Justin Ratcliffe

Transulnar catheterization in patients with ipsilateral radial artery occlusion.

The transradial approach to percutaneous coronary intervention (PCI) has recently gained popularity among interventionalists. However, radial artery occlusion (RAO) limits the ability for repeat catheterization. In current practice, transulnar catheterization is thought to be a contraindication in patients with ipsilateral RAO.

A Novel Technique in the Use of Fractional Flow Reserve in Coronary Artery Bifurcation Lesions

The side branch (SB) in bifurcation lesions is a frequently encountered challenge that interventional cardiologists must face. There is great interest in determining fractional flow reserve (FFR) in the SB to help guide treatment decisions; however, difficulty with the pressure guidewire limits its widespread use. We propose a novel technique that will ease the incorporation of FFR in routine evaluation of bifurcation lesions, and allow better assessment of provisional stenting and need for SB intervention. Conventionally, to measure SB FFR, the jailed SB is re-crossed through the stent strut using a pressure wire. Our technique involves the use of a microcatheter and wire exchange within the SB, thereby alleviating some of the technical difficulties associated with the FFR wire. In light of the difficulties and clinical concerns associated with bifurcation lesions, we propose an innovative method to ease the incorporation of FFR to allow better assessment of provisional stenting and need for SB intervention.

Comparison of TR Band™ and VasoStat™ Hemostasis Devices following Transpedal Catheterization for Lower Extremity Revascularization for Peripheral Arterial Disease.

BACKGROUND Transpedal access is increasingly utilized for peripheral vascular catheterization. There is a paucity of data on the use of radial hemostasis devices as an alternative to manual compression for achievement of hemostasis after this approach. OBJECTIVE To compare safety and efficacy of two hemostasis devices following transpedal catheterization for lower extremity revascularization for peripheral arterial disease. METHODS A consecutive cohort of patients with bilateral Rutherford 2-5 disease who underwent transpedal catheterization for peripheral vascular interventions were retrospectively analyzed. In each patient, retrograde tibial artery access was obtained, a 4 French sheath was placed, and all revascularization was performed via tibial access. In all patients, a TR Band™ (Terumo Medical, n = 215) and/or VasoStat™ (Forge Medical, n = 99) were used to apply puncture site compression, following removal of the tibial sheath until hemostasis was achieved. Safety and efficacy of each device was compared. RESULTS Puncture site hemostasis was achieved in all patients within 2 hours of sheath removal facilitating early discharge. Two access site pseudoaneurysms occurred within 30 days of revascularization, one of which followed TR Band™ placement and the other following VasoStat™ placement (P = 0.53). Each patient was successfully treated with ultrasound-guided thrombin injection. Loss of access site patency by duplex ultrasound occurred in 2 patients following the TR Band™ and a single patient following the VasoStat™ (P = 1.0). CONCLUSION Both the TR Band™ and the VasoStat™ were effective in achieving hemostasis following transpedal catheterization with low rates of complications.

Transpedal approach for iliac artery stenting: A pilot study.

OBJECTIVE To demonstrate the safety and feasibility of the transpedal approach as an alternate arterial access site for iliac artery intervention. BACKGROUND The common femoral artery is the traditional access site for the endovascular treatment of iliac artery stenoses. However, this approach is associated with complication rates as high as 2%, including retroperitoneal bleeding which carries high patient morbidity and mortality. Furthermore, the standard femoral approach is associated with longer recovery times and longer time to ambulation which are important considerations especially when performing procedures in an ambulatory setting. METHODS Twelve patients were prospectively followed after treatment for symptomatic iliac artery stenosis via transpedal access. Under ultrasound guidance, one of the pedal arteries was visualized and accessed, and stenting of the iliac arteries were performed as per protocol. The patient was monitored immediately post procedure and clinical follow up was performed at one week and one month later. RESULTS The average age of the patients was 71years old. 58% were male. Most patients had Rutherford class III symptoms. Successful stent placement was achieved in all 12 patients via transpedal access. No conversion to femoral access was required. No complications immediately post procedure nor at any time period during follow up were noted. Lower extremity arterial duplex at one month showed patent stents and patent pedal access site vessels in all patients. CONCLUSION Transpedal arterial access may be a safe and feasible approach for iliac artery stenting. Given the possible benefits of avoiding femoral artery access, larger studies should be conducted directly comparing the different approaches.

Pseudoaneurysm after transpedal arterial access for evaluation and treatment of peripheral arterial disease

BACKGROUND There has been an increasing use of transpedal arterial access (TPA) for evaluation and treatment of peripheral arterial disease (PAD) over a transfemoral approach (TFA). TPA, it is expected to be associated with better patient comfort, less recovery time and possibly less access site complications compared to standard TFA. Access site complications and pseudoaneurysm (PSA) associated with the TPA have not been previously reported. OBJECTIVE Here we report a series of pedal artery PSA related to access site complicating TPA catheterization. METHODS We studied 1460 patients with symptomatic PAD who underwent 2236 peripheral diagnostic and/or interventional procedures between 06/2014 and 01/2016 via TPA. Hemostasis was achieved using patent hemostasis technique by a radial artery compression device for 2h. PSA related to the access site were suspected clinically and confirmed with arterial duplex ultrasound. RESULTS The incidence of PSA related to any access site was 0.002%. In this series all PSA occurred only in the posterior tibial artery, after an interventional procedure. All patients were treated successfully with thrombin injection with no residual complications. CONCLUSIONS PSA associated with TPA is extremely rare and seems to occur exclusively after posterior tibial artery access. It is easily treatable by thrombin injection.

TCT-787 The Evolution of Therapy For Infrainguinal Arterial Occlusive Disease: Improvement in Quality of Life With Endovascular Interventions via Transpedal Access

durable mid-term outcomes after DES implantation were documented, substantial incidence of stent thrombosis was also reported. To prevent stent thrombosis, dual-antiplatelet therapy (DAPT) using aspirin and P2Y12 inhibitor are recommended at least for 2 months after DES implantation. However, the association between the effect of P2Y12 inhibitor and intra-stent thrombus has not been well explored.

TCT-794 Expanding The Paradigm of Treatment in Infrapopliteal Arterial Occlusive Disease: Quality of Life Benefits of Transpedal Access Single Tibial Vessel Intervention

For patients suffering from peripheral arterial disease (PAD), quality of life (QOL) is as important as mortality, morbidity and amputation, to evaluate the effect of disease and treatment. There is paucity of data to support single tibial vessel intervention for tibial occlusive disease. We report

Precordial T wave Inversions on Electrocardiogram

T wave inversions on an electrocardiogram (EKG) can manifest from any process that result in a relative delay in regional ventricular repolarization. The differential diagnosis of right precordial T wave inversions, leads V1-V3, include myocardial ischemia, a normal athlete’s heart, arrhythmogenic right ventricular dysplasia, and pulmonary embolism amongst others. The case discussed below is of a 73 year old man who presented to a cardiologist with chest pain and shortness of breath. He had an initial ECG that showed a normal sinus rhythm with T wave inversions across the right precordial leads. He had an unrevealing coronary angiogram and an echocardiogram that only showed right-sided strain. Thereafter, he had a ventilation perfusion scan, which diagnosed pulmonary embolus. He was treated with anticoagulation and his symptoms resolved. The present case delineates the importance of recognizing this ECG pattern and, in the correct clinical setting, can facilitate in diagnosis and treatment of a relatively common medical condition.