Hospital results of endovascular treatment of patients with Acute Coronary Syndrome (ACS) through distal radial access

Abstract Background Radial access is traditionally the first line method for percutaneous coronary interventions (PCI). However, it has its drawbacks. Recently a new distal radial approach (DRA) has been proposed. The results of using this method in patients with ACS are not defined. Aim of this study To evaluate the safety, efficacy and hospital outcomes ot treatment of patients with ACS using DRA during PCI as compared to traditional radial access (TRA). Materials and methods A single-center randomized trial included 264 people who underwent PCI in the period from November 2018 to May 2019 at our clinic. The proportion of patients with unstable angina was 60.6% (n=160), with acute myocardial infarction 39.4% (n=104). Patients were divided into 2 groups: in the 1st gr. (n=132) was used DRA, in the control 2nd gr. (n=132) - TRA. The studied groups were comparable according to the initial clinical and angiographic data. All interventions were performed by experienced endovascular cardiologists who perform more than 300 PCI per year. Statistical methods We used a program Statistica 6.0, v. 15, Pearson's criterion, Fisher's exact test, t-test. Results During PCI, 228 drug-coated stents were implanted in 104 patients. 10 patients had access conversion during PCI: from DRA to TRA in 3 patients, to femoral access - in 4 (the total number of conversions from DRA was 5.3%), from transradial to femoral in 3 people (2.3%), and therefore in the 1st group left 125 patients for observation, in the second - 129, respectively. The average puncture time was 125.1±11.9 sec. in the 1 gr. and 58.8±8.2 sec. in the 2 gr. (p≤0.00005). There was no difference in the total execution time of PCI: 30.5±7.1 min. in the 1 gr. and 29.4±4.6 min. in the 2 gr. (p≥0.1428). The duration of hemostasis was significantly higher in the TRA group: 354.2±28.1 min. against 125.4±15.3 min. in the 1 gr. (p≤0.00005). In the DRA group, there was a lower incidence of hematomas: in 1 patient (0.8%) versus 9 (7.0%) in the TRA group (p=0.019), radial artery spasm: in 7 patients (5.6%) versus 17 (13.2%) in the 2 gr. (p=0.039) and thrombosis at the access site: occlusion radial artery was observed only in 1 patient (0.8%) in the DRA group, while in the TRA group - in 8 (6.2%), p=0.036. The frequency of Major Adverse Cardiac Events (MACE) in the studied groups at the hospital stage was similar: 2.4% of cases (n=3) in the 1st gr. and 2.3% (n=3) in the 2nd group (p=1.0). Conclusions Our one-center prospective study showed: The use of distal radial access does not extend the overall procedure time compared to transradial approach. The frequency of major complications is comparable in the two studied groups. We noted a significantly lower frequency of local complications when using DRA compared to TRA. So, distal radial approach may be an alternative to transradial access, however, large randomized trials are needed for a final conclusion. Funding Acknowledgement Type of funding source: None

Download Full-text

Abstract 374: Trans-radial Access Angiography Learning Curve

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.374 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Julian Chan ◽

Rosanna Tavella ◽

John F Beltrame ◽

Matthew Worthley ◽

Sivabaskari Pasupathy ◽

...

Keyword(s):

Coronary Angiography ◽

Learning Curve ◽

Radial Artery ◽

Vascular Access ◽

Best Practice ◽

Femoral Access ◽

Coronary Syndrome ◽

Radial Access ◽

Increased Risk ◽

Radial Operators

Introduction: Radial artery access has been adopted widely around the world as standard best practice for coronary angiography with or without percutaneous coronary intervention. Radial artery access offers benefits in regard to reduced major bleeding, reduced hospital stay, fewer vascular complications, similar procedural times, patient preference and a mortality benefit in acute coronary syndrome/STEMI management. Despite transradial access being best practice, there has been a slow uptake of this technique amongst some cardiologists/interventionalists, particularly in the USA. This may partially be attributed to uncertainties regarding the learning curve and concerns regarding delaying treatment in STEMI if radial access fails. Methods: Using the data from the Coronary Angiography Database Of South Australia registry (CADOSA), we sought to determine the radial access failure rates for acute cases during transition from routine femoral access to routine radial access from 2012 to 2016, a period when the greatest transition in practice occurred. Data regarding initial vascular access, success or failure, and subsequent vascular access was prospectively recorded for all cases. Operators with at least a 70% rate of initial radial access were deemed to be established radial operators and acted as controls for operators transitioning from femoral access (at least 70% of cases) to radial access during the study period. Cases were further classified as elective, urgent (eg inpatient ACS) or emergency (eg STEMI). Results: There were 23 operators with sufficient volumes, responsible for 20,073 cath lab visits during the 5 year period studied. The overall radial access rate increased from 57% in 2012 to 78% in 2016. For operators transitioning from a default femoral access (76% of case) to a default radial access (75% of cases), the radial access failure rate for urgent and emergency cases was 3.7%, compared to 3.5% for experienced radial operators over the same period. Conclusion: Despite strong evidence of benefit for radial access angiography and intervention, compared to femoral access, some operators remain reluctant to transition. Utilising the CADOSA database, we observed a safe transition from femoral to radial access without an increased risk of access site failure for acute cases. Transition from femoral to radial access can be made safely by a range of clinicians managing acute cases.

