On-line estimated peak skin dose during percutaneous coronary intervention for chronic total occlusion using new patient dose mapping technology.

BACKGROUND: X-ray exposure during complex percutaneous coronary intervention is a very important issue. AIM: To reduce patient peak skin dose during percutaneous coronary intervention procedures for chronic total occlusion using on-line estimated peak skin dose software (Dose Map). METHODS: Throughout the procedure, Dose Map provided a map of local cumulative peak skin dose. This map was displayed in-room from 1Gy cumulative air kerma, and was updated every 0.5Gy. The operator's actions to minimize deterministic risks following map notification were collected. Skin reaction was evaluated 3 months after the procedure. A comparison with our historical X-ray exposure data (207 patients from January 2013 to July 2014) was performed. RESULTS: From November 2015 to October 2016, 97 patients (Japanese chronic total occlusion score 2.1±1.1; 100 percutaneous coronary intervention procedures for chronic total occlusion) were prospectively enrolled. Fluoroscopy time was 40.8 (21.6-60.3) minutes, cumulative air kerma 1884 (1144-3231) mGy, estimated peak skin dose 962 (604-1474) mGy and kerma area product 115.8 (71.5-206.7) Gy.cm2. Cumulative air kerma was>3Gy in 28% of cases, and>5Gy in 11% of cases. In 68% of cases, at least one action was taken by the operator after map notification to optimize skin dose distribution. Main changes included: gantry angulation (52%); field of view (25%); and collimation (13%). No skin injuries were observed at follow-up. In comparison with our chronic total occlusion historical radiation data, median cumulative air kerma and kerma area product were reduced by 31% and 33%, respectively (P<0.005. CONCLUSION: Online skin dose mapping software allows the distribution of patient skin dose during complex percutaneous coronary intervention procedures, and may minimize X-ray exposure.

Comparison of Transradial vs Transfemoral Access for Aortoiliac and Femoropopliteal Interventions: A Single-Center Experience.

PURPOSE: To compare the procedure and safety outcomes of the transradial approach (TRA) with the femoral approach (FA) for treating aortoiliac and femoropopliteal stenoses and occlusions. METHODS: A single-center retrospective study was conducted involving 188 patients (mean age 66.4±10.8 years; 116 men) with lower limb claudication or critical limb ischemia who underwent aortoiliac (131, 62.4%) or femoropopliteal (79, 37.6%) interventions on 210 lesions over a 3-year period. Operator discretion determined TRA suitability; exclusions included Raynaud's disease, upper limb occlusive disease, previous TRA difficulties, or planned hemodialysis. Lesion characteristics, clinical endpoints, and access site complications were compared. RESULTS: FA was used primarily in 123 patients and the TRA (12 left and 53 right radial arteries) in 65 procedures. Eleven (16.9%) TRAs failed vs 9 (7.3%) FAs (p=0.42). Crossover to FA was due to occlusive lesions requiring alternative equipment in 9 cases and to tortuosity of the aortic arch vessels in 2 patients. The 134 FA interventions (balloon angioplasty, stents) were retrograde (112, 83.6%) or antegrade (22, 16.4%). There were significantly more TASC C/D lesions in the FA group (p=0.02). Sheath sizes (5-F to 8-F) did not differ between groups, and no significant differences were found between FA vs TRA in terms of procedure time (50.0±28.9 vs 46.8±25.1 minutes, p=0.50) or length of stay (2.2±0.6 vs 2.1±0.3 days, p=0.24). While there were no strokes, access site complications occurred in 6.0% of the FA patients vs 3.7% of the TRA patients (p=0.12). CONCLUSION: The transradial approach for aortoiliac and femoropopliteal interventions is safe and efficacious compared with the transfemoral approach for a range of lesion subtypes. Nevertheless, there remains a need for improvements in peripheral device and catheter technology to decrease transradial failure rates.

CMR assessment of AMI patients treated by PCI shows delays in myocardial reperfusion despite initial achievement of TIMI 3 flow.

AIMS: Cardiovascular magnetic resonance imaging (CMR) perfusion studies performed early after successful angioplasty in AMI nearly always shows incomplete tissue reperfusion despite normal coronary blood flow by TIMI score. In contrast, when performed a few weeks or months after AMI, CMR first-pass perfusion (FP) is usually normal. This study was conducted to determine the kinetics of tissue reperfusion after reperfused AMI in humans. METHODS AND RESULTS: We prospectively analyzed patients who presented with ST-segment elevation myocardial infarction between July 2002 and January 2005. Included patients had TIMI 3 flow after acute PCI and CMR FP imaging within four months post-MI. CMR FP was performed after injection of 20 cc of gadolinium chelate and imaging was performed with a Siemens Symphony 1.5 T. For FP analysis, each slice was divided into 8 segments which were subdivided into subepicardial and subendocardial layers. Normal perfusion was defined as less than 5% of segments involved by hypoperfusion. Patients were divided into groups according to the delay between MI/reperfusion and CMR. The reperfusion curve was established by plotting the percentage of patients with normal perfusion in each subgroup. A total of 184 CMR were analysed out of 146 patients included in the study. Probability of normal perfusion was 24%, 31%, 35%, 33% and 43% at respectively day 1, day 2, day 4, day 6 and day 8. This probability increased to 67% at week 2, and at week 3 reached a 100% probability (Spearman's rho -0.471, p = 0.001). CONCLUSIONS: Despite complete restoration of epicardial flow, early myocardial reperfusion as assessed by CMR is very uncommon. Myocardial perfusion is progressively restored and capillary blood volume recovered normal values between weeks 2 and 4 after MI.

Less invasive PTCA of a gastroepiploic artery combining the transradial approach and 5 Fr guiding catheter: a case report.

The gastroepiploic artery has been successfully used as an arterial conduit in selected patients undergoing CABG with acceptable immediate and long-term results. Myocardial ischemia may occur during the follow-up period as a result of spasm, occlusion, or stenosis at the anastomosis site. Because of tortuosity and in order to avoid graft spasm and to obtain good extra backup support, we require low-profile wide-lumen guiding catheters for deep intubation and increased procedural success. In the case presented here, a gastroepiploic graft stenosis was treated by balloon angioplasty performed through a less invasive approach combining transradial access and use of 5 Fr guiding catheter.