups when compared with the RS group. This study demonstrated the benefits of a long (12.7 cm) 20- G angiocath placed in the radial artery.

Pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic arteriovenous fistulas maturation.

PURPOSE: The aim of this study was to investigate the effectiveness and safety of the pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic AVF maturation. METHODS: We retrospective studied a total of 62 patients with immature radiocephalic AVF, who received balloon-assisted maturation in our hospital. 15 patients received pull-through technique through radial artery without sheath insertion and 47 patients received treatment through a regular venous approach. RESULTS: The success rate of pull-through technique group and control group was 86.7% (13 out of 15), 89.1% (41 out of 46) respectively. There was no significant difference between two groups (P > 0.05). In our study, there were 2 patients in the pull-through technique group and 3 patients in the control group, which had hematoma in the vein puncture site (P = 0.59). There were also no differences in the primary patency rate between two groups at 6 months and 12 months (76.9% vs 70.7%, 38.4% vs 41.5%, respectively, P > 0.05). CONCLUSION: The pull-through technique through antegrade radial artery without sheath insertion in promoting radiocephalic AVF maturation is effective and safe.

[Feasibility and safety study of distal radial artery approach in emergency PCI of elderly STEMI patients].

Objective: To investigate the feasibility and safety of distal radial artery approach in emergency percutaneous coronary intervention(PCI) of elderly ST-segment elevation myocardial infarction(STEMI) patients. Methods: This study is a cross-sectional study. Elderly patients with acute myocardial infarction who received emergency PCI at the Third Central Hospital of Tianjin from January 2020 to December 2022 were selected. They were divided into the distal radial artery group and the classic radial artery group based on the puncture location. The success rate, puncture time, surgical success rate, and surgical time of the two groups were observed; The incidence of complications in patients, including radial artery occlusion rate, radial artery spasm rate, local hematoma rate, aneurysm incidence rate were recorded. Results: There were 70 cases in the distal radial artery group, including 33 males (47.1%), aged (65.6±6.7) years old; There were 70 cases in the classic radial artery group, including 35 males (50.0%), aged (66.4±6.9) years old. There was no statistically significant difference in puncture success rate, puncture time, surgical success rate, and surgical time between the distal radial artery group and the classical radial artery group (P>0.05). The incidence of radial artery occlusion in the distal radial artery group was significantly lower than that in the classical radial artery group (1.4% vs. 8.6%, P=0.024). The postoperative compression time in the distal radial artery group was significantly shorter than that in the classical radial artery group ((291.6±10.5) min vs. (343.5±9.8) min, P=0.047). There was no statistically significant difference in the incidence of radial artery spasm, local hematoma, and aneurysm between the two groups (P>0.05). Conclusions: The distal radial artery approach has a lower radial artery occlusion rate, shorter compression time, and better safety. It can be used as a new approach for emergency PCI in elderly patients with STEMI for clinical application.

Neuro-Interventional Diagnosis and Treatment Using the Right Transradial Approach in Patients with Aberrant Right Subclavian Artery.

OBJECTIVE: To assess the effectiveness and safety of neurological interventions using the right transradial approach (R-TRA) in patients with aberrant right subclavian artery (ARSA). METHODS: We retrospectively analyzed cases that underwent cerebral angiography and interventions at Huangpi District People's Hospital from January 2023 to July 2023. Out of 335 cases, 5 patients with ARSA were identified. RESULTS: All 5 cases underwent diagnostic cerebral angiography via R-TRA. Two of the patients received interventions via R-TRA: 1 underwent right internal carotid artery balloon dilation angioplasty, while another underwent left vertebral artery stenting. No surgery-related complications were observed during these procedures. CONCLUSIONS: R-TRA proves to be a safe and effective option for neuro-interventional surgery in patients with ARSA.

Comparison of long-term radial artery occlusion via distal vs. conventional transradial access (CONDITION): a randomized controlled trial.

