Ipsilateral transulnar artery approach catheterizations after failure of the radial approach-Are two sheaths in the same arm safe?

AIMS: To assess the safety and feasibility of ipsilateral transulnar access (TUA) after failure of radial access (TRA), with two sheaths placed in the radial and ulnar arteries (RA and UA) in the same arm. MATERIALS AND METHODS: All consecutive patients with TUA due to inability to cross from ipsilateral TRA in the period from March 2011 until September 2020 were included in the study. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TRA. Patients were assessed by duplex ultrasound post-procedure (at an average of 56 ± 31 months) and followed clinically (functional and pain assessment). RESULTS: In this period, out of 51,866 patients 112 (0.2%) had a transulnar artery approach due to inability to cross from ipsilateral radial approach. Mean age of patients was 65 ± 11 years with 44% females. Cause for crossover to ipsilateral TUA was inability to cross a RA anomaly in 107 (95%) patients, mostly due to the presence of a "360°" RA loop in 88 patients. Type 3 and 4 EASY Score hematoma was present in 3 patients (2.6%). Six (5.3%) of the patients had new ipsilateral radial artery occlusion noted on duplex on follow up. There were no ulnar artery occlusions detected. There were no clinical or ischemic hand complications seen during a median 4.3 years of follow up. CONCLUSION: Ipsilateral transulnar artery access following failed radial artery access crossing is safe and successful for coronary angiography and intervention with low rates of complications.

Benefit of routine preprocedural radial artery angiography in STEMI patients.

AIMS: To assess the benefit of routine preprocedural radial artery (RA) angiography in patients with ST segment elevation myocardial infarction (STEMI). METHODS AND RESULTS: All consecutive STEMI patients, in the period from January 2010 until December 2016 were included in the study. Preprocedural radial artery angiography was performed in all patients since March 2011. We compared clinical and procedure characteristics, access site bleeding complications and failure of primary chosen TRA between two groups of STEMI patients before and after we started performing routine RA angiography. We compared 762 STEMI patients from 2010 until March 2011 and 4306 STEMI patients after March 2011 until December 2016. Mean age of patients was 60 ± 11 years with 73% males. The latter group had more elderly and obese patients (P < .0001 both). Prior percutaneous coronary interventions was present in 7% of patients and 0, 1% had prior coronary bypass surgery. Procedure duration (38 ± 16 vs. 32 ± 20 min) was significantly longer in the first group (P value < .0001), but contrast volume (120 ± 33 vs. 110 ± 35 ml), and fluoroscopy time (8.6 ± 6 vs. 8.7 ± 8 min) were similar in both groups. Access crossover from primary TRA was 4, 6% in the first group, with a significant decrease to 3, 1% in the second (P < .0001), after introducing preprocedural RA angiography. Access site bleeding complications were significantly higher in the first group 6.8% vs. 4.3% in the second (p < .0001). CONCLUSION: Routine preprocedural radial artery angiography in STEMI patients is associated with lower rate of access site bleeding complications and reduced overall procedural time and TRA crossover rate.

Early coronary revascularization among "stable" patients with non-ST-segment elevation acute coronary syndromes: the role of diabetes and age.

AIMS: To investigate the impact of an early coronary revascularization (<24 hours) compared with initial conservative strategy on clinical outcomes in diabetic patients with non-ST elevation acute coronary syndrome (NSTE-ACS) who are in stable condition at hospital admission. METHODS AND RESULTS: The ISACS-TC database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Patients with cardiac arrest, hemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using logistic regression and inverse probability of treatment weighting models. Primary outcome measure was all cause 30-day mortality. Risk ratios (RRs) and odds ratios (ORs) with their 95% CIs were employed. Of the 7,589 NSTE-ACS patients identified, 2,343 were diabetics. The data show a notable reduction in mortality for the elderly (> 65 years) undergoing early revascularization compared to those receiving an initial conservative strategy both in the diabetic (3.3% versus 6.7%; RR: 0.48; 95% CI: 0.28-0.80) and nondiabetic patients (2.7% versus 4.7%: RR: 0.57; 95% CI: 0.36-0.90). In multivariate analyses, diabetes was a strong independent predictor of mortality in the elderly (OR: 1.43; 95% CI: 1.03-1.99), but not in the younger patients OR: 1.04; 95% CI: 0.53-2.06). CONCLUSIONS: Early coronary revascularization does not lead to any survival advantage within 30 days from admission in young NSTE-ACS patients who present to hospital in stable conditions with and without diabetes. An early invasive management strategy may be best reserved for the elderly. Factors beyond revascularization are of considerable importance for outcome in elderly diabetic subjects with NSTE-ACS. REGISTRATION: ClinicalTrials.gov: NCT01218776.

EAPCI Core Curriculum for Percutaneous Cardiovascular Interventions (2020): Committee for Education and Training European Association of Percutaneous Cardiovascular Interventions (EAPCI). A branch of the European Society of Cardiology.

