Antonella Tommasino

Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study

BACKGROUND most of the studies assessing transradial approach for coronary angiography (CA) have been performed through right radial approach (RRA). Our aim was to evaluate the safety and efficacy of left radial approach (LRA) compared with RRA for coronary procedures. METHODS from January 2009 to December 2009, in 2 hospitals, 1,540 patients were randomized to RRA (770 patients) or LRA (770 patients) for percutaneous coronary procedures. The primary end point was fluoroscopy time for CA and for percutaneous coronary intervention (PCI) evaluated independently. Prespecified subgroup analyses according to patient age and operator experience were planned. RESULTS in 1,467 patients (732 RRA and 735 LRA), a CA (diagnostic group) was performed, and in 688 (344 each for RRA and LRA), a PCI. In the diagnostic group, LRA was associated with significantly lower fluoroscopy time (149 seconds, interquartile range [IQR] 95-270 seconds) and dose area product fluoroscopy (10.7 Gy cm(2), IQR 6-20.5 Gy cm(2)) compared with the RRA (168 seconds, IQR 110-277 seconds, P = .0025 and 12.1 Gy cm(2), IQR 7-23.8 Gy cm(2), P = .004, respectively). In the PCI group, there were no significant differences in fluoroscopy time (614 seconds, IQR 367-1,087 seconds for LRA and 695 seconds, IQR 415-1,235 seconds, P = .087 for RRA) and dose area product fluoroscopy (53.7 Gy cm(2), IQR 29-101 Gy cm(2) for LRA and 63.1 Gy cm(2), IQR 31-119 Gy cm(2), P = .17 for RRA). According to subgroup analyses, the differences between LRA and RRA were confined to older patients (≥ 70 years old) and to operators in training. CONCLUSIONS left radial approach for coronary diagnostic procedures is associated with lower fluoroscopy time and radiation dose adsorbed by patients compared with the RRA, particularly in older patients and for operators in training.

Prospective Randomized Comparison of Sirolimus- or Everolimus-Eluting Stent to Treat Bifurcated Lesions by Provisional Approach

OBJECTIVES This study sought to compare the procedural performance and the acute angiographic result on side-branch ostium obtained using 2 different drug-eluting stents (DES) to treat patients with bifurcated coronary lesions. BACKGROUND Drug-eluting stents are routinely used in percutaneous coronary interventions (PCI) of bifurcated coronary lesions. Different DES types have major technical differences that may influence the procedural and clinical performance in bifurcation PCI. METHODS Consecutive patients with bifurcated lesions undergoing DES implantation using a systematic provisional-stenting strategy were randomized to sirolimus-eluting stent (SES) or everolimus-eluting stent (EES) before intervention. The procedural details for PCI were prospectively recorded to assess the occurrence of any trouble in the side-branch (SB) management (primary end point). Post-PCI angiographic result (primary end point: minimal lumen diameter at SB ostium) was evaluated offline by 3-dimensional reconstruction and quantitative coronary analysis. Clinical outcome was prospectively recorded up to 18 months to assess the occurrence of target bifurcation failure. RESULTS A total of 150 patients were enrolled in the study (29% diabetics, 17% unprotected left main). The stent was successfully implanted according to randomization in all cases. Procedural performance was not significantly different between the 2 kinds of DES. Three-dimensional reconstruction and quantitative coronary analysis showed similar post-PCI results in the main vessel and better results in the SB with EES than with SES (minimal lumen diameter at SB ostium: 1.94 ± 0.72 mm vs. 1.64 ± 0.62 mm; p = 0.013). At 18 months, target bifurcation failure occurred in 7 (9.0%) of SES-treated patients versus 8 (10.7%) of EES patients (p = 0.57). CONCLUSIONS In patients with bifurcated lesions treated by provisional stenting technique, EES compared with SES is associated with similar procedural performance and better 3-dimensional reconstruction and quantitative coronary analysis result in the SB. Both DES are associated with low rates of major adverse events and angiographic failure. (Sirolimus Versus Everolimus-Eluting Stent Randomized Assessment in Bifurcated Lesions and Clinical Significance of Residual Side-Branch Stenosis [SEA-SIDE]; NCT00697372).