BACKGROUND: The distal transradial access (dTRA) has become an attractive and alternative access to the conventional transradial access (TRA) for cardiovascular interventional diagnosis and/or treatment. There was a lack of randomized clinical trials to evaluate the effect of the dTRA on the long-term radial artery occlusion (RAO). METHODS: This was a prospective, randomized controlled study. The primary endpoint was the incidence of long-term RAO at 3 months after discharge. The secondary endpoints included the successful puncture rate, puncture time, and other access-related complications. RESULTS: The incidence of long-term RAO was 0.8% (3/361) for dTRA and 3.3% (12/365) for TRA (risk ratio = 0.25, 95% confidence interval = 0.07-0.88, P = 0.02). The incidence of RAO at 24 h was significantly lower in the dTRA group than in the TRA group (2.5% vs. 6.7%, P < 0.01). The puncture success rate (96.0% vs. 98.5%, P = 0.03) and single puncture attempt (70.9% vs. 83.9%, P < 0.01) were significantly lower in the dTRA group than in the TRA group. However, the number of puncture attempts and puncture time were higher in the dTRA group. The dTRA group had a lower incidence of bleeding than the TRA group (1.5% vs. 6.0%, P < 0.01). There was no difference in the success rate of the procedure, total fluoroscopy time, or incidence of other access-related complications between the two groups. In the per-protocol analysis, the incidence of mEASY type ≥ II haematoma was significantly lower in the dTRA group, which was consistent with that in the as-treated analysis. CONCLUSIONS: The dTRA significantly reduced the incidence of long-term RAO, bleeding or haematoma. TRIAL REGISTRATION: ClinicalTrials.gov identifer: NCT05253820.

[Analysis of the experience and procedural complications of trans-radial access versus trans-femoral access for hepatic arterial perfusion chemotherapy in patients with advanced hepatic malignancies:a retrospective study].

Objective: To analyze the differences between trans-radial access (TRA) and trans-femoral access (TFA) in hepatic arterial perfusion chemotherapy (HAIC) in terms of patient experience, postoperative complications, and patient preferences; explore whether TRA in HAIC is associated with better patient experience and compliance; and determine whether it is safer than TFA. Methods: The study was a retrospective cohort study of patients with advanced hepatocellular carcinoma and liver metastases from colorectal cancer treated with HAIC. We enrolled a total of 91 patients with advanced liver malignancies treated with HAIC from November 2022 to May 2023 in the Department of Interventional Therapy and Hepatobiliary Medicine at Tianjin Medical University Cancer Hospital. The patients were divided into three groups: group TRA (n=20, receiving TRA HAIC only), group TFA (n=33, receiving TFA HAIC only), and crossover group [n=19, receiving TFA HAIC (Cross-TFA group) first, followed by TRA HAIC (Cross-TRA group)]. Meanwhile, to facilitate the expression of partial results, all patients receiving TRA HAIC were defined as the TRA-HAIC group (n=39, TRA+Cross-TRA group), and all patients receiving TFA HAIC were defined as the TFA-HAIC group (n=52, TFA+Cross-TFA group). The primary research index was the Quality of Life (QOL) visualization scale score. The secondary research index included approach-related and catheter-related adverse events, duration of surgery, and mean length of patient stay. We used various statistical methods such as Mann-Whitney U test, t-test, Chi-square test, Fisher's exact test, univariate logistic regression analysis, and multi-factor analysis. Results: TRA patients had significantly lower QOL scores than TFA patients (all P<0.001). The QOL scores of the Cross-TRA group were significantly lower than those of the Cross-TFA group (pain at the puncture site Z=-3.24, P=0.001, others P<0.001). The QOL scores of the Cross-TRA group were compared with those of the TRA group, which showed that the scores of the Cross-TRA group in overall discomfort (Z=-3.07,P=0.002), postoperative toilet difficulty (Z=-2.12, P=0.034), and walking difficulty (Z=-2.58, P=0.010) were significantly lower than those of the TRA group. Satisfaction scores were significantly higher in the Cross-TRA group than in the Cross-TFA group (Z=-3.78, P<0.001), and patients were more likely to receive TRA HAIC as the next procedure (χ2=30.42, P<0.001). In terms of mean length of stay, patients receiving TRA HAIC had a significantly lower mean length of stay than those receiving TFA HAIC (50.1±3.2 h vs. 58.4±6.4 h, t=7.98, P<0.001). The incidence of radial artery occlusion (RAO) as an approach-related adverse event was 15.4% (6/39) in the TRA-HAIC group, which was significantly higher than that in the TFA-HAIC group (15.4% vs. 0, χ2=8.56, P=0.005). Notably, multifactorial analysis of RAO-related factors showed that intraoperative enoxaparin use and patency of radial artery flow during pressure were significantly associated with a reduced risk of postoperative RAO (P=0.037 for enoxaparin use and P=0.049 for pressure). Conclusions: With respect to procedure approach, TRA was significantly better than TFA in terms of patient satisfaction and mean length of stay. Through further process optimization and prevention of adverse reactions, the incidence of adverse reactions can be maintained at a relatively low level, so that patients can benefit from TRA in future operations in terms of cost-effectiveness and medical efficiency.

