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

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

Safety and Efficacy of Robotic-Assisted PCI.

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

Percutaneous Retrieval of Dislodged Chemo Port Catheter With Inaccessible Tips by a Simplified Technique.

Central venous port catheters (CVPCs) are commonly employed for long-term chemotherapy. One of the rare complications associated with CVPCs is catheter fracture and further embolization of the fragmented segment into the heart. The most common site of embolization is the superior vena cava-right atrium (RA) junction. However, infrequently, the catheter may embolize further distally into the right ventricle (RV) and beyond making the fragmented tips difficult to access directly with a snare. Here, we report a case wherein both the catheter tips were lodged in the RV cavity forming a loop in the RA. This necessitated the use of a modified technique to retrieve the fragment percutaneously.

Tricuspid Atresia Type 1B With Persistent Left Superior Vena Cava in a Four-Month-Old Child: An Unusual Combination.

Tricuspid atresia (TA) is a rare cyanotic congenital heart disease. A persistent left superior vena cava (LSVC) may be associated with TA. The presence of LSVC raises important considerations for eventual repair, in that it may lead to persistent arterial desaturation even after corrective surgery, if associated with an unroofed coronary sinus. Here, we present the case of a four-month-old child who was diagnosed with TA type 1B, LSVC and a dilated coronary sinus by transthoracic echocardiography.

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

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

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

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

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

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

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

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

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

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

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

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

Vascular Complications of the Wrist: Prevention and Management.

Transradial access has increased in utilization and has been shown to be superior compared with transfemoral access. Although infrequent, several transradial access site-related complications occur. By understanding potential mechanisms related to these complications, several prevention and treatment strategies can be implemented to mitigate adverse outcomes.

Long Distance Tele-Robotic-Assisted Percutaneous Coronary Intervention: A Report of First-in-Human Experience.

BACKGROUND: Robotic-assisted percutaneous coronary intervention (R-PCI) has been successfully employed in the United States since 2011. Performing R-PCI from a remote location has never been reported but if feasible would extend availability of treatment to many patients with coronary artery disease (CAD) who would otherwise go without. OBJECTIVE: To assess the feasibility of remote tele-R-PCI with the operator 20 miles away from the patients. METHODS: Five patients with single, type A coronary artery lesions treatable by PCI consented to participate. The primary endpoint was procedural success with no major adverse cardiac events (MACE) before discharge. Procedural success was defined as achieving < 10% diametric stenosis of the occluded target vessel utilizing tele-R-PCI balloon angioplasty and stent deployment (CorPath GRX®, Corindus Vascular Robotics, USA) without converting to in-lab manual PCI by an on-site standby team. Procedural, angiographic, and safety data were collected as were questionnaire scores from the remote operator evaluating the robot-network composite, image clarity, and overall confidence in the procedure. RESULTS: The primary endpoint was achieved in 100% of patients. No procedural complications or adverse events occurred, and all patients were discharged the following day without MACE. The operator scores were favorable with the operators rating the procedure as equivalent to an in-lab procedure. CONCLUSIONS: Performing long distance tele-R-PCI in patients with CAD is feasible with predictably successful outcomes if reliable network connectivity and local cardiac catheterization facilities are available.

Percutaneous Treatment of Long Coronary Aneurysms: Novel Technique for Increased Efficacy and Safety.

Although covered stents have been available for percutaneous treatment of coronary aneurysms, patients with longer aneurysmal segments have been difficult to treat with covered stents. We describe a case of a right coronary artery aneurysm with an angiographically estimated length exceeding 30 mm treated percutaneously using covered stents and conventionally available hardware. (Level of Difficulty: Advanced.).

Reporting a novel variant of type VI dual left anterior descending artery: a rare coronary anomaly.

A dual left anterior descending artery (LAD) is a rare congenital coronary anomaly and is classified into six types based on the origin and course of the long LAD. In type VI dual LAD, the short LAD arises from the left main coronary artery, and the long anomalous LAD, from the proximal right coronary artery (RCA), coursing between the right ventricular outflow tract and aortic root to reach its normal course in the mid interventricular groove. We present a novel variant of type VI dual LAD where the course of the long LAD is the same but the origin is not from the RCA but, instead, separately, from the right coronary sinus.

Saphenous Vein Graft Perforation During Percutaneous Coronary Intervention - A Nightmare to be Avoided.

Percutaneous coronary interventions (PCIs) of saphenous vein grafts (SVGs) is challenging and is associated with adverse short- and long-term clinical outcome as compared to native coronary arteries. SVG perforation is rare but catastrophic and needs immediate attention. Various factors predisposing for SVG perforation are old degenerated graft, ulcerated plaque, severe fibrotic, or calcified lesion necessitating high pressure balloon or stent inflation, use of intravascular ultrasound (IVUS) or other atheroablative devices. Management includes prolonged balloon occlusion, reversal of anticoagulation, use of covered stent, and emergency pericadiocentesis if required.

Unusual retrograde aortic arch dissection during percutaneous coronary intervention: A case report.

Coronary dissection is one of the most frequently occurring complications during coronary interventional procedures. However, extensive coronary dissection retrograde to the coronary sinus of Valsalva and to the arch of aorta is very rarely observed. The authors report a case of retrograde coronary dissection extending into the arch of aorta. Management and coronary angiography at 6-month follow-up are discussed.

Transradial primary angioplasty and stenting in Indian patients with acute myocardial infarction: acute results and 6-month follow-up.

BACKGROUND: Coronary angioplasty and stent implantation is effective as primary intervention in acute myocardial infarction. Because of fewer puncture site complications and improved patient comfort, transradial access has been increasingly used as an alternative to transfemoral access for percutaneous coronary interventions. METHODS AND RESULTS: We studied 103 patients (94 men, 9 women: mean age 52.5 +/- 11.96 years) with a diagnosis of acute myocardial infarction (<12 hours after onset), who underwent primary percutaneous coronary intervention. Transradial access was used in all patients with a normal Allen's test and transfemoral access was used additionally only if intra-aortic balloon counterpulsation was required. Follow-up duration was 6 months. Transradial access was successfully achieved in all patients. Radial artery cannulation took <2 min in more than 85% patients. During percutaneous coronary intervention, cannulation to balloon inflation times and total procedure times were 11.3 +/- 5.2 min and 19.9 +/- 10.8 min, respectively. Stents were implanted in 99 (96.1%) patients andplain balloon angioplastywas performed in 3.9%. The primary success rate was 98.1%, with no major bleeding complications. Total length of hospitalization averaged 2.4 +/- 0.8 days. In-hospital major adverse clinical events rate was 5.9%. Six-month clinical follow-up was achieved for 84 (86.6%) patients. Six (7.1%) patients died during follow-up. Follow-up coronary angiography was performed in 22 (26.2%) patients. After 6 months, 7 patients required revascularizationof the target lesion. The rate of survival without myocardial infarction, bypass surgery or repeat coronary angioplasty was 88.5% at 6 months. CONCLUSIONS: Transradial access may represent a safe and feasible technique for performing primary percutaneous coronary intervention with good acute results and without major bleeding complications.

The modified Inoue technique: a simple troubleshooting approach to a proximal segment tear of an Inoue balloon.

A tear in the proximal segment of an Inoue balloon was encountered during the dilatation of a calcific mitral stenosis. As a troubleshooting measure, we modified the steps of the standard Inoue technique. The mitral valve was successfully dilated using the same Inoue balloon.