Download Full-text

P4597Impact of operator experience with radial approach for clinical outcome on percutaneous coronary intervention in acute coronary syndrome performed with femoral artery access site

European Heart Journal ◽

10.1093/eurheartj/ehz745.0981 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T Tokarek ◽

A Dziewierz ◽

K Plens ◽

T Rakowski ◽

M Zabojszcz ◽

...

Keyword(s):

Percutaneous Coronary Intervention ◽

Acute Coronary Syndrome ◽

Radial Artery ◽

Femoral Artery ◽

Coronary Intervention ◽

Access Site ◽

Radial Approach ◽

Coronary Syndrome ◽

Radial Access ◽

Percutaneous Coronary

Abstract Introduction Radial approach (RA) for percutaneous coronary intervention (PCI) is associated with reduced mortality and access site complications. The routine use of the RA in patients should be strongly considered, keeping in mind the learning curve associated with the technique. However, promotion of RA may interfere with the equally important goal of maintaining proficiency in the femoral approach (FA), which is essential in a variety of procedures as well as when RA fails. There is possible risk of higher rate of complications in PCI with FA performed by operators mainly using radial artery as access site. Purpose The aim of this study was to evaluate impact of experience and proficiency with RA for clinical outcomes on PCI via FA in “real-world” patients with acute coronary syndrome (ACS). Methods A total of 539 invasive cardiologists performing PCI in 151 invasive cardiology centers on the Polish territory between 2014 and 2017 were included in study analysis. Proficiency threshold has been set at >400 procedures during four consecutive years per individual operator. They were categorized to quartiles according to total volume of radial artery utilization during all PCIs. Procedures performed on patients with Killip-Kimball class IV on admission to catheterisation laboratory were excluded from analysis. Results The most of the operators performed >75% of all procedures via radial artery (326 (60.5%)), 112 (20.8%) used RA in 50–75% of cases, 67 (12.4%) in 25–50% of all PCIs and only 34 (6.3%) invasive cardiologist were using RA in less than 25% of all procedures. Mortality during PCI via FA was higher in group of invasive cardiologist with >75% of all procedures performed with radial access (>75% vs. 50–75% vs. 25–50% vs. <25%: 1.63% (±2.52%) vs. 0.93% (±1.05%) vs. 0.68% (±0.73%) vs. 0.31% (±0.40%); p=0.01). A trend towards higher rate of bleeding at the puncture site during PCI procedures with femoral artery were reported in groups of operators with higher expertise in RA (>75% vs. 50–75% vs. 25–50% vs. <25%: 0.43% (±1.09%) vs. 0.14% (±0.36%) vs. 0.21% (±0.45%) vs. 0.14% (±0.37%); p=0.09). Conclusions Higher experience in radial access might be linked to worse outcome in PCI via FA in ACS settings. Femoral artery is important vascular approach and should not be abandoned while learning procedures with radial artery utilization. Acknowledgement/Funding None

Download Full-text

Association Between Radial Versus Femoral Access for Percutaneous Coronary Intervention and Long‐Term Mortality

Journal of the American Heart Association ◽

10.1161/jaha.121.021256 ◽

2021 ◽

Author(s):

Andrew Kei‐Yan Ng ◽

Pauline Yeung Ng ◽

April Ip ◽

Man‐Hong Jim ◽

Chung‐Wah Siu

Keyword(s):

