Zoltán Ruzsa

Anterograde recanalisation of the radial artery followed by transradial angioplasty

We report a patient with critical hand ischemia after transradial coronary angioplasty. The radial artery occlusion was confirmed by angiography. The report discusses the role of angioplasty for the treatment of symptