Extremity Dysfunction After Large‐Bore Radial and Femoral Arterial Access

Background The use of large‐bore (LB) arterial access and guiding catheters has been advocated for complex percutaneous coronary intervention. However, the impact of LB transradial access (TRA) and transfemoral access (TFA) on extremity dysfunction is currently unknown. Methods and Results The predefined substudy of the COLOR (Complex Large‐Bore Radial PCI) trial aimed to assess upper and lower‐extremity dysfunction after LB radial and femoral access. Upper‐extremity function was assessed in LB TRA‐treated patients by the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire and lower‐extremity function in LB TFA‐treated patients by the Lower Extremity Functional Scale questionnaire. Extremity pain and effect of access site complications and risk factors on extremity dysfunction was also analyzed. There were 343 patients who completed analyzable questionnaires. Overall, upper and lower‐extremity function did not decrease over time when LB TRA and TFA were used for complex percutaneous coronary intervention, as represented by the median Quick Disabilities of the Arm, Shoulder, and Hand score (6.8 at baseline and 2.1 at follow‐up, higher is worse) and Lower Extremity Functional Scale score (56 at baseline and 58 at follow‐up, lower is worse). Clinically relevant extremity dysfunction occurred in 6% after TRA and 9% after TFA. A trend for more pronounced upper‐limb dysfunction was present in female patients after LB TRA ( P =0.05). Lower‐extremity pain at discharge was significantly higher in patients with femoral access site complications ( P =0.02). Conclusions Following LB TRA and TFA, self‐reported upper and lower‐limb function did not decrease over time in the majority of patients. Clinically relevant limb dysfunction occurs in a small minority of patients regardless of radial or femoral access. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03846752.

Acceptance and safety of femoral versus radial access for percutaneous coronary intervention (PCI): results from a large monitor-controlled German registry (QuIK)

Background In 2015 and 2018, European Society of Cardiology guidelines for percutaneous coronary intervention (PCI) favoring radial access over femoral access were published. These recommendations were based on randomized trials suggesting that patients treated radially experienced reduced bleeding complications and all-cause mortality. We aimed to assess acceptance and results of radial access in a real-world scenario by analyzing all PCI cases in the Quality Assurance in Invasive Cardiology (QuIK) registry. Methods The QuIK registry prospectively collects data on all diagnostic and interventional coronary procedures from 148 private practice cardiology centers in Germany. Major adverse cardiac and cerebrovascular events (MACE) were defined as myocardial infarction, stroke, or death during hospitalization. Results From 2012 to 2018, 189,917 patients underwent PCI via either access method. The rate of radial approach steadily increased from 13 to 49%. The groups did not differ significantly with respect to age or extent of coronary disease. Femoral approach was significantly more common in patients with ST elevation myocardial infarction and cardiogenic shock. Overall, there were significant differences in MACE (radial 0.12%; femoral 0.24%; p < 0.0009) and access site complications (radial 0.2%; femoral 0.8% (p < 0.0009). Conclusion Our data reveals an increase in use of radial access in recent years in Germany. The radial approach emerged as favorable regarding MACE in non-myocardial infarction patients, as well as favorable regarding access site complication regardless of indication for percutaneous intervention.

After A Year of Follow Up Non-Cirrhotic Portal Hypertension Patient with Partial Spleen Embolization (PSE) Management

Non-cirrhotic portal hypertension (NCPH) is a heterogeneous group of liver disorders leading to portal hypertension. There are multiple approaches to managing portal hypertension' clinical complications to treat/prevent spontaneous hemorrhage by mitigating thrombocytopenia. Portal hypertension complications have been traditionally managed with serial endoscopic variceal ligation (EVL) or with invasive open surgical procedures such as orthotopic liver transplantation (OLT) or portosystemic shunting, splenectomy.6–9 There are several risks associated with splenectomies, such as hemorrhagic complications or intraoperative blood loss.5,6,14 Partial Spleen Embolization (PSE) ‎may overcome the limitations of splenectomy and provide patients with an alternative treatment. An eighteen-year-old male has a splenomegaly history since he was 12 years old and has recurring hematemesis and melena. After performing abdominal computed tomography, laboratory studies, and several endoscopies, the results indicated secondary hypersplenism due to non-cirrhotic portal hypertension. The patient had 13 endoscopies and 2 EVL in 5 years. Despite adequate treatment, the patients developed recurrent variceal bleeding and no improvement in blood function. The patient underwent PSE at Integrated Cardiovascular Center in Dr. Cipto Mangunkusumo, General Hospital, Jakarta, Indonesia. It was performed through the femoral access with a PVA (polyvinyl alcohol) embolus. The procedure went successful, and there was no major complication with the patient. Twenty days after the patient had an abdominal CT scan, it showed no abscess, and the spleen volume was reduced by 20%. Long-term results over a year after the procedure are presented. PSE is a safe, effective, semi-invasive alternative to splenectomy in non-cirrhotic portal hypertension because it preserves functional spleen mass and avoids postprocedure accelerated liver disease or encephalopathy.

