Transradial access in a cath lab with moderate procedural volume: a single operator's experience.

AIM: The transradial access (TRA) for cardiovascular interventions has become increasingly popular and was shown to be effective in many clinical settings, including acute coronary syndromes. Despite offering many advantages, such as a striking reduction in access site complications, the penetration of TRA in routine practice is still low. One reason for this could be that many studies about TRA were performed in high-volume centers by expert operators, making their results not fully applicable to the real world. In order to assess the efficacy of TRA, we retrospectively reviewed the caseload of a single operator working in a community hospital with moderate procedural volume. METHODS: We considered 873 consecutive procedures, of which 406 percutaneous coronary interventions (PCI), performed by a single operator (S.R.) who had previously completed the learning curve in TRA at a high volume center. RESULTS: TRA was selected in 48.3% of patients, transfemoral approach (TFA) in 50.9% and transbrachial approach in 0.8%. TFA was used more frequently in PCI (62.5% vs 37.5%; P<0.001), largely because it was the access of choice in primary PCI. The overall procedural success rate was 94% in TRA and 98% in TFA (P=0.035); access failure was more frequent in TRA (5.9% vs 1.1%; P<0.001), whereas an increased rate of access-related vascular complications was observed in TFA as compared to TRA (1.1% vs 0%; P=0.029). CONCLUSION: After an adequate training period, the overall performance of TRA is good even in moderate-volume hospitals. Despite reducing access site complications, TRA is limited by a slightly higher rate of procedural failure as compared to TFA.

A randomized comparison between rotational and standard coronary angiography.

AIM: Selective coronary angiography is nowadays the gold standard in the definition of coronary anatomy as well as the basis for percutaneous coronary interventions. However, the diagnostic accuracy of coronary angiography can be reduced if the number of angiographic views is inadequate or if the operator does not select appropriate projections. Rotational angiography (RA) has been proposed as an alternative technique in order to provide a more complete definition of coronary anatomy reducing, at the same time, radiation exposure and contrast medium dose. METHODS: We randomly assigned 31 eligible patients, undergoing diagnostic cardiac catheterization, to RA (n=16) and traditional angiography (TA, n=15). Total procedural time, fluoroscopy time, number of cine-runs, X-ray dose and contrast medium volume were recorded in both groups. RESULTS: There were no statistically significant differences between groups in age (59+/-5.8 vs 62.8+/-9.6 years, P=ns), body mass index (26.7+/-3.5 vs 27.1+/-3.4 kg/m2, P=ns), total procedural time (20.6+/-6.6 vs 22.2+/-11.3 min, P=ns) and fluoroscopy time (3.9+/-1.5 vs 4.9+/-1.8 min, P=ns). On the contrary, number of cine-runs, X-ray dose and contrast medium volume were significantly lower in RA patients as compared with TA patients (6.2+/-1.2 vs 9.7+/-2.1, P<0.01; 530.6+/-271.6 vs 831.2+/-343.9 mGy, P<0.05; 76.9+/-22.4 vs 102.9+/-26.4 ml, P<0.01, respectively). CONCLUSIONS: RA is safe and effective in defining coronary anatomy, leading to a significant reduction in radiation exposure and contrast medium volume.

Single coronary artery, anomalous origin of the right coronary artery from the left anterior descending artery.

We present a patient with an abnormal origin of the right coronary artery from the left anterior descending artery. The patient had chest pain probably related to myocardial ischaemia. This anomaly is very rare and has previously been reported in only three cases. The abnormal vessel travelled rightwards and remained anterior to the main pulmonary artery, it was free of significant stenosis. The mechanism of anterior myocardial ischaemia remains unexplained.

[The clinical, angiographic and procedural predictors of thrombosis and restenosis in Micro stent II (AVE) coronary stents]. / Predittori clinici, angiografici e procedurali di trombosi e di restenosi in stent coronarici Micro stent II (AVE).

The aim of the study was to assess the incidence and the predictors of thrombosis and restenosis in Micro stent II AVE. In a sample of 197 stents successfully implanted in 181 consecutive patients, the incidence of thrombosis was 4.1%. The multivariate analysis showed the minimum lumen diameter post-stenting to be the only independent predictor of overall thrombosis. In fact, we found that the risk of thrombosis increases as the minimal lumen diameter decreases. Angiographic follow-up was available in 74% of the stents at 6.8 +/- 4.1 months and stent restenosis occurred in 26.2% of cases. Independent predictors of restenosis (multivariate linear discriminant analysis) were: 1) nominal stent diameter (the risk of restenosis decreases as the stent diameter increases); 2) the ratio between the diameter of the balloon carrying the stent measured at the maximum pressure/nominal stent diameter (the risk increases as the ratio decreases); 3) stented vessel (the risk increases in the following order: right coronary < circumflex < left anterior descending); 4) the American Heart Association classification of lesion morphology (the risk increases in the order A < B < C); 5) a lower risk was found in the absence of diabetes mellitus.

[The usefulness of the echo-dipyridamole test in the early period after an uncomplicated acute myocardial infarct]. / Utilità del test eco-dipiridamolo in fase precoce dopo infarto miocardico acuto non complicato.

OBJECTIVES: The aim of this study was to examine the ability of Dipyridamole Echocardiography Test (DET)--performed early after an acute myocardial infarction (AMI)--to assess: a) the presence of induced ischemia and its relation with coronary artery stenoses; b) the presence of myocardial viability and the comparison with late wall motion; c) the appearance of cardiac events during hospitalization and in the following period. METHODS: Ninety-five patients with AMI, subjected to thrombolytic therapy and without complications, underwent a DET on the 4th-5th day. All had a coronary angiography on the 8th-10th day; stenoses were deemed significative when > or = 70%. DET was carried out after drug discontinuance and following standard protocol; parietal kinesis was analyzed according to a 14 segment model. The myocardium was deemed viable when an improvement of a basal dyskinesis was noted; ischemia was considered when a new asynergy appeared or a basal dyskinesis worsened or enlarged; a wall motion score index (WMSI) was calculated. All 95 pts. had a clinical follow-up at 12 +/- 6 months (3-18); 62 pts. had a late echocardiographic examination at 6 +/- 3 months (3-15). RESULTS: Induced ischemia appeared in 59/95 pts. (62%): in 6/14 pts. (42%) without significative stenoses, in 29/49 pts. (59%) with a single vessel disease, and in 24/32 pts. (75%) with multivessel disease. In identifying multivessel disease, DET sensibility (SE) was 75% and specificity (SP) was 95-97%. In single or no vessel disease WMSI changed from 1.42 to 1.49 (p < 0.0001); in multivessel disease WMSI changed from 1.52 to 1.69 (p < 0.0001). As regards the assessment of diseased vessel(s), DET showed little accuracy when dyskinesis appeared in the basal segments of the inferior and lateral wall or in the mid-apical segments of the anterior and lateral wall; DET properly identified the culprit vessel when dyskinesis appeared in the remaining segments. Myocardial viability was noted in 26% of dyskinetic segments. In single or no vessel disease WMSI changed from 1.41 (basal--> B) to 1.35 (viability phase--> V) and was found 1.31 at the late echocardiography (L): p < 0.0001 between B and V, and between B and L. In multivessel disease WMSI changed from 1.5 (B) to 1.47 (V) and to 1.5 (L): p < 0.05 between B and V, NS between B and L. In comparison with late echocardiography, DET SE was 70%, SP 99%, positive predictive value (PPV) 97%, negative predictive value (NPV) 86%. As regards the prognostic value about cardiac events, DET SE was 80% and NPV was 78%; about only major cardiac events, the respective values are 91% and 97%. CONCLUSIONS: DET performed early after an AMI allows a better prognostic assessment, as it provides information about: a) the place and the severity of coronary artery stenoses; b) the presence and the extension of induced ischemia and of myocardial viability; c) the risk of subsequent cardiac events.