Arnold H. Seto

Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial).

OBJECTIVES The aim of this study was to compare the procedural and clinical outcomes of femoral arterial access with ultrasound (US) guidance with standard fluoroscopic guidance. BACKGROUND Real-time US guidance reduces time to access, number of attempts, and complications in central venous access but has not been adequately assessed in femoral artery cannulation. METHODS Patients (n = 1,004) undergoing retrograde femoral arterial access were randomized 1:1 to either fluoroscopic or US guidance. The primary end point was successful common femoral artery (CFA) cannulation by femoral angiography. Secondary end points included time to sheath insertion, number of forward needle advancements, first pass success, accidental venipunctures, and vascular access complications at 30 days. RESULTS Compared with fluoroscopic guidance, US guidance produced no difference in CFA cannulation rates (86.4% vs. 83.3%, p = 0.17), except in the subgroup of patients with CFA bifurcations occurring over the femoral head (82.6% vs. 69.8%, p < 0.01). US guidance resulted in an improved first-pass success rate (83% vs. 46%, p < 0.0001), reduced number of attempts (1.3 vs. 3.0, p < 0.0001), reduced risk of venipuncture (2.4% vs. 15.8%, p < 0.0001), and reduced median time to access (136 s vs. 148 s, p = 0.003). Vascular complications occurred in 7 of 503 and 17 of 501 in the US and fluoroscopy groups, respectively (1.4% vs. 3.4% p = 0.04). CONCLUSIONS In this multicenter randomized controlled trial, routine real-time US guidance improved CFA cannulation only in patients with high CFA bifurcations but reduced the number of attempts, time to access, risk of venipunctures, and vascular complications in femoral arterial access. (Femoral Arterial Access With Ultrasound Trial [FAUST]; NCT00667381).

Use of the Instantaneous Wave-free Ratio or Fractional Flow Reserve in PCI

Background Coronary revascularization guided by fractional flow reserve (FFR) is associated with better patient outcomes after the procedure than revascularization guided by angiography alone. It is unknown whether the instantaneous wave‐free ratio (iFR), an alternative measure that does not require the administration of adenosine, will offer benefits similar to those of FFR. Methods We randomly assigned 2492 patients with coronary artery disease, in a 1:1 ratio, to undergo either iFR‐guided or FFR‐guided coronary revascularization. The primary end point was the 1‐year risk of major adverse cardiac events, which were a composite of death from any cause, nonfatal myocardial infarction, or unplanned revascularization. The trial was designed to show the noninferiority of iFR to FFR, with a margin of 3.4 percentage points for the difference in risk. Results At 1 year, the primary end point had occurred in 78 of 1148 patients (6.8%) in the iFR group and in 83 of 1182 patients (7.0%) in the FFR group (difference in risk, ‐0.2 percentage points; 95% confidence interval [CI], ‐2.3 to 1.8; P<0.001 for noninferiority; hazard ratio, 0.95; 95% CI, 0.68 to 1.33; P=0.78). The risk of each component of the primary end point and of death from cardiovascular or noncardiovascular causes did not differ significantly between the groups. The number of patients who had adverse procedural symptoms and clinical signs was significantly lower in the iFR group than in the FFR group (39 patients [3.1%] vs. 385 patients [30.8%], P<0.001), and the median procedural time was significantly shorter (40.5 minutes vs. 45.0 minutes, P=0.001). Conclusions Coronary revascularization guided by iFR was noninferior to revascularization guided by FFR with respect to the risk of major adverse cardiac events at 1 year. The rate of adverse procedural signs and symptoms was lower and the procedural time was shorter with iFR than with FFR. (Funded by Philips Volcano; DEFINE‐FLAIR ClinicalTrials.gov number, NCT02053038.)

Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial).

OBJECTIVES This study sought to assess the utility of ultrasound (US) guidance for transradial arterial access. BACKGROUND US guidance has been demonstrated to facilitate vascular access, but has not been tested in a multicenter randomized fashion for transradial cardiac catheterization. METHODS We conducted a prospective multicenter randomized controlled trial of 698 patients undergoing transradial cardiac catheterization. Patients were randomized to needle insertion with either palpation or real-time US guidance (351 palpation, 347 US). Primary endpoints were the number of forward attempts required for access, first-pass success rate, and time to access. RESULTS The number of attempts was reduced with US guidance [mean: 1.65 ± 1.2 vs. 3.05 ± 3.4, p < 0.0001; median: 1 (interquartile range [IQR]: 1 to 2) vs. 2 (1 to 3), p < 0.0001] and the first-pass success rate improved (64.8% vs. 43.9%, p < 0.0001). The time to access was reduced (88 ± 78 s vs. 108 ± 112 s, p = 0.006; median: 64 [IQR: 45 to 94] s vs. 74 [IQR: 49 to 120] s, p = 0.01). Ten patients in the control group required crossover to US guidance after 5 min of failed palpation attempts with 8 of 10 (80%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (2.4% vs. 18.6% for ≥5 attempts, p < 0.001; 3.7% vs. 6.8% for ≥5min, p = 0.07). No significant differences were observed in the rate of operator-reported spasm, patient pain scores following the procedure, or bleeding complications. CONCLUSIONS Ultrasound guidance improves the success and efficiency of radial artery cannulation in patients presenting for transradial catheterization. (Radial Artery Access With Ultrasound Trial [RAUST]; NCT01605292).

Variations of coronary hemodynamic responses to intravenous adenosine infusion: implications for fractional flow reserve measurements.

Continuous intravenous adenosine infusion reportedly produces stable and maximal hyperemia to allow for fractional flow reserve (FFR) measurement; however, several observers have noted variation of the coronary/aortic (Pd/Pa) pressure ratio during the course of an adenosine infusion.

