Sanjay Chugh

Radial Artery Occlusion After Transradial Interventions: A Systematic Review and Meta‐Analysis

Background Radial artery occlusion (RAO) may occur posttransradial intervention and limits the radial artery as a future access site, thus precluding its use as an arterial conduit. In this study, we investigate the incidence and factors influencing the RAO in the current literature. Methods and Results We searched MEDLINE and EMBASE for studies of RAO in transradial access. Relevant studies were identified and data were extracted. Data were synthesized by meta‐analysis, quantitative pooling, graphical representation, or by narrative synthesis. A total of 66 studies with 31 345 participants were included in the analysis. Incident RAO ranged between <1% and 33% and varied with timing of assessment of radial artery patency (incidence of RAO within 24 hours was 7.7%, which decreased to 5.5% at >1 week follow‐up). The most efficacious measure in reducing RAO was higher dose of heparin, because lower doses of heparin were associated with increased RAO (risk ratio 0.36, 95% CI 0.17–0.76), whereas shorter compression times also reduced RAO (risk ratio 0.28, 95% CI 0.05–1.50). Several factors were found to be associated with RAO including age, sex, sheath size, and diameter of radial artery, but these factors were not consistent across all studies. Conclusions RAO is a common complication of transradial access. Maintenance of radial patency should be an integral part of all procedures undertaken through the radial approach. High‐dose heparin along with shorter compression times and patent hemostasis is recommended in reducing RAO.

Feasibility and utility of pre‐procedure ultrasound imaging of the arm to facilitate transradial coronary diagnostic and interventional procedures (PRIMAFACIE‐TRI)

To assess feasibility and utility of imaging of both arms using ultrasound to facilitate transradial (TR) and transulnar (TU) coronary angiograms (CA) and intervention.Objectives To assess feasibility and utility of imaging of both arms using ultrasound to facilitate transradial (TR) and transulnar (TU) coronary angiograms (CA) and intervention. Background Despite well recognized advantages, transradial approach (TRA) has challenges that reduce procedural success including small arterial size, anatomical variations, and anomalies of radial artery (RA). The utility of routine pre-procedural ultrasound of the arm arteries (PPUAA) in facilitating TRA has not been previously studied. Methods To determine the role of PPUAA, we performed a single center registry of consecutive patients undergoing diagnostic and interventional procedures between 2006 and 2011. All patients underwent PPUAA of the right and left radial, ulnar (UA), as well as the brachial arteries (BA) in the antecubital fossa using a linear probe. End-points assessed included the incidence and correlates of arterial sizes, vascular anomalies, procedure success, and fluoroscopy as well as ultrasound assessment times. RA occlusion rates were studied in the last 10 months of the study period. Results Complete data on radial (mean 1.9 mm (male);1.7 mm (female)) and ulnar artery size (mean 1.8 mm (male); 1.6 mm (female)) and data on brachial branching anatomy were available in 2,344 patients; 1,872 of whom underwent a TR or TU procedure. The mean time to perform bilateral PPUAA was 6.4 min ± 1.8 min. The incidence of arterial abnormalities was 9.8% in PPUAA. Procedure success was 98.7% for CA and 97.5% for percutaneous coronary intervention. Outcomes were better in this cohort compared with remaining 3,781 patients in whom PPUAA data were not available. Conclusion This single center prospective registry shows that PPUAA is feasible, requires minimum time, and provides anatomical information that may improve procedure success while reducing patient discomfort, arterial spasm, and fluoroscopy time. These findings should be confirmed in a randomized trial.

How to tackle complications in radial procedures: Tip and tricks.

Transradial interventions (TRI) are becoming increasingly popular because of accumulating recent evidence suggesting improved survival and reduced morbidity. Complications, though rare, do occur, especially for operators on their learning curve. The complications are best prevented by utilization of proper technique. Forearm hematoma are preventable and easy to treat, but a delay in detecting and managing them can lead to disastrous consequences compartment syndrome being the most dreaded one. This review deals with tips and tricks to prevent as also treat the common and rare complications.