Percutaneous Coronary Intervention ◽

Coronary Intervention ◽

Cardiac Events ◽

Femoral Access ◽

Arterial Access ◽

Radial Access ◽

Adverse Cardiac Events ◽

Percutaneous Coronary ◽

All Cause Mortality

Background Percutaneous coronary intervention with radial arterial access has been associated with fewer occurrences of major bleeding. However, published data on the long‐term mortality and major adverse cardiac events after percutaneous coronary intervention with radial or femoral arterial access are inconclusive. Method and Results This was a territory‐wide retrospective cohort study including 26 022 patients who underwent first‐ever percutaneous coronary intervention between January 1, 2010 and December 31, 2017 in Hong Kong. Among the 14 614 patients matched by propensity score (7307 patients in each group), 558 (7.6%) and 787 (10.8%) patients died during the observation period in the radial group and femoral group, respectively, resulting in annualized all‐cause mortality rates of 2.69% and 3.87%, respectively. The radial group had a lower risk of all‐cause mortality compared with the femoral group up to 3 years after percutaneous coronary intervention (hazard ratio [HR], 0.70; 95% CI, 0.63–0.78; P <0.001). Radial access was associated with a lower risk of major adverse cardiac events (HR, 0.78; 95% CI, 0.73–0.83, P <0.001), myocardial infarction after hospital discharge (HR, 0.78; 95% CI, 0.70–0.87, P <0.001), and unplanned revascularization (HR, 0.76; 95% CI, 0.68–0.85, P <0.001). The risks of stroke were similar across the 2 groups (HR, 0.96; 95% CI, 0.82–1.13, P =0.655). Conclusions Radial access was associated with a significant reduction in all‐cause mortality at 3 years compared with femoral access. Radial access was associated with reduced risks of myocardial infarction and unplanned revascularization, but not stroke. The benefits were sustained beyond the early postoperative period.

Download Full-text

Radial versus femoral access for coronary angiography and interventions: a systematic review and meta-analysis of randomized trials

European Heart Journal ◽

10.1093/ehjci/ehaa946.2454 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Chiarito ◽

D Cao ◽

J Nicolas ◽

A Roumeliotis ◽

D Power ◽

...

Keyword(s):

Myocardial Infarction ◽

Coronary Angiography ◽

Major Bleeding ◽

Randomized Trials ◽

Significant Risk ◽

Number Needed To Treat ◽

Femoral Access ◽

Coronary Syndrome ◽

Radial Access ◽

All Cause Mortality

Abstract Background The presence of any benefits associated with radial or femoral access among patients undergoing coronary angiography and percutaneous coronary interventions (PCI) is still debated. Purpose Our aim is to provide a comprehensive quantitative appraisal of the effects of access site on the risks of stroke, myocardial infarction, and major bleeding in patients undergoing coronary angiography with or without PCI. Methods In January 2020, we searched PubMed, Embase, and meeting abstracts for randomized trials comparing radial versus femoral access for coronary angiography with or without subsequent PCI. Odds ratios (OR) were used as metric of choice for treatment effects with random-effects models. Co-primary efficacy endpoints were stroke and myocardial infarction. Primary safety endpoint was major bleeding. Secondary endpoints were all cause mortality and vascular complications. Heterogeneity was assessed with the I-squared index. This study is registered with PROSPERO. Results We identified 31 trials, including 30,414 patients. Risks of stroke (OR 1.11, 95% CI 0.76–1.64, I2=0%) and myocardial infarction (OR 0.90, 95% CI 0.79–1.03, I2=0%) were comparable between radial and femoral access. Radial access was associated with a reduction for the risk of major bleeding as compared to femoral access (OR 0.53, 95% CI 0.42–0.67, I2=3.3%) with a number needed to treat of 92. Findings were consistent regardless clinical features and procedure performed, with the only exception of an increased benefit of the radial access in patients with chronic coronary syndrome (p forinteraction=0.005). The risk for all-cause mortality (OR 0.73, 95% CI 0.61–0.89, I2=0%) and vascular complication (OR 0.32, 95% CI 0.23–0.44, I2=16.7%) was significantly lower in the radial compared to femoral access group. Conclusions In patients undergoing coronary angiography with or without PCI, radial compared to femoral access did not reduce the risk of stroke and myocardial infarction, with no impact on the effect estimates of clinical presentation, age, gender, or subsequent PCI. Whereas, radial access is associated with a significant risk reduction of major bleeding as compared to femoral access. The benefit favoring radial access is of important clinical relevance in view of the relatively low number needed to treat to prevent a major bleeding and the significant impact on mortality. Funding Acknowledgement Type of funding source: None

Download Full-text

Radial artery occlusion after primary percutaneous coronary interventions performed using different radial approaches

Patologiya krovoobrashcheniya i kardiokhirurgiya ◽

10.21688/1681-3472-2020-3s-33-42 ◽

2020 ◽

Vol 24 (3S) ◽

pp. 33

Author(s):