Trans-radial artery microcatheter angiography-assisted juvenile ruptured brainstem arteriovenous malformation resection.

BACKGROUND: Due to their crucial functional location, surgical treatment of brainstem arteriovenous malformations (AVMs) has always been challenging. For unruptured AVMs, we can determine whether radiological therapy, interventional treatment, or surgical resection is feasible based on the AVM structure. However, for ruptured AVMs, microsurgical resection and interventional embolization are effective methods to prevent further rupture. In the microsurgical resection of AVMs, we usually use a hybrid operation to confirm the AVM structure and determine if the AVM is completely resected during the surgery. METHOD: We report a case of juvenile ruptured brainstem AVM resection. The right lateral position and left suboccipital retrosigmoid approach were used. We established an interventional approach via left radial artery and set a microcatheter in the feeding artery. Methylene blue injection via a microcatheter showed the AVM structure, and we totally resected the brainstem AVM under electrophysiological monitoring and navigation. Intraoperative angiography was performed to ensure complete resection without residual nidus. CONCLUSION: This case demonstrates that the trans-radial approach is convenient and safe for special positions in hybrid operations. Methylene blue injection via a microcatheter in the feeding artery provides clearer visualization of the AVM structure under the microscope.

Feasibility of early radial artery occlusion recanalization and reuse through transradial access for neuroendovascular procedures.

BACKGROUND: Radial artery occlusion (RAO) remains a significant limitation of neuroendovascular procedures peformed through transradial access (TRA) when radial artery needs to be reused. Instances of early RAO recanalization to successfully complete neuroendovascular procedures have been rarely documented. MATERIALS AND METHODS: Documents and imaging data were extracted retrospectively for all patients who underwent TRA diagnostic angiography and neuroendovascular procedures in our center from June 2022 to February 2023. The patients with early RAO who required repeat TRA were included. RESULTS: A total of 46 patients underwent repeat TRA, and 13 consecutive patients who experienced early RAO after angiography as confirmed by ultrasonography were enrolled in this study. The occluded radial arteries were successfully recanalized, and subsequent neuroendovascular procedures were carried out successful. During an average follow-up time of 7.1 months, no patients exhibited symptomatic RAO, dissection, hematoma or pseudoaneurysm. CONCLUSIONS: Early RAO recanalization and reused for neuroendovascular procedures through TRA is feasible. A visually guided and stable puncture process plays a crucial role in successfully recanalizing early RAO.

Trans-Distal Radial Artery Carotid Revascularization with Forearm Flow Reversal: An Alternative Option of CAS in the TCAR Era.

BACKGROUND: Transcarotid artery revascularization (TCAR) has emerged as an alternative to carotid artery stenting (CAS). TCAR demonstrated its superiority by avoiding femoral artery puncture and establishing proximal protection without crossing the stenotic lesion. In the TCAR era, we focused on the possibility of a trans-distal radial approach (DRA). A balloon-guide catheter was navigated via DRA to establish proximal protection before lesion crossing. The forearm subcutaneous vein was used as the flow-reversal circuit. METHODS: Six internal carotid artery stenosis patients underwent CAS using "the forearm flow reversal technique." Every procedure was performed under continuous flow reversal from the common carotid artery to the forearm cephalic vein. RESULTS: Successful revascularization was achieved without ischemic or access-site complications. The distal radial artery was patent at discharge in all cases. CONCLUSIONS: Trans-distal radial CAS with forearm flow reversal is a feasible and less invasive technical option.

Association of radiocephalic arteriovenous anatomical markers with post-angioplasty blood flow volume.

BACKGROUND: Doppler ultrasound (DUS) blood volume flow (VF) calculation is the most reliable method for demonstrating the success of endovascular treatment of dysfunctional radiocephalic arteriovenous fistula (AVF). Due to the difficulty of this method for the interventionalist, VF-correlated markers are required during the procedure. PURPOSE: To investigate the relationship between intraprocedural anatomical markers (AMs) and changes in VF induced by percutaneous transluminal angioplasty (PTA). MATERIAL AND METHODS: The study included 56 patients with dysfunctional radiocephalic AVF who underwent PTA between September 2020 and 2022. The VF of all patients was measured using DUS before and 1 h after PTA. AMs were determined from 10 images, five before and five after balloon angioplasty. RESULTS: The mean post-PTA VF was 637 ± 277 mL/min compared to baseline (151 ± 107 mL/min). Before and after balloon angioplasty, vein diameter (VD), artery diameter (AD), stenosis minimum luminal diameter (MLD), stenosis percentage (SP), and VF values were statistically significant (P = 0.001). Spearman's correlation analysis showed a positive strong linear relationship between VF and MLD (rs = 0.850, P <0.001), and a negative strong linear relationship between VF and SP (rs = 0.815). Receiver operating characteristic curve analysis showed that the sensitivity and specificity for VF ≥400 mL/min at cutoffs of SP <50% and MLD >2.5 mm were 81% and 82%, and 81% and 90%, respectively. CONCLUSION: Among the AMs readily available during PTA, first MLD and then SP provided satisfactory results in predicting VF.