Transradial approach to treat superficial femoral artery in-stent restenosis†

Transradial access reduces the incidence of access site complications of percutaneous revascularization procedures. However, in patients with peripheral vascular disease, the adoption of transradial approach for superficial femoral artery (SFA) angioplasty is usually prevented by the distance between the vascular access and the target lesions; thus, SFA angioplasty is commonly performed by transfemoral approach. Recently, low‐profile balloons with extended shaft length became available, allowing to potentially address SFA lesions by transradial approach. As plain balloon angioplasty represents a valuable option for SFA in‐stent restenosis treatment, we evaluated the feasibility of transradial approach in this clinical setting.

Transradial renal stenting: Why and how†

Transradial vascular access for invasive procedures is gaining increasingly acceptance due to reduced access‐site complications and improved patients comfort compared with transfemoral. However, the adoption of transradial access in peripheral vascular procedures is actually limited by anatomical and technical considerations. Yet, among all the peripheral vascular districts, the renal one seems to be particularly suitable for transradial approach. In this article, we discuss the rationale for preferring the radial approach instead of femoral and review the specific technical issues related to transradial renal artery stenting (RAS).

Feasibility of complex coronary and peripheral interventions by trans-radial approach using large sheaths

Background: Trans‐radial approach (TRA) reduces vascular access‐site complications but has some technical limitations. Usually, TRA procedures are performed using 5 Fr or 6 Fr sheaths, whereas complex interventions requiring larger sheaths are approached by trans‐femoral access. Methods: During 4 years, at two Institutions with high TRA use, we have attempted to perform selected complex coronary or peripheral interventions by TRA using sheaths larger than 6 Fr. Clinical and procedural data were prospectively collected. Attempt to place a 7 Fr or 8 Fr sheath (according to the planned strategy of the procedure) was performed after 5–6 Fr sheath insertion, administration of intra‐arterial nitrates and radial artery angiography. Late (>3 months) patency of the radial artery was checked (by angiography in the case of repeated procedures or by palpation + reverse Allen test). Results: We collected 60 patients in which TRA large sheath insertion was attempted. The large sheath (87% 7 Fr, 13% 8 Fr) was successfully placed in all cases. Most of the procedures were complex coronary interventions (bifurcated or highly thrombotic or calcific chronic total occlusive lesions), whereas 8.3% were carotid interventions. Procedural success rate was 98.3% (1 failure to reopen a chronic total occlusion). No access‐site related complication occurred. In 57 (95%) patients, late radial artery patency was assessed and showed patency in 90% of the cases, the remaining patients having asymptomatic collateralized occlusion. Conclusions: In selected patients, complex percutaneous interventions requiring 7–8 Fr sheaths can be successfully performed by RA approach without access‐site clinical consequences.

Comparison of the transradial and transfemoral approaches for coronary angiographic evaluation in patients with internal mammary artery grafts.

Objective Transradial access for coronary angiography may offer some advantages in comparison with conventional transfemoral access in specific subgroups of patients. Therefore, the aim of this study was to compare the transradial and transfemoral approaches in patients with previous coronary artery bypass graft (CABG) surgery using the left internal mammary artery (IMA). Methods The time to left IMA cannulation, the time needed for left IMA evaluation, and total procedure time were compared in 60 patients previously submitted to CABG surgery using the left IMA. The homolateral radial access was attempted in 20 consecutive patients (TR group), whereas the transfemoral approach was undertaken in 40 patients (2: 1, TF group), matched for age, sex and number of grafts. Results In the TR group, the time to left IMA cannulation and the time needed for left IMA evaluation were 39% and 46%, respectively, lower than those in the TF group (P = 0.01 and P = 0.001, respectively), whereas total procedure time was similar. In the subgroup of patients with less than three saphenous vein grafts (n = 36), the time to left IMA cannulation, the time needed for left IMA evaluation as well as total procedure time were significantly reduced (P = 0.01, P = 0.001 and P = 0.004, respectively). The rate of ad-hoc coronary angioplasty procedures was unaffected by the access site (20% in the TR group and 27% in the TF group, P = 0.53). Conclusions The present study shows that the homolateral transradial approach facilitates left IMA evaluation in patients with previous CABG surgery undergoing coronary angiography, in particular in patients with a lower number of coronary artery bypass conduits, in the absence of an excess of periprocedural complications.

Pushing the limits forward: transradial superficial femoral artery stenting.