The proposed 2020 Core Curriculum for Percutaneous Cardiovascular Interventions aims to provide an updated European consensus that defines the level of experience and knowledge in the field of percutaneous cardiovascular intervention (PCI). It promotes homogenous education and training programmes among countries, and is the cornerstone of the new EAPCI certification, designed to support the recognition of competencies at the European level and the free movement of certified specialists in the European Community. It is based on a thorough review of the ESC guidelines and of the EAPCI textbook on percutaneous interventional cardiovascular medicine. The structure of the current core curriculum evolved from previous EAPCI core curricula and from the "2013 core curriculum of the general cardiologist" to follow the current ESC recommendations for core curricula. In most subject areas, there was a wide - if not unanimous - consensus among the task force members on the training required for the interventional cardiologist of the future. The document recommends that acquisition of competence in interventional cardiology requires at least two years of postgraduate training, in addition to four years devoted to cardiology. The first part of the curriculum covers general aspects of training and is followed by a comprehensive description of the specific components in 54 chapters. Each of the chapters includes statements of the objectives, and is further subdivided into the required knowledge, skills, behaviours, and attitudes.

Depression in Survivors of Acute Myocardial Infarction.

INTRODUCTION: There was growing evidence of increased cardiovascular risk in patients with depressive disorders. AIM: To determinate the percentage of depression of the three investigated groups of patients with myocardial infarction and to determinate the correlation between sociodemographic characteristic and level of depression in survivors of AMI. METHODS: The study was designed as observation cross-section including 120 patients treated at the University Clinic of Cardiology Skopje during 2018-2019 year, observed as 3 groups: group 1 was presented with patients during hospitalization for AMI, group 2 were patients survivors after 3 months of the acute coronary event and group 3 patients survivors after 12 months of the acute coronary event, Depression status was assessed using BDI. RESULTS: the three groups presented almost equal representation of depression according BDI (X²=1,182, df=2, p=0,913) presented with 34,1 %, 30,8% and 30% respectively. The three groups of patients did not show significant difference according distribution of gender smoking , physical activity, stress, diabetes mellitus, age, mean BDI, BMI, Systolic BP, age of education and marital status . Only group 3 presented significantly higher diastole BP comparing in group 1 and group 2 (F=9,532, df=2,p< 0,001). The depression (BDI score) in examination groups was associated with sociodemographic and clinical parameters where female gender, higher education level, decreased BMI, smoking, decreased physical activity, younger age and single status are independent predictors of depression in patients who survived acute myocardial infarction. CONCLUSION: The results obtained in our study showed indicative representation of depression in patients survivors of AMI and significant association with sociodemographic and clinical parameters as predictors of depressive disorder. Regular screening for depression in patients survivors of AMI may improve the therapy decision, prognosis and the quality of patients' life.

Macedonia: coronary and structural heart interventions from 2010 to 2015.

The aim of this report is to describe invasive cardiology procedural practice in Macedonia during the period from 2010 to 2015. Details of all consecutive 39,899 patients who underwent cardiovascular, peripheral or structural heart procedures during the period from 2010 until 2015 were examined. Clinical and procedure characteristics, access site, procedural success and complications were analysed. The number of coronary angiographies increased from 5,540 in 2010 to 8,550 in 2015. Transfemoral access (TFA) was present in 4% of coronary angiographies in 2010 and had decreased to 1% in 2015. The number of primary percutaneous coronary interventions (PCI) for acute ST-segment elevation myocardial infarction increased from 763 to 1,175 and both chronic total occlusion and left main coronary artery interventions also increased over time. In 2015, the drug-eluting stent penetration rate was 65%. Structural heart interventions, including transcatheter aortic valve implantations (TAVI) were introduced in 2014 and 23 TAVI cases have since been performed. Transradial access was performed in 38,455 (96%) of all patients. Wrist access adoption in the majority of cardiovascular interventions is possible in all PCI centres in Europe if an appropriate national strategy is developed.

Transradial versus transfemoral access for female patients who underwent primary PCI in STEMI: Two years follow-up data from acute STEMI interventional registry.

BACKGROUND: Female patients possess a higher risk for poorer outcome in ST segment elevation myocardial infarction (STEMI). There is possibility that transradial access (TRA) for primary percutaneous coronary intervention (PPCI) could provide better outcome than transfemoral access (TFA) in female patients with STEMI. METHODS: From 2008 to 2010, 418 female patients (out of 1808 patients) underwent PPCI for acute STEMI. The registry recruited all-comers patients with acute STEMI. Cardiac mortality, major bleeding, and overall MACE rates (composite of death, stroke, re MI and target vessel revascularization-TVR) after 2years follow-up were compared between TRA and TFA. RESULTS: TRA for PPCI was performed in 261 patients and 157 underwent TFA PPCI. The 30-days, 1year mortality and 2year mortality rates were lower in TRA compared to TFA (6.9% vs.14.6%, p=0.012, 8.8% vs. 15.3%, p=0.045, and 9.2% vs. 16.6%, p=0.027respectively). After 2years follow-up, the overall MACE rates were similar (26.4% vs. 31.2%, p=0.336). The overall major bleeding and major vascular access site bleeding were more favorable for TRA than TFA (4.4 vs. 14%, p<0.001, and 2.7 vs. 10.8%, p<0.001, respectively). CONCLUSION: Transradial access for primary PCI in female patients provided better clinical outcomes with lower cardiac mortality and reduced major bleeding in comparison to TFA. There was no significant difference at 2years MACE between TRA and TFA.

First Bioresorbable Vascular Scaffold Implantation in Patients with Acute Coronary Syndrome in the Republic of Macedonia.

BACKGROUND: The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia. These high-risk manifestations of coronary atherosclerosis are important causes of the use of emergency medical care and hospitalization. We evaluated the feasibility and the acute performance of the everolimus-eluting bioresorbable vascular scaffolds (BVS) for the treatment of patients presenting with ACS. METHODS AND RESULTS: The present investigation was a prospective, single-centre study. Clinical outcomes were reported at the 30-day, 6-month, 1 year and 2 years follow-up. The procedural success was 100.0%. After the BVS implantation a TIMI flow 3 was achieved in all 15 patients and the postprocedure percentage diameter stenosis was 16.4 ± 8.6%. No patients had angiographically visible residual thrombus at the end of the procedure. Optical coherence tomography (OCT) analysis was performed in 8 patients (53.3%) and showed that the post-procedure mean lumen area was 7.86 ± 1.81 mm(2), minimum lumen area 5.51 ± 1.58 mm(2). At the 30-day, 6-month, 1 year (15 patients) and 2 years follow-up (5 patients) target-lesion failure rate was 0%. Non-target vessel revascularization and target vessel myocardial infarction were not reported. No cases of cardiac death or scaffold thrombosis were observed. CONCLUSION: BVS implantation in patients presenting with ACS appeared feasible, with high rate of final TIMI-flow 3 and good scaffold apposition.

Aortic root and extensive coronary dissections complicating recanalization of chronic right coronary artery occlusion: refraining from stenting may have a favorable outcome!

Aortic root dissection is a rare, potentially life-threatening complication of revascularization procedures. We report a case of recanalization of chronic total occlusion of the right coronary artery. A huge coronary dissection with a false lumen was created using commercially available guidewires during attempts to establish a connection with the distal true vessel lumen. In addition, an aortic root dissection from the right coronary cusp occurred. The patient was asymptomatic and a decision was made to refrain from stent deployment in order not to close communications between the false, true lumen and branches. The hospital stay was uneventful and the patient was discharged on conservative management. Control angiography at 3 months revealed patency of the right coronary artery with complete healing of the aortic wall dissection and improved clinical status of the patient.

Complete transitioning to the radial approach for primary percutaneous coronary intervention: a real-world single-center registry of 1808 consecutive patients with acute ST-elevation myocardial infarction.

OBJECTIVES: To compare the short- and long-term outcomes of transradial approach (TRA) versus transfemoral approach (TFA) for primary percutaneous coronary intervention (PPCI) during a complete institutional transition from TFA to TRA. METHODS AND RESULTS: An all-comer population of ST-elevation myocardial infarction (STEMI) patients (n=1808) who underwent PPCI using TRA (n=1162) and TFA (n=646) from October 2007 to December 2010 were enrolled. TRA was used in 25% of PPCIs by 2007 and in 96% of PPCIs in 2010. Primary endpoints were cardiovascular death and major adverse cardiac event (MACE), defined as a composite of death, stroke, reinfarction, and target vessel revascularization at 30 days and 1 year. At 30 days, TRA compared to TFA was associated with a significant reduction of cardiovascular mortality (5.2% vs 10.5%; P<.001), significant MACE reduction (7.3% vs 12.5%; P<.001), fewer access-site complications (0.9% vs 8.2%; P<.001), and lower TIMI major bleeding (1.1% vs 4.3%; P<.001). At 1 year, the cardiovascular mortality and MACE rates were also in favor of the TRA group (6.9% vs 11.5%; P<.001 and 11.6% vs 20.1%; P<.001), respectively. CONCLUSION: Complete transition from femoral access to a preferred radial access is safe and effective for STEMI patients undergoing PPCI, with a favorable effect on short- and long-term outcomes.

Distal embolization at the site of a stenotic distal anastomosis of a saphenous vein graft, leading to dye entrapment.

This case report describes the entrapment of contrast media after recanalization of a recently occluded saphenous vein graft with balloon predilation, thrombectomy and stent implantation. Recanalization of the respective coronary artery was performed, and the entrapped contrast media within the saphenous vein graft progressed to the left circumflex artery.