Pedro Beraldo de Andrade

Utilização do acesso radial elimina a ocorrência de sangramento grave relacionado ao sítio de punção após intervenção coronária percutânea primária

Transradial Approach Eliminates Puncture Site Major Bleeding After Primary Percutaneous Coronary Intervention Background: Transradial approach is associated with a low incidence of vascular complications. This peculiarity makes it useful in acute coronary syndromes, where aggressive antiplatelet and antithrombotic therapy is frequently used. The aim of this study was to evaluate the efficacy and safety of transradial approach in primary percutaneous intervention, where delays in achieving reperfusion resulting from technical difficulties are unacceptable. Method: Registry including consecutive patients undergoing primary percutaneous intervention by transradial approach. The efficacy endpoints were in-hospital mortality, door-to-balloon time, final TIMI III flow and access site crossover. Safety was assessed by the rate of major bleeding and complications related to the puncture site. Results: From February 2007 to November 2009, 211 patients underwent primary percutaneous intervention, 201 of them by transradial approach. Mean age was 59 years, 27.4% were female and 22.4% had diabetes mellitus. Final TIMI III flow was achieved in 91.5% of patients, ST segment resolution > 50% in 88.5%, with a crossover rate of 1.5%. In-hospital mortality was 4.5% and the rate of major bleeding was 1%, with one episode of upper gastrointestinal bleeding and a decrease in hemoglobin > 5 g/dl. Vascular complications related to the puncture site were limited to 3 cases of type II hematoma and 2 cases of type III hematoma, with no clinical impact and spontaneous resolution. Conclusion: The transradial approach, RESUMO Introducao: O acesso radial associa-se a baixa ocorrencia de complicacoes vasculares. Essa caracteristica o torna vantajoso nas sindromes coronarias agudas, em que e frequente o uso agressivo de terapias antiplaquetaria e antitrombotica. O objetivo do estudo foi avaliar a eficacia e a seguranca do acesso radial na realizacao de intervencao percutânea primaria, em que atrasos na reperfusao advindos de maior dificuldade tecnica representariam um fator limitante. Metodo: Registro envolvendo pacientes submetidos a intervencao percutânea primaria pelo acesso radial. Os desfechos de eficacia constituiram-se em mortalidade hospitalar, tempo porta-balao, obtencao de fluxo final TIMI III e conclusao do procedimento sem troca da via de acesso. A seguranca foi avaliada por meio de taxa de sangramento grave e ocorrencia de complicacoes relacionadas ao sitio de puncao. Resultados: Entre fevereiro de 2007 e novembro de 2009, 211 pacientes foram submetidos a intervencao percutânea primaria, 201 por meio de acesso radial. A media de idade foi de 59 anos, sendo 27,4% do sexo feminino e 22,4% portadores de diabetes melito. Foram obtidos fluxo final TIMI III em 91,5% dos pacientes e resolucao do segmento ST > 50% em 88,5%, com taxa de crossover de 1,5%. A mortalidade hospitalar foi de 4,5% e a taxa de sangramento grave foi de 1%, sendo um episodio de hemorragia digestiva alta e uma queda de hemoglobina de 5 g/dl. As complicacoes vasculares relacionadas ao sitio de puncao limitaram-se a tres casos de hematoma tipo II e a dois casos de hematoma tipo III, sem repercussao clinica e com resolucao espontânea. Conclusao: O acesso radial representa uma via eficaz e segura para

Coronariografia via transradial: curva de aprendizagem, avaliada por estudo multicêntrico

ABSTRACT Transradial Coronary Angiography: Learning Curve,Evaluated by a Multicenter Study Background: Femoral access for diagnostic and therapeuticcoronary procedures has been the dominant approachworldwide, despite an increased risk of vascular and he-morrhagic complications. The transradial approach is amore recent technique used to reduce these complications,providing more comfort and reducing hospitalization costs.However, it is associated with an inherent learning curve.The aim of the study was to evaluate transradial coronaryangiography performed by inexperienced operators andcompare the success and complication rates of this techniquewith the classical approach (Sones and femoral), analyzingthe influence of the learning curve. Methods: Multicenter,randomized study, in 14 hospitals in Sao Paulo State in aone-year period. One thousand patients were randomizedto the transradial or classical techniques. Results: Thesuccess rate was similar in both groups (97.8% vs. 98.5%;P = 0.47). Sones technique was used in 95.2% of theprocedures in the classical technique group. The numberof catheters used, the duration of the procedure and X-rayexposure were greater in the transradial group (P < 0.001).There were no differences in the major cardiac adverseevents (death, infarct and stroke), and vascular and bleedingcomplications. Operators who had performed over 100procedures using the transradial approach (3 centers/5operators) had a lower failure rate (1.6% vs. 3.6%; P = 0.04).

Radial approach in percutaneous coronary interventions: current status in Brazil

FUNDAMENTO: Embora a tecnica radial exiba resultados incontestaveis na reducao de complicacoes vasculares e ocorrencia de sangramento grave quando comparada a tecnica femoral, seu emprego permanece restrito a poucos centros que a elegeram como via de acesso preferencial. OBJETIVO: Avaliar o cenario atual das intervencoes coronarianas percutâneas no Brasil quanto a utilizacao da via de acesso radial. METODOS: Analise dos dados cadastrados de forma espontânea na Central Nacional de Intervencoes Cardiovasculares (CENIC) durante o quadrienio de 2005-2008, o que totaliza 83.376 procedimentos. RESULTADOS: A tecnica radial foi utilizada em 12,6% dos procedimentos efetivados, e a tecnica femoral, em 84,3%. Os 3,1% restantes foram representados pela disseccao ou puncao braquial. Com uma taxa de sucesso de 97,5%, a opcao pelo acesso radial associou-se a reducao significativa de complicacoes vasculares quando comparado ao femoral (2,5% versus 3,6%, p < 0,0001). CONCLUSAO: A utilizacao da tecnica radial permanece baixa no Brasil. Ausencia de programas de treinamento, incertezas quanto a curva de aprendizagem e carencia de estudos em larga escala, que corroboram os beneficios demonstrados ate o momento, sao possiveis justificativas para esses achados.BACKGROUND Although the radial approach offers an unquestionable result in terms of reduction of vascular complications and occurrence of severe bleeding in comparison to the femoral approach, so far it has only been used in few centers which elected it as the preferential access. OBJECTIVE To evaluate the current status of percutaneous coronary interventions in Brazil, as regards the use of the radial approach. METHODS Analysis of data spontaneously recorded in Central Nacional de Intervenções Cardiovasculares - CENIC (National Center for Cardiovascular Interventions) from 2005 to 2008, in a total of 83,376 procedures. RESULTS The radial approach was used in 12.6% of the procedures performed, and the femoral approach, in 84.3%. The remaining 3.1% corresponded to brachial artery dissection or puncture. With a success rate of 97.5%, the choice of the radial approach was associated with a significant reduction of vascular complications in comparison to the femoral approach (2.5% versus 3.6 %, p < 0.0001). CONCLUSION The radial approach remains uncommonly used in Brazil, and this is possibly explained by the lack of training programs, uncertainties regarding the learning curve, and the lack of large-scale studies corroborating the benefits demonstrated to date.

Acesso radial em intervenções coronarianas percutâneas: panorama atual brasileiro

FUNDAMENTO: Embora a tecnica radial exiba resultados incontestaveis na reducao de complicacoes vasculares e ocorrencia de sangramento grave quando comparada a tecnica femoral, seu emprego permanece restrito a poucos centros que a elegeram como via de acesso preferencial. OBJETIVO: Avaliar o cenario atual das intervencoes coronarianas percutâneas no Brasil quanto a utilizacao da via de acesso radial. METODOS: Analise dos dados cadastrados de forma espontânea na Central Nacional de Intervencoes Cardiovasculares (CENIC) durante o quadrienio de 2005-2008, o que totaliza 83.376 procedimentos. RESULTADOS: A tecnica radial foi utilizada em 12,6% dos procedimentos efetivados, e a tecnica femoral, em 84,3%. Os 3,1% restantes foram representados pela disseccao ou puncao braquial. Com uma taxa de sucesso de 97,5%, a opcao pelo acesso radial associou-se a reducao significativa de complicacoes vasculares quando comparado ao femoral (2,5% versus 3,6%, p < 0,0001). CONCLUSAO: A utilizacao da tecnica radial permanece baixa no Brasil. Ausencia de programas de treinamento, incertezas quanto a curva de aprendizagem e carencia de estudos em larga escala, que corroboram os beneficios demonstrados ate o momento, sao possiveis justificativas para esses achados.BACKGROUND Although the radial approach offers an unquestionable result in terms of reduction of vascular complications and occurrence of severe bleeding in comparison to the femoral approach, so far it has only been used in few centers which elected it as the preferential access. OBJECTIVE To evaluate the current status of percutaneous coronary interventions in Brazil, as regards the use of the radial approach. METHODS Analysis of data spontaneously recorded in Central Nacional de Intervenções Cardiovasculares - CENIC (National Center for Cardiovascular Interventions) from 2005 to 2008, in a total of 83,376 procedures. RESULTS The radial approach was used in 12.6% of the procedures performed, and the femoral approach, in 84.3%. The remaining 3.1% corresponded to brachial artery dissection or puncture. With a success rate of 97.5%, the choice of the radial approach was associated with a significant reduction of vascular complications in comparison to the femoral approach (2.5% versus 3.6 %, p < 0.0001). CONCLUSION The radial approach remains uncommonly used in Brazil, and this is possibly explained by the lack of training programs, uncertainties regarding the learning curve, and the lack of large-scale studies corroborating the benefits demonstrated to date.

Performance of Coronary Procedures through the Transulnar Access without Assessment of the Integrity of the Deep Palmar Arch

Occurrence of ischemic complications after transulnar coronary procedures is virtually absent. The presence of a complete deep palmar arch in approximately 95% of the population as well as the great capacity of the collateral circulation of the hand might justify these findings. We report the occurrence of complications in 62 patients submitted to coronary procedures through the transulnar approach, without assessment of the integrity of the deep palmar arch by the inverse Allens test. The rate of asymptomatic occlusion of the ulnar artery was 3%, without any ischemic complication. We believe the performance of Allens test is not necessary when using transulnar access.

Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial

Importance The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. Objective To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. Design, Setting, and Participants Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. Interventions Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. Main Outcomes and Measures The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. Results Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, −0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. Conclusions and Relevance Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management. Trial Registration clinicaltrials.gov Identifier: NCT01448642

Impacto da utilização do acesso radial na ocorrência de sangramento grave entre idosos submetidos a intervenção coronária percutânea

BACKGROUND: The occurrence of major bleeding after percutaneous coronary intervention (PCI) is associated to higher morbidity and mortality, and advanced age is one of its main predictors. The aim of this analysis was to evaluate the impact of the use of the transradial approach in the incidence of bleeding complications in elderly patients undergoing PCI. METHODS: Consecutive and controlled registry including patients over 60 years of age undergoing PCI by transradial approach. Angiographic procedure success, technical failure, and the incidence of ischemic adverse events and major bleeding were evaluated. RESULTS: Between May 2008 and December 2010, 707 elderly patients underwent PCI, of whom 635 (89.8%) used the transradial approach. Mean age was 69.9 ± 7.2 years, 11.5% were > 80 years of age, 39.7% were female and 30.9% had diabetes mellitus. Acute ischemic syndrome accounted for 72% of clinical indications. The angiographic success rate was 96.8% with a crossover rate of 2.8%. The in-hospital mortality rate was 2.4%, myocardial infarction occurred in 0.9%, stroke in 0.3% and stent thrombosis in 0.9%. Hematomas were reported in 1.6% of procedures, with a major bleeding rate of 0.8%. CONCLUSIONS: In elderly patients undergoing PCI, representing the real-world practice and at a high risk for bleeding, the use of the transradial approach was associated with a low major bleeding rate.

Intervenção coronariana percutânea primária pelo acesso transulnar: segurança e eficácia

The transradial approach is safe and effective for coronary procedures. However, its use may be compromised in cases of variations in radial artery anatomy, spasms, and negative Allens test. The transulnar approach emerges as a viable alternative to transradial approach. We report on a patient who underwent primary angioplasty via ulnar artery without ischemic hand complications despite prior occlusion of the ipsilateral radial artery.

Comparison of a vascular closure device versus the radial approach to reduce access site complications in non-ST-segment elevation acute coronary syndrome patients: The angio-seal versus the radial approach in acute coronary syndrome trial

To compare the radial versus femoral approach using Angio‐Seal for the incidence of access site complications among non‐ST‐segment elevation acute coronary syndrome patients undergoing invasive strategy.

Registro prospectivo de avaliação da segurança e eficácia da técnica ulnar na realização de procedimentos coronários

SUMMARYEvaluation of Safety and Efficacy of the TransulnarAccess for Coronary ProceduresBackground: The use of the transradial approach is asso-ciated with low rates of complications at the puncturesite, reduced costs, shorter hospital stay and is more con-fortable to the patient. However, its is not feasible in 5%-15% of the cases due to significant anatomic variations,vessel spasms and negative results in the Allen’s test. Theaim of this study was to evaluate the safety and efficacyof the transulnar access as an alternative approach inthese situations. Methods: Coronary procedures performedthrough the transulnar approach were included in a pros-pective registry. We evaluated the success rates, definedas adequate coronary opacity in coronary angiography ora percutaneous coronary intervention (PCI) with residualstenosis < 30%, with no need to change the access site;procedure and fluoroscopy times and the rate of in-hos-pital and 30-day complications. Results: Between May2007 and May 2008, 102 coronary procedures wereincluded in the registry. The mean age was 61 ± 11 years,53% were female patients and 34% were diabetic. Successrates were 94.5% and 100% for coronary angiographyand PCI, respectively. There was a low rate of complications,including 2% of asymptomatic occlusion of the ulnar arteryand 1% of hematoma not requiring vascular repair orblood transfusion.