Correlation of the telomere length with type 2 diabetes mellitus in patients with ischemic heart disease

Objective The study aimed to explore the relationship of the telomere length with type 2 diabetes mellitus (DM) among patients with ischemic heart disease (IHD). Method This 2-year cross-sectional study included 130 male patients diagnosed with IHD through echocardiography and coronary angiography, wherein consecutive IHD patients with type 2 DM (65) and without type 2 DM (65) were selected. Baseline characteristics including age, gender, body mass index, and blood pressure were recorded. Laboratory investigations such as random blood sugar (RBS), fasting lipid profile, serum creatinine, and serum urea levels were measured. Quantitative real-time polymerase chain reaction was used for the measurement of the telomere length. The logistic regression analysis was used to predict the relationship of the telomere length with age and type 2 DM among patients with IHD. Results All the patients in the study were men, and most of them (diabetics = 22; nondiabetics = 20) were aged between 56 and 65 years. Age (p = 0.003), telomere length (p < 0.001), RBS (p < 0.001), serum creatinine (p < 0013), and serum urea (p < 0.04) were significantly higher in the diabetic subset than in the nondiabetic subset. No significant relationship was observed between age and the telomere length (p = 0.813); however, the mean telomere length was significantly high among the patients with type 2 DM than those without type 2 DM (p = 0.005). The logistic regression analysis showed that the telomere shortening (p = 0.00019) and RBS (p < 0.0001) were the significant risk factors for type 2 DM in patients with IHD. Conclusion The telomere shortening was significantly correlated with type 2 DM among the patients with IHD. However, multicentric studies with larger samples are required to validate the current observation.

Safety and feasibility of 5 French Glidesheath Slender for complex transradial interventions in small diameter radial arteries

Transradial(TR) access has limitations in patients with small diameter radial arteries (SDRA) because of increased risk of radial artery(RA) spasm(RAS), access site crossover, procedure failure, and RA occlusion (RAO) despite adequate anticoagulation & patent hemostasis. A wide variation in RA diameter (RAD)have been reported in patients worldwide: from 2.4 to 3.2mm (SE Asia);1.8–1.9mm (India);1.8–2.8mm (North America). RAD is 1.5mm in 8–10% of our patients. The outer diameter of radial sheaths varies with manufacturers ( 2.4mm for 5F sheaths and 2.7mm for 6Fr sheaths). The Glidesheath Slender (GSS TM Terumo, Japan) has a thinner wall, that reduces its outer diameter to 4Fr & has the potential to minimize RA: Sheath size mismatch, which is associated with higher risk of RAS and RAO especially in patients with SDRA. This non-randomized prospective study was performed on consecutive patients who presented to the Mission hospital Durgapur, India for coronary angiograms and/or angioplasty in July 2015 with the aim of assessing the safety and feasibility of the 5 Fr-GSS for complex coronary interventions in patients with SDRA using 5Fr guiding catheters. All patients underwent ultrasound of arm arteries (UAA), to evaluate for internal diameters of bilateral RA and UA, cubital loops and vascular anomalies, to which the operators were blinded. Consenting patientswith right RAD<1.8mm& coronary lesions of AHA/ACC type B2 or C were included. The inclusion of patients with RAD <1.8mm was based on prior data showing that these patients had greater post-procedure (PP) RAO. Patients with RAD [20_TD

Balloon assisted tracking: a double edged sword.