Dural arteriovenous fistula presenting as reversible dementia

DAVF is an abnormal connection between arteries and veins, where supply is mainly through branches arising from the external carotid artery. A 30 years old male had multiple episodes of seizures and progressive behavioral and cognitive decline, inattention and disorientation to time, place and person, along with ptosis and ophthalmoplegia in the right eye. DSA provided a definitive diagnosis of hypervascular Dural AV fistula at the right transverse sigmoid junction with significant cortical venous hypertension. Through femoral access, both underwent transarterial embolization through the Middle Meningeal branch of the right external carotid artery using onyx, resulting in complete occlusion of fistula and resolution of venous hypertension. Post embolisation, cognitive function assessment revealed increased attention span and improved orientation with time, place and person. Thus, DAVF can be one of the rare but reversible causes of dementia. Early diagnosis and treatment may help to dramatically improve patients’ clinical condition and minimize long-term disability.

Successful Left Atrial Appendage Closure with Watchman Device Implantation in Two Patients with Inferior Vena Cava Filters

Percutaneous procedures through femoral access in patients with inferior vena cava (IVC) filter may be at risk of complications. We evaluated the feasibility and safety of left atrial appendage closure (LAAC) through femoral access in patients previously implanted with IVC filter. We described the WatchmanTM device implantation in two patients with formal contraindication for oral anticoagulation. First patient had a GreenfieldTM filter and the second one an OpteaseTM filter, and in this patient an attempt to withdrawal the filter immediately before the LAAC procedure failed. A femoral approach was performed in both patients using a 14 Fr sheath. Before crossing IVC filters, venographies did not detect any thrombus. All steps of IVC filter crossing were performed under fluoroscopic guidance. No immediate or intrahospital complications related to the procedure occurred. Herein, we presented two cases of successful LAAC closure with Watchman device in patients with two different kinds of IVC filters.

Influence of polyvascular disease on clinical outcome in patients undergoing transcatheter aortic valve implantation via transfemoral access

Background The influence of polyvascular disease (PVD) on the short- and long-term clinical outcomes of patients undergoing transcatheter aortic valve implantation via trans-femoral access (TF-TAVI) has not been fully elucidated. Methods A total of 2167 patients from the Optimized CathEter vAlvular iNtervention-TAVI (OCEAN-TAVI) registry who underwent TF-TAVI was studied. PVD was defined as the presence of at least two of the following vascular bed (VB) diseases: concomitant coronary artery disease (CAD), cerebrovascular disease (CVD), and peripheral artery disease (PAD). Results Patients with PVD (288 patients, 13.3%) had a higher incidence of in-hospital complications, such as AKI (16.3% vs. 7.0%, p<0.01) and disabling stroke (3.5% vs. 1.2%, p<0.01) than patients without PVD. These complications caused higher rates of procedural mortality (4.5% vs. 2.0%, p<0.01). PVD increased the risk of the 2-year rate of cardiovascular death (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.04–2.50; p<0.05); however, non-cardiovascular death, myocardial infarction, or ischemic stroke was not associated with PVD. Worsening heart failure (4.6% vs. 1.1%, p<0.01) was the main cause of cardiovascular death among patients with PVD. In a sub-analysis, compared with patients with AS alone, those with 2 VB diseases (CAD+PAD; adjusted HR, 1.93; 95% CI, 1.06–3.53; p<0.05) and 3 VB diseases (CAD+CVD+PAD; adjusted HR, 2.61; 95% CI, 1.21–5.62; p<0.05) had a higher risk of 2-year cardiovascular death. Conclusions The increased prevalence of concomitant atherosclerotic VB diseases before TF-TAVI may increase the rates of in-hospital complications and 2-year cardiovascular death. Given the higher rate of mortality in patients with PVD undergoing TF-TAVI, future studies focusing on medical therapy are needed to reduce long-term cardiovascular events in this high-risk subset.

The Most Relevant Factors Affecting the Perioperative Death Rate in Patients with Acute Coronary Syndrome and COVID-19, Based on Annual Follow-Up in the ORPKI Registry

Background: The COVID-19 pandemic is significantly affecting the functioning of the entire healthcare system. The disease itself may be associated with thromboembolic complications. The purpose of this study is to compare patients with acute coronary syndrome (ACS) and patients with ACS who were diagnosed with COVID-19 in terms of their clinical profile, management, treatment complications, and prognosis. Methods: We analyzed 47,940 cases of patients treated for ACS in 2020, including 44,952 patients (93.8%) who were not diagnosed with COVID-19 and 2988 patients (6.2%) who tested positive for COVID-19. Results: Patients with COVID-19 were significantly more likely to experience out-of-hospital sudden cardiac arrest (7.9 vs. 1.1%; p < 0.0001) and be transported directly to a catheterization laboratory (21.3% vs. 8.1%; p < 0.0001). Mortality was significantly higher in this group (0.9% vs. 0.4%; p < 0.0001). The risk of perioperative death was increased by age over 65 years, use of glycoprotein IIb/IIIa inhibitors (GPI IIb/IIIa), femoral access, critical left main stem coronary artery (LMCA) vascular lesions, ST elevation myocardial infarction (STEMI), and no-reflow phenomenon. Conclusions: Despite the pandemic, patients with COVID-19 were treated equally to healthy patients. Efficient organization of the healthcare system allowed the prompt transportation of patients to catheterization laboratories. The study group was characterized by a worse prognosis that was affected by multiple factors.

