Standardized Forearm Angiography Increases Procedural Success Rates of Coronary Angiography and PCI: A Retrospective Analysis of an All-Comers Patient Cohort

Background: There is a consensus, that transradial-access (TRA) for coronary procedures should be preferred over transfemoral-access (TFA). Previously, forearm-artery-angiography was mainly performed when difficulties during the advancement of the guidewire were encountered. We explored the implication of a standardized forearm-angiography (SFA) on procedural success rates of TRA.Methods: 1191 consecutive cases were assessed retrospectively. Primary TFA rates, crossover to TFA, reasons for forearm-artery-access (FAA) failure, the prevalence of kinking at the level of the forearm and the occurrence of vascular complications were analyzed.Results: Primary FAA access was attempted in 97.9%. Crossover to TFA after a primary or secondary FAA attempt was necessary in 2.8%. Severe kinking was the most frequent cause of FAA failure and occurred in 3.0%. A second or third FAA attempt to avoid TFA was successful in 81%. Severe kinking at the level of the forearm was reported in 1.8%.Conclusion:This is the first study to provide detailed success rates of a primary FAA strategy combined with SFA. While severe kinking proved to be a rare but relevant challenge for FAA success, the prevalence of arterial spasm was marginal. Multiple attempts of FAA to avoid TFA might be safe possibly due to collateral blood supply.

High blood pressure

High blood pressure prof. J. Pal (Die rztliche Praxis, No. 6, 1929) divides into two main forms: acute and permanent; The first is arterial spasm, and the second is the hypertensive setting of the muscle cells of the arterial wall ("Die hypertonische Einstellung der Muskelzellen der Arterienwand"), in which the prearterioles and arterioles are in a tense state, functionally giving rise to blood pressure. Recent research by the author has established the fallacy of the existing opinion that any persistently high blood pressure is the result of renal tissue disease. The author distinguishes primary or essential or genuinic hypertension, which, however, can lead to a shriveled kidney. Therapeutically, acute increases in blood pressure are most effectively eliminated by chloral hydrate, heat and bloodletting, and in angina pectoris - atropine, papaverine, nitrites. The author recommends treating constant increases in blood pressure with theobromine and its various combinations, bearing in mind that theobromine dilates the vessels of the heart, kidneys and brain. Balneotherapy measures are often psychogenically beneficial. The food of such patients should be poor in purines and table salt.

Ductal arterial spasm: a nightmare

Ductal arterial spasm is a very potentially dangerous incidence during percutaneous device closure of patent ductus arteriosus (PDA), which, otherwise, is a very safe catheter intervention. It is essential to notice its occurrence before device sizing and deploying. Without awareness, it can mislead device selection and can result in serious complication. In this report, we shared our nightmare of ductal spasm during transcatheter closure of PDA in two children which had led to death in one patient.

Use of ViperSlide Lubricant to Extract Entrapped Sheath after Severe Radial Artery Spasm during Coronary Angiography

Radial artery spasm is a known complication of transradial cardiac catheterization. However, severe spasm with sheath entrapment is rare. We describe such a case, and the condition's response to an alternative removal method after conventional efforts failed. A 68-year-old man presented for coronary angiography. We introduced a 5F sheath into the right radial artery, but, because of severe arterial spasm, we could not aspirate blood from the sheath or retract it. We sedated the patient and waited for the spasm to subside; however, the radial sheath remained entrapped. Nitroglycerin injection enabled blood aspiration and vasodilator injection, but not sheath removal. Finally, we injected ViperSlide lubricant into the sheath for its rapid, easy extraction. When sedation and vasodilator therapy fail, we recommend using ViperSlide for radial sheath removal before applying nerve block or general anesthesia.

The Role of Cortical Spreading Depolarizations in Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage

Delayed cerebral ischemia (DCI) is the leading potentiallytreatable cause of mortality and disability in patients with aneurysmal subarachnoid hemorrhage (SAH). However, to date there is no effective treatment for this entity. The recently demonstrated lack of clinical response to pharmacologic reversal of arterial spasm as a result of SAH has spurred a reassessment of the pathophysiological concepts on DCI that follows SAH. DCI was long believed the consequence of the angiographically visible arterial spasm observed in patients with SAH. Since the measurement of cortical spreading depolarizations (CSD) in patients with SAH, increasing evidence has suggested a role for these phenomena in the pathophysiology of DCI. When inducedin a healthy brain, CSDs are associated with an increasein regional cerebral blood flow that facilitates the delivery ofthe necessary energy substrates for cellular repolarization. In a brain that has been injured, however, CSDs can induce microvascular constriction, or cortical spreading ischemia. This inverse hemodynamic response to CSD was first discovered in an animal model replicating the conditions following SAH, and later demonstrated in patients with SAH. The spreading ischemia leads to energy substrates shortage and hypoxia, resulting in cortical lesions, and may explain similar lesion patterns which occur in SAH patients. This review describes the salient characteristics of CSD and its potential relevance in the pathophysiology, monitoring, and treatment of ischemic complications following SAH.