Traumatic Brachial Arteriovenous Fistula - History Also Matters

Transradial intervention usually does not mandate history of arm or forearm injury; we report a case of traumatic AV fistula with focal narrowing of brachial artery for which right transradial angiogram could not be performed and coronary angiogram was accomplished from left transradial access. This rare case teaches us the fact that planning a transradial intervention also requires a history of trauma or surgical intervention to arm or forearm to avoid inadvertent complications during transradial access. Communication between an artery and a vein is known as arteriovenous fistula (AVF) which may be congenital, acquired or surgically created. Acquired arteriovenous fistula is most commonly due to traumatic injury. Following vascular injury, a hematoma develops locally, local healing and fibrosis leads to adhesion between artery and vein creating an arteriovenous fistula.1 Large arteriovenous fistula results in high output cardiac failure and rarely accounts for chronic ischaemia.2 Degree of arteriovenous shunting decides the timeframe of clinical presentation which is often subtle with delay in diagnosis. We report a case of post traumatic brachial AV fistula presenting with feeble pulse, difficult radial puncture and right transradial access failure with switch over to right transfemoral access for accomplishing coronary intervention.

Acute compartment syndrome of the forearm associated with transradial coronary intervention

This study documents our experience with acute forearm compartment syndrome after percutaneous transradial coronary artery intervention and suggests several strategies to achieve good results. A retrospective review identified the medical records of four patients with acute forearm compartment syndrome after transradial intervention who were treated by urgent fasciotomy. The mean time from the onset of symptoms to operation was 5.7 hours. In three cases bleeding was from radial artery rupture at the puncture site, and one case was caused by brachial artery rupture at the level of the distal humerus and radial artery rupture at the level of proximal forearm. We obtained satisfactory results without any complications. If acute forearm compartment syndrome after transradial intervention is diagnosed, the site of bleeding should be identified preoperatively. Early surgical decompression produced satisfactory results even in elderly patients. Level of evidence: IV

P3583Optimal procedural strategy to improve clinical outcome in primary percutaneous coronary intervention

Background Current guideline recommends potent antiplatelet agents and transradial intervention. However, it is uncertain whether routine use of IVUS, thrombus aspiration and glycoprotein IIB-IIIA inhibitor is beneficial for improving clinical outcome in patients with ST-segment elevation myocardial infarction (STEMI). Purpose The aim of this study was to investigate optimal procedural strategy to improve clinical outcome. Methods A total of 6,046 patients who underwent primary percutaneous coronary intervention (PCI) for STEMI were analyzed from the Korean Acute Myocardial Infarction Registry (KAMIR) – National Institute of Health (NIH) database. MACCEs were defined as a composition of all cause death, non-fatal MI, repeat revascularizations including repeated percutaneous coronary intervention and coronary bypass grafting, cerebrovascular accident and rehospitalizations. This research was supported by a fund by Research of Korea Centers for Disease Control and Prevention. Results During the primary PCI, potent antiplatelet agents such as prasugrel and ticagrelor were used in 2342 (38.4%). PCI was performed through transradial approach in 1490 (25.2%). Thrombus aspiration and intravascular ultrasound (IVUS) examination was done in 2204 (36.1%) and 1079 (18.1%), respectively. Glycoprotein IIB-IIIA inhibitor was administered in 1295 (21.7%). Among them, potent antiplatelet agents, transradial intervention, IVUS, and thrombus aspiration significantly reduced MACCEs at 1 year. Glycoprotein IIB-IIIA inhibitor was not effective to improved clinical outcome. In Cox-proportional hazards model, potent antiplatelet agents (hazard ratio 0.82, 95% confidence interval 0.67–0.99; p=0.045) and transradial intervention (hazard ratio 0.61, 95% confidence interval 0.47–0.78; p<0.001) was an independent predictor of MACCEs after adjusting for confounding variables. Combined use of potent antiplatelet agents and transradial intervention (hazard ratio 0.54; 95% confidence interval 0.37–0.80; p=0.002) substantially reduced MACCEs at 1 year. Conclusion Among evidence based procedures during the primary PCI, combined use of potent antiplatelet agents and transradial intervention was optimal procedural strategy to improve clinical outcome.