494 Glycoprotein IIB/IIIA inhibitors may modulate the clinical benefit of radial access as compared to femoral access in primary percutaneous coronary intervention: a meta-regression and a meta-analysis of randomized trials

Aims Several randomized controlled trials (RCTs) consistently reported better clinical outcomes with radial as compared to femoral access for primary percutaneous coronary intervention (PCI). Nevertheless, heterogeneous use of potent antiplatelet drugs, such as Gp IIb/IIIa inhibitors (GPI), across different studies could have biased the results in favour of radial access. We performed an updated meta-analysis and meta-regression of RCTs in order to appraise whether the use of GPI had an impact on pooled estimates of clinical outcomes according to vascular access. Methods and results We computed pooled estimates by the random effects model for the following outcomes: mortality, major adverse cardiovascular events (death, myocardial infarction, stroke, and target vessel revascularization), and major bleedings. Additionally, we performed meta-regression analysis to investigate the impact of GPI use on pooled estimates of clinical outcomes. We analysed 14 randomized controlled trials and 11 090 patients who were treated by radial (5497) and femoral access (5593), respectively. Radial access was associated with better outcomes for mortality [risk difference 0.01 (0.00, 0.01), P = 0.03], MACE [risk difference 0.01 (0.00, 0.02), P = 0.003], and major bleedings [risk difference 0.01 (0.00, 0.02), P = 0.02]. At meta-regression, we observed a significant correlation of mortality with both GPI use (P = 0.011) and year of publication (P = 0.0073), whereas no correlation was observed with major bleedings. Conclusions In this meta-analysis, the use of radial access for primary PCI was associated with better clinical outcomes as compared to femoral access. However, the effect size on mortality was modulated by GPI rate, with greater benefit of radial access in studies with larger use of these drugs.

26 Procedural planning and tip-to-base lampoon to succeed in a complex valve-in-valve TMVR procedure

Aims Left ventricle outflow tract (LVOT) obstruction is a feared complication of transcatheter mitral valve replacement (TMVR) procedures. Multimodal imaging evaluation is the key to identify at-risk patient and select the best management. Methods and results An 83-year-old woman with a history of mitral valve replacement with a 27-mm Carpentier-Edwards bioprosthesis (Edwards Lifesciences, Irvine, CA) for rheumatic heart disease was admitted to our department complaining worsening effort dyspnoea. Clinical evaluation revealed a grade 3/6 holosystolic murmur. She underwent combined transthoracic and transesophageal echocardiography (TEE) which demonstrated mitral bioprosthesis degeneration leading to severe stenosis (mean gradient = 13 mmHg, PHT-derived area = 0.9 cm2) and moderate regurgitation, with preserved biventricular function, and severe pulmonary hypertension (pulmonary artery systolic pression = 65 mmHg). The patient presented a high estimated risk for redo-surgery (Society of Thoracic Surgeons score estimated mortality: 6%) due to her complex medical history, including advanced chronic kidney disease and permanent atrial fibrillation; therefore, she underwent evaluation for valve-in-valve TMVR. Cardiac computed tomography (CT) revealed bioprosthetic anterior leaflet in tight contact with the septum in systole; predicted neo-LVOT using virtual 26-mm Sapien S3 (Edwards Lifesciences, Irvine, CA) valve was 150 mm2, conferring a high risk of fixed LVOTO. A 26-mm Sapien S3 valve was selected based on CT derived surgical valve ID of 24 mm. After Heart Team discussion, we performed a modified LAMPOON technique to achieve tip-to-base laceration of the bioprosthetic leaflet beside the LVOT, in order to prevent LVOT obstruction. Briefly, after transseptal puncture through right femoral vein access (16 Fr), we crossed the mitral prosthesis using a balloon wedge end-hole catheter, through which we advanced a 300 cm 0.014-inch wire into the ascending aorta, where it was snared from left arterial femoral access (8 Fr) and covered by a micro-catheter. The wire was previously kinked mid-shaft to form a ‘flying-V’ that was focally denuded and positioned at the target bioprosthetic leaflet’s tip using TEE and fluoroscopy. The guidewire was pulled toward the valve ring and electrified at 70 W with continuous 5% dextrose flush until adequate tip-to-base leaflet laceration. Thereafter, we successfully implant a 26-mm Sapien S3 valve. Maximal LVOT gradient post implant was 5 mmHg. The patient was discharged on post-operative day two and she recovered well, reporting functional and symptomatic improvement at 6-month follow-up. Conclusions our case highlights the importance of multimodality imaging and careful procedural planning to succeed even in complex valve-in-valve TMVR procedures. Transcatheter electrosurgery is an emerging tool for percutaneous structural heart interventions.