Outcomes of Radial Artery Versus Saphenous Vein as A Second Conduit After Coronary Artery Bypass Grafting.

Despite the advantages of multiarterial grafting, saphenous vein (SV) configurations predominate in coronary artery bypass grafting (CABG). In addition, the benefits of radial artery (RA) utilization in multivessel CABG remain unclear. This study aims to compare the clinical outcomes of patients who received RA grafts during CABG with those of patients who received SV grafts. A retrospective, single-institution cohort study was performed in 8,774 adults who underwent isolated CABG surgery with multiple grafts between 2010 and 2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:2 (RA/SV) match ratio. Long-term postoperative survival was compared in RA and SV graft groups. Similarly, major adverse cardiac and cerebrovascular event (MACCE) rates were compared in the cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for both mortality and MACCE. A total of 7,218 patients (82.3%) who underwent multivessel CABG were included in this analysis. Of these patients, 341 (4.7%) received RA grafts, and 6,877 (95.3%) received SV grafts secondary to left internal mammary artery use. PSM yielded a cohort of 335 patients with RA and 670 patients with SV. After matching, groups were well balanced across all baseline variables. No significant differences were observed in either immediate postoperative morbidities or long-term survival. However, Kaplan-Meier estimates of long-term postoperative freedom from MACCE were significantly greater in matched patients with SV (73.3%) than in those with RA (67.4%) (p = 0.044, cluster log-rank), with patients with SV also possessing significantly greater freedom from coronary revascularization and MI. In conclusion, RA and SV secondary conduits for CABG were associated with comparable immediate postoperative complications and long-term survival after PSM. SV grafting was associated with significantly decreased rates of postoperative MACCE, likely owing to lower rates of coronary revascularization and MI than in RA grafting.

A new very-small-bore Simmons guiding sheath for transradial neurointervention: Technical note and initial experience.

Transradial access during neurointerventions has increased in popularity because of reduced complications and patient preference. Nevertheless, transradial cannulation into the left common carotid artery can be difficult technically because of the lack of catheter support in the aortic arch. Furthermore, the use of large sheaths can increase the risk of complications at the access site. Here, we developed a new very-small-bore transradial system using a 3F Simmons guiding sheath, to increase the procedural success rate and minimize access-site complications. This system can represent a valuable treatment option for neurointerventions and has the potential to expand the indications for transradial access.

Reconstruction of circumferential fingertip defect using free superficial palmar branch of the radial artery flap: Report of two cases.

Wide local excision of noninvasive malignant melanomas has been increasingly performed instead of digit amputation, which often results in extensive fingertip defects. Owing to the unique anatomical characteristics of the fingertips, achieving favorable outcomes in both function and cosmesis is challenging during reconstruction. The free superficial palmar branch of the radial artery (SPBRA) flap is advantageous for finger reconstruction. However, its application in circumferential fingertip defects has rarely been reported. In this report, we describe two cases of circumferential fingertip defect reconstruction using a free SPBRA flap after wide local excision of subungual melanoma. The patients were women aged 74 and 63 years at the time of surgery. They presented with subungual melanoma on the right fourth finger and left thumb, in which both biopsies confirmed malignant melanoma in situ (Tis N0 M0), Breslow thickness of 0 mm (noninvasive). After wide local excision, circumferential defects, sized 2.5 × 6 and 2.7 × 7 cm, were formed on their fingertips. A vertically designed free SPBRA flap measuring 2.7 × 6 and 3 × 6 cm was elevated from the unaffected palm in each patient. After performing microvascular anastomosis, the flap was inserted transversely, wrapping the exposed phalangeal bone in a conical shape. The donor site was primarily closed. All flaps survived, and postoperative complications did not develop. Neither local recurrence nor distant metastasis was detected at the latest follow-up in either patient at 24 or 28 months postoperatively. The patients were satisfied with the natural contour of the reconstructed fingertip and recovered functions. In the evaluation of subjective sensory recovery using four scales (excellent, good, fair, and poor), they responded "fair" and "good," respectively. We suggest that the free SPBRA flap could be a reliable reconstructive method for circumferential fingertip defects.