R. V. Akhramovich ◽

S. P. Semitko ◽

A. V. Azarov ◽

I. S. Melnichenko ◽

A. I. Analeev ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Radial Artery ◽

Artery Occlusion ◽

Percutaneous Coronary Interventions ◽

Radial Approach ◽

Coronary Syndrome ◽

Coronary Interventions ◽

Percutaneous Coronary ◽

Radial Artery Occlusion ◽

Approach Group

Aim. The analyses of radial artery patency during hospitalisation in patients with acute coronary syndrome after percutaneous coronary interventions were performed using three options of radial approaches, i.e. traditional, classical and dorsopalmar distal radial approaches.Methods. Patients (n = 178) with acute coronary syndrome on whom endovascular procedure by the traditional and two options of distal radial approach were performed met the entry criteria. The classical distal radial approach was performed within an anatomic snuffbox in 65 patients (36.5%), and the dorsopalmar type was performed in 29 patients (16.3%); the traditional radial approach was performed in 84 patients (47.2%). On completion of the percutaneous coronary interventions and final radial artery angiography, hemostasis was performed with bandage application for 6 h. From the 5th to the 7th day after intervention, examination, palpation and ultrasound duplex scan were performed in every patient.Results. Examination, palpation and ultrasound duplex scan performed from the 5th to 7th day after intervention revealed 3 cases (1.7%) of forearm radial artery occlusion (high type). All the 3 cases were in the traditional radial approach group. Access side radial artery occlusion (at the anatomical snuffbox and the dorsum of the plant [local type]) with saved blood supplement on the forearm was registered in the classical distal radial approach group in 4 cases (2.3%). There were no cases of access side radial artery occlusion in the dorsopalmar group.Conclusion. The use of the distal radial approach for primary percutaneous coronary intervention in patients with acute coronary syndrome definitely reduces the risk of radial artery occlusion of the forearm, whereas the dorsopalmar distal radial approach can be considered as a basic approach.Received 11 May 2020. Revised 31 May 2020. Accepted 3 June 2020.Funding: The study did not have sponsorship.Conflict of interest: Authors declare no conflict of interest.Author contributions Conception and design: S.P. Semitko, R.V. Akhramovich Data collection and analysis: R.V. Akhramovich, I.S. Melnichenko Drafting the article: R.V. Akhramovich Critical revision of the article: S.P. Semitko Final approval of the version to be published: R.V. Akhramovich, S.P. Semitko, A.V. Azarov, I.S. Melnichenko, A.I. Analeev, I.E. Chernyisheva, A.A. Tretyakov, D.G. Ioseliani

Download Full-text

Abstract 2602: Elevated Serum Neopterin Levels and Adverse Cardiac Events in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome

Circulation ◽

10.1161/circ.116.suppl_16.ii_576-b ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Juan Carlos Kaski ◽

Luciano Consuegra-Sanchez ◽

Daniel J. Fernandez-Berges ◽

Jose M Cruz-Fernandez ◽

Xavier Garcia-Moll ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Unstable Angina ◽

Elevated Serum ◽

Cardiac Events ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Adverse Cardiac Events ◽

Elevation Acute Coronary Syndrome

Objectives: We sought to assess whether plasma neopterin predicts adverse clinical outcomes in patients with NSTEACS. Background: Circulating C reactive protein (CRP), a marker of inflammation, correlates with events in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). High neopterin levels - a marker of macrophage activation - predict cardiovascular events in stable angina patients but their prognostic role in NSTEACS has not been systematically evaluated. Methods: We prospectively assessed 397 patients (74 % men) admitted with NSTEACS: 169 (42.5%) had unstable angina and 228 (57.5%) non-ST-segment elevation myocardial infarction (NSTEMI). Blood samples for neopterin and CRP assessment were obtained at admission. TIMI risk score was also assessed among other clinical and biochemical variables. The study end point was the composite of cardiac death, acute myocardial infarction and recurrent angina at 180-days. Results: Baseline neopterin concentrations (nmol/L) were similar in unstable angina and NSTEMI patients (8.3 [6.5–10.6] vs 8.0 [6.2–11.1], p = 0.54). Fifty-nine patients (14.9 %) had events during follow-up (highest third (%) 21.5 vs 1 st and 2 nd thirds 11.5, log rank 7.341, p = 0.007). On multivariable hazard Cox regression, only neopterin (highest vs 1 st and 2 nd thirds, HR 2.15, 95 % CI [1.21–3.81]) was independently associated with the combined endpoint.CRP levels, however, were not significantly different in patients with events compared to those without events (adjusted HR = 0.98, p = 0.89, 95% CI 0.80 –1.21). Conclusion: Increased neopterin levels are an independent predictor of 180-day adverse cardiac events in patients with NSTEACS.