Percutaneous revascularization of superficial femoral artery (SFA) is increasingly carried out to treat patients with peripheral vascular disease and either intermittent claudication or critical limb ischemia. Transradial vascular access is increasingly adopted for invasive procedures due to reduced access‐site complications and improved patients comfort, compared with transfemoral. However, compared with coronary interventions, the adoption of transradial access in peripheral procedures is limited. Concerning SFA interventions, transradial access is usually prevented by the distance between the vascular access and the target lesion, which extends over the length of the currently available devices. Thanks to technical improvements, resulting in specifically dedicated low‐profile equipment with adequate shaft length availability, transradial access is now feasible for the treatment of selected SFA lesions. We report the first two cases of SFA stenting performed by transradial access with a new specifically developed self‐expanding nitinol stent with extended delivery system length. This report suggests that, with proper technique and specifically dedicated equipment, transradial SFA stenting is feasible. Treatment of SFA disease by transradial route, allowing for immediate post‐procedure walking and simultaneous bilateral interventions, may represent an alternative for effective treatment of selected patients with SFA lesions.

Safety and feasibility of iliac endovascular interventions with a radial approach. Results from a multicenter study coordinated by the Italian Radial Force

BACKGROUND Percutaneous angioplasty of lower limb disease is commonly performed with a transfemoral access. In the coronary field, a transradial approach has shown to reduce access-site bleeding and adverse clinical events. This route has not yet been well studied for the majority of peripheral interventions, like those involving the iliac arteries. In this study we sought to evaluate the feasibility and safety of this approach for iliac interventions. METHODS Multicenter study was performed at high-volume centers with experience in transradial percutaneous interventions. Primary endpoint of the study was procedural success; secondary endpoints included in-hospital bleeding, 1-month freedom from adverse events and the rate of radial occlusion. Feasibility of this technique was evaluated by recording procedural and fluoroscopy time and contrast load. RESULTS A total of 149 patients from 5 centers were enrolled. The population had a medium risk profile, with 48% of patients having TASC 2 or 3 lesions. Procedural success was achieved in 98.7% of the population, and we did not register in-hospital complications, including both vascular access site and procedural-related complications. An ancillary transfemoral approach was used in 13% of patients. One-month freedom from symptoms was achieved in 97.3% of patients, and the rate of radial occlusion was 2.7%. Major determinants of an unsuccessful procedure were the use of normal 6 or 7-Fr introducer with guiding catheter, TASC D lesion attempt, lesion length>30 mm and total occlusion. CONCLUSIONS A transradial approach for iliac disease may be a feasible and safe alternative to the transfemoral route in experienced hands, in the light of significant technical improvements and dedicated devices.

Baseline inflammatory status and long-term changes in renal function after percutaneous renal artery stenting: a prospective study

OBJECTIVES To investigate a possible independent predictive role of systemic inflammation markers on renal function after renal artery stenting. BACKGROUND An elevated baseline serum creatinine has previously been shown to be the strongest predictor of improved renal function after percutaneous renal artery stenting. The inflammatory system is implicated in every stage of chronic kidney disease, and we hypothesized an additional value of markers of systemic inflammation in predicting response after renal artery stenting. METHODS This single center, prospective study includes 62 consecutive patients with chronic kidney disease at stage ≥ 3 or resistant hypertension who underwent stent placement for 74 angiographically significant atherosclerotic renal lesions. Inflammatory markers, including serum C-reactive protein (CRP), erythrocyte sedimentation rate, and white blood cell count were determined prior to renal angioplasty and related to changes in renal function at follow-up. RESULTS Six-month clinical follow up was completed in 57 patients. Overall, median serum creatinine concentration exhibited a non significant reduction from 1.40 mg/dl (quartiles: 1.20, 1.75 mg/dl) at baseline to 1.30 mg/dl (quartiles: 1.1, 1.55 mg/dl) at 6 months (p=0.17). Significant multivariate independent predictors of decreased creatinine included higher baseline serum creatinine levels (adjusted OR per quartile increment, 2.5 [1.3 to 4.7], p=0.004) and lower C-reactive protein levels (adjusted OR per quartile increment 0.39 [0.19 to 0.82], p=0.013). CONCLUSIONS Patients with higher serum creatinine and lower CRP derive the most benefit from renal artery stenting.

Impact of radial-to-aorta vascular anatomical variants on risk of failure in trans-radial coronary procedures.

To assess the impact of an “operative” classification of vascular anatomic variants on the feasibility of trans‐radial approach.