Percutaneous ecoguided endovascular lithotripsy to recruit failed-to-mature arteriovenous fistula due to completely calcified radial artery.

The first-choice vascular access for starting dialysis is autogenous distal forearm arteriovenous-fistula (AVF); the increasing demand to create more fistulas may lead to their creation in borderline vessels and, in this setting, the early failure (EF) and failure of maturation (FTM) remain the main issues. The size of vessels or preexisting stenotic lesions of artery or vein are no longer considered absolute exclusion criteria for the creation of distal AVF, but huge arterial calcification still represents an indication to create upper arm AVF. A novel approach to treat arterial calcifications is represented by intravascular lithotripsy (IVL). This technique could represent a valid option to save failed to mature AVF due to extended calcified artery. We describe a case of a male patient, 43 years old with middle forearm AVF failed to mature with a completely calcified radial artery, low brachial flow (Qa) and small efferent vein. We treated the patient AVF with less invasive, percutaneous, endovascular, eco-guided IVL on the entire radial artery. After the procedure was observed a rapid increase of Qa, with reduction of calcification in the arterial wall, increase of arterial caliper and flow. This procedure could represent a valid alternative to surgical upper-arm AVF creation in patient with functioning but failed to mature fistula due to spread artery calcification, with a rapid, less invasive procedure.

The Zoom RDL radial access system for neurointervention: An early single-center experience.

BACKGROUND: The transradial approach (TRA) for neurointerventional procedures is increasingly being used given its technical feasibility and safety. However, catheter trackability and device deliverability are reported barriers to TRA adoption. METHODS: This is the first report describing the technical feasibility and performance of using the Zoom RDL Radial Access System (Imperative Care, Inc., Campbell, CA) in 29 patients who underwent neurointerventional procedures from October 2022 to January 2023 in a single-center institution. RESULTS: Mean age of the study population was 61.9±17.2 years, 79.3% were male (23/29), and 62.1% were black (18/29). The most common procedures were stroke thrombectomy (31.0%, 9/29) and aneurysm embolization (27.6%, 8/29). All the stroke thrombectomy procedures were successfully performed; first-pass effect rate (mTICI≥2 c in one pass) was achieved in 66.7% (6/9) of cases. We used TRA in 86.2% of cases (25/29), including distal radial/snuffbox access in 31.0% (9/29) of cases. The radial diameter was >2 mm for all cases. An intermediate/aspiration catheter was used in 89.7% (26/29) of cases. Access success was achieved in 89.7% of cases (26/29); two cases required conversion from TRA to transfemoral approach (6.9%) and one case required conversion to a different guide catheter (3.4%). There were no access site complications or other Zoom RDL-related complications. One intracerebral hemorrhage, and one procedure-related thrombus were observed. CONCLUSIONS: The use of Zoom RDL Radial Access System is technically feasible and effective for complex neurointerventional procedures with low complication rates.

Comparison of Radial Versus Femoral Access for Neuroendovascular Procedures in Very High Body Mass Index Individuals.

BACKGROUND: Femoral access (TFA) for neuroendovascular procedures may present a challenge in very high body mass index (BMI) individuals. Whether radial access (TRA) confers a comparative benefit in this specific population has not been studied. METHODS: We retrospectively identified all patients undergoing neuroendovascular procedures at our center between 2017 and 2021 with BMI ≥35 kg/m2. A total of 335 patients met our inclusion criteria, with 224 undergoing femoral access and 111 undergoing radial access. Electronic medical records were reviewed for baseline clinical and angiographic characteristics and procedural outcomes. RESULTS: The primary outcome of any bleeding complication occurred in 7% of the femoral group and 2% of the radial group (odds ratio 4.2, 95% confidence interval 1.0-18.6, P = 0.0421). Radial access was also associated with significantly shorter mean procedure times (median 43 minutes for radial, median 58 minutes for femoral, P = 0.0009) and mean fluoroscopy exposure times (median 15 minutes for radial, median 20 minutes for femoral, P = 0.0003). There were no significant differences in nonaccess site complications, procedural failure, length of stay, or deaths during hospitalization. CONCLUSIONS: When compared to TRA, TFA was associated with a significantly greater rate of bleeding complications in very high BMI patients undergoing neuroendovascular procedures. Procedure time and fluoroscopy time were both significantly longer when using TFA compared to TRA in this patient population.