Minimizing femoral artery access complications during percutaneous coronary intervention: A comprehensive review

Major bleeding complications after percutaneous coronary intervention (PCI) increase patient morbidity, prolong the hospital stay and costs, and are associated with reduced survival. Transfemoral access is still preferred at many centers given its familiarity and ease of use and is necessary in cases where large bore access is needed. Multimodality imaging with fluoroscopy, ultrasonography, and angiography can facilitate proper puncture of the common femoral artery. A proper technique (which includes femoral artery puncture and vascular access site closure) associated with adequate pharmacotherapy (both during PCI and peri‐procedural, for the treatment of the underlying coronary artery disease) has been shown to reduce the risk of bleeding and vascular complications associated with femoral artery access. Avoiding the use of arterial sheaths >6 French may further reduce the risk of bleeding. Data with vascular closure devices as a bleeding avoidance strategy are evolving but when used appropriately may further reduce the risk of bleeding and vascular access complications, and in this regard are synergistic with bivalirudin. Randomized trials to confirm these recommendations are needed.

Invasive Testing for Coronary Artery Disease : FFR, IVUS, OCT, NIRS

Coronary angiography is the gold standard for the diagnosis of coronary artery disease and guides revascularization strategies. The emergence of new diagnostic modalities has provided clinicians with adjunctive physiologic and image-based data to help formulate treatment strategies. Fractional flow reserve can predict whether percutaneous intervention will benefit a patient. Intravascular ultrasonography and optical coherence tomography are intracoronary imaging modalities that facilitate the anatomic visualization of the vessel lumen and characterize plaques. Near-infrared spectroscopy can characterize plaque composition and potentially provide valuable prognostic information. This article reviews the indications, basic technology, and supporting clinical studies for these modalities.

Ultrasound‐Guided Venous Access for Pacemakers and Defibrillators

Ultrasound‐Guided Lead Placement. Introduction: Ultrasound guidance is widely recommended to reduce the risk of complications during central venous catheter placement. However, ultrasound guidance is not commonly utilized for implanting leads for cardiac rhythm management devices.

The guideliner: Keeping your procedure on track or derailing it?†

The Guideliner catheter (Vascular Solutions, Minneapolis, MN) is a unique rapid exchange guide extension that has quickly gained popularity amongst interventionalists requiring extra guide support, coaxial alignment in tortuous vessels, or deep guide seating [1]. Compared with other techniques that facilitate stent positioning in difficult situations such as buddy wires, wire exchanges, or guide catheter exchange while maintaining distal wire position, the Guideliner is quick, simple, and generally effective. Particularly for transradial interventions where guide support may be inadequate, the Guideliner can convert a passive guide into a deeply seated, supportive yet flexible guide, enabling completion of the procedure with minimal hassle. However, simplicity does not necessarily translate into safety, and the list of potential complications with the Guideliner continues to grow (Table 1) [2] and is now expanded by the case from Murphy [3] demonstrating damage to a stent catheter preventing deployment. The case posed a few rather idiosyncratic challenges to the Guideliner device: (1) the Guideliner is not typically used for ostial lesions, (2) it is rarely used to cross the lesion and retracted to reveal a stent (desheathing), and (3) it was used in a sharply angled Kimney guide catheter. In their case, upon retraction of the Guideliner the proximal collar kinked off and disrupted the stent catheter, creating a leak that prevented the transmission of deployment pressure to the balloon. Our experience confirms the observation of Murphy [3] of the risk of the proximal collar of the Guideliner. This week we witnessed the destruction of two stents upon attempted forward movement through the proximal collar of the Guideliner (Fig. 1). We have also noted that stent deformation or dislodgment can occur on attempted withdrawal of a stent through the distal band of the Guideliner, and generally remove the Guideliner before pulling back an undeployed stent. Fig. 1. Stent destruction through Guideliner. Resistance to advancement of 2.5 3 12 and 2.5 3 15 mm Vision bare metal stents was likely due to lifting up of the proximal cells of the stents (black arrowheads) against the proximal collar of the Guideliner. The Guideliner had to be removed completely to enable stent passage.

Invasive Testing for Coronary Artery Disease: FFR, IVUS, OCT, NIRS

Coronary angiography is the gold standard for the diagnosis of coronary artery disease and guides revascularization strategies. The emergence of new diagnostic modalities has provided clinicians with adjunctive physiologic and image-based data to help formulate treatment strategies. Fractional flow reserve can predict whether percutaneous intervention will benefit a patient. Intravascular ultrasonography and optical coherence tomography are intracoronary imaging modalities that facilitate the anatomic visualization of the vessel lumen and characterize plaques. Near-infrared spectroscopy can characterize plaque composition and potentially provide valuable prognostic information. This article reviews the indications, basic technology, and supporting clinical studies for these modalities.

Transcatheter closure of a mechanical perivalvular leak using real-time three-dimensional transesophageal echocardiography guidance.

A 47‐year‐old female with symptomatic mitral stenosis from a prior undersized mitral annuloplasty ring underwent mitral valve replacement with a mechanical valve. Later, she developed heart failure from a severe paravalvular leak (PVL). Because of the excessive mortality risks from a possible third open heart procedure, the patient was instead referred for transcatheter PVL closure. Standard fluoroscopy, invasive hemodynamics, and two‐dimensional (2D) and three‐dimensional (3D) transesophageal echocardiography (TEE) imaging were performed during device placement with excellent image quality. The case highlights the unique benefit of 3D TEE imaging for preprocedure sizing, guidance of device deployment intraprocedure, and confirmation of PVL closure.