Download Full-text

Abstract 17406: Early Experience With Ultrasound Guided Distal Trans-Radial Access in the Anatomical Snuffbox in Coronary Angiography and Intervention

Circulation ◽

10.1161/circ.138.suppl_1.17406 ◽

2018 ◽

Vol 138 (Suppl_1) ◽

Author(s):

Sangyeub Lee ◽

Woong-su Yoon ◽

Daehwan Bae ◽

Min Kim ◽

Sang Min Kim ◽

...

Keyword(s):

Coronary Angiography ◽

Success Rate ◽

Radial Artery ◽

Early Experience ◽

Coronary Intervention ◽

Ultra Sound ◽

Potential Candidate ◽

Ultrasound Guided ◽

Radial Approach ◽

Radial Access

Early experience with ultrasound guided distal trans-radial access in the anatomical snuffbox in coronary angiography and intervention. Objective: We aimed to demonstrate the feasibility and safety of the ultrasound guided distal trans-radial coronary angiography and intervention. Methods: Patients assigned to one operator program underwent diagnostic or procedural intervention through distal trans-radial approach in the anatomical snuffbox between January 2018 and May 2018. All of patients had palpable artery in their distal radial artery. The operator did the coronary procedure via distal radial access at anatomical snuffbox. When the pulse was weak or the target artery was very small, the operator punctured under ultrasound guidance (V-scan with dual probe, GE heathcare, USA) Results: 56 patients were enrolled. Mean age of patients was 65.1 years old and 68% were male. About 70% of patients were presented with stable angina feature. In diagnostic procedure, 4F (3, 5.6%) or 5F (29, 54.7%) sheath was used and we did coronary intervention via 6F (21, 39.6%) Sheath. Ultrasound guided puncture was done for 33 patients (58.9%). Overall Success rate of distal trans-radial angiography and intervention was 94.6% (3 failed cases). Success rate of ultrasound guided procedure was 97% (only 1 failed case). Left distal radial puncture was done for 18 patients (33.9%). 16% of patients had chronic kidney disease, especially end stage renal disease (11%) to preserve radial artery which was potential candidate of arteriovenous fistulae for dialysis. There was no BARC type 2-5 bleeding in hospital stay and follow up at out-patient clinic. Conclusion: Ultra sound guided distal radial approach is feasible and safe as a good alternative technique for coronary angiography and interventions.

Download Full-text

Abstract 16260: Thirty Days Major Adverse Cardiac Events Following Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Non-ste-acute Coronary Syndrome: A Meta-analysis With Meta-regression

Circulation ◽

10.1161/circ.142.suppl_3.16260 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Kiro Barssoum ◽

Ashish Kumar ◽

Devesh Rai ◽

Adnan Kharsa ◽

Medhat Chowdhury ◽

...

Keyword(s):

Coronary Artery ◽

Meta Analysis ◽

Artery Bypass ◽

Coronary Intervention ◽

Cardiac Events ◽

Coronary Syndrome ◽

Adverse Cardiac Events ◽

History Of ◽

Meta Regression ◽

Meta Regression Analysis

Background: The optimum revascularization modality in multi-vessel and left main disease patients presenting with non-ST elevation acute coronary syndrome (non-STE-ACS) is not well studied. The current recommendations are based on studies that primarily included patients with stable angina. Patients with non-STE-ACS were under-represented in clinical trials. We performed a meta-analysis of studies comparing coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in non-STE-ACS, and reporting 30 days major adverse cardiac events (MACE). Methods: We searched Medline, EmCare, CINAHL, Cochrane database, and Google Scholar for relevant articles. We excluded studies that included patients with stable coronary artery disease and ST elevation myocardial infarction. Our primary outcome was 30 days MACE defined as all-cause death, stroke, repeat revascularization and re-infarction. We used the Paule-Mandel method with the Hartung-Knapp-Sidik-Jonkman adjustment to estimate risk ratio (RR) with a 95% confidence interval (CI). Heterogeneity was assessed using Higgin’s I 2 statistics. To account for heterogeneity, a meta-regression analysis was performed. Results: Five observational studies met our inclusion criteria summing to a total number of 7161 patients. At 30 days, there was no difference between CABG vs. PCI in terms of MACE, RR: 0.96, 95% CI 0.38 to 2.39, I 2 = 81% (Panel A). A meta-regression analysis reported that a history of PCI was associated with a lower risk of MACE with CABG compared to PCI (Panel B). Conclusion: At 30 days, there was no difference in MACE between the CABG and PCI groups. However, a history of PCI was associated with a lower risk of MACE in patients who underwent CABG.

Download Full-text