DIFF][19_TD

How good are best practices for transradial angiography and intervention without preprocedure ultrasound of arm arteries

DIFF]31.8mm, acute ST elevation myocardial infarction, those with thrombotic lesions requiring thrombosuction (TRTS) or the presence of known bifurcation lesions with side branch >2mm (SB2); calcific lesions requiring rotablation & those unable to consent were excluded. Transradial intervention (TRI) was done using standard procedures via right radial access. PPhemostasis was achieved by manual compression after sheath removal when the activated clotting time was <160 s. Average time to hemostasis was 18+/–7min. UAA was repeated in patients at 0, 7 and 30days PP to detect RAO. Out of 19 consecutive patients, 9 met inclusion criteria {(Chronic total occlusion(n = 5),B2-lesions (n = 4)}; while 10 were excluded{TRTS (n = 3), SB2 (n =2), Lesion A/B1 (n = 3), RAD >1.8mm (n=2)}. The mean RAD (1.6 0.2mm) in our cohort was smaller than those from prior observational studies. PP-RAO occurred in one patient on day-0 with bilateral parallel RA and UA and high origin of the SDRA from the axillary artery. This patient also had intra-procedure grade 2 spasm. Another patient had a minor arm hematoma from injury by the tip of a 0.035” glidewire. This was contained by inflating a sphygmomanometer cuff. In one patient with a cubital loop, right radial access failed, necessitating access site change to left RA. In no case the GSS kinked or fractured. Although this initial study is too small for any conclusions on RAO; we found the new 5 Fr GSS, to be safe and feasible in the patients with SDRA (<1.8mm), who underwent complex TRI at our hospital without any major complications.

The dilemma of evaluating a continuous murmur in a patient of aneurysm of sinus of Valsalva and coronary cameral fistula presenting with supraventricular tachycardia

We read with great interest and would like to congratulate the authors on their novel technique of using Balloon Assisted Tracking (BAT) [1] in complex arterial lesions encountered in transradial interventions (TRIs), which is an attempt to help ease the steep learning curve associated with TRIs amongst operators. The authors describe this technique for use in patients with arteries smaller than 1.5 mm in diameter, as well as situations of severe radial artery (RA) spasm, tortuosity, loops, and subclavian tortuosity / stenosis. The manuscript, however, lacks clarity on whether the same technique can be implemented to tackle complex lesions using larger guiding catheters in patients who have radial arteries >1.5mm. There are several other concerns regarding this innovative technique:

TCT-822 Overcoming The Challenge Of Transradial Interventions In Women : Insights From a Color Doppler Study

I read with interest the consensus statement and congratulate the authors for this first of its kind, much needed document on the subject [1]. However, as a member of the transradial working group since its inception, I am disappointed that there is no reference to our technique [2] of using preprocedure ultrasound of bilateral arm (PPUAA) arteries to size them and rule out any anomaly, enabling the selection of the straightest and largest forearm vessel for access in just 6.3 min [2]. We showed enhanced procedural success, reduced spasm, and radiation exposure using this technique. As this is also a quality issue, it should have formed part of the best practice document, even though consensus may be lacking in the American Healthcare System regarding the use of ultrasound for this purpose secondary to logistic and financial issues. A cost–benefit analysis was not done in our study but it stands to reason that if a technique reduces risk of complications, in addition to reduced spasm and associated pain, fluoroscopy time, and crossover to transfemoral access, while enhancing success; then the benefits override the cost of PPUAA. I hope that in the interest of patient safety and comfort, the authors of the consensus document will incorporate this technique [2] as an addendum.

Chapter-03 Slender Transradial Interventions

A 39-year-old hypothyroid woman on thyroxine replacement therapy presented with an unresolving episode of palpitations (narrow-complex tachycardia). Clinical examination, after reversion to normal sinus rhythm revealed a precordial continuous murmur. Initial transthoracic echocardiogram showed an unruptured aneurysm of left sinus of Valsalva (LSOV), however, because a continuous murmur could not be explained by this condition, a repeat colour Doppler study was made, revealing a communicating tract from the left main coronary artery (LMCA) and terminating in the right atrium (RA). A transesophageal echocardiogram revealed an aneurysmal LMCA and LSOV, with similar colour Doppler findings. A further CT scan and coronary angiogram confirmed a coronary cameral fistula opening into RA. In conclusion, the relevance of a diligent clinical examination and imaging after conversion to normal sinus rhythm in picking up such anomalies cannot be over-emphasised, as previous routine echocardiograms on the same patient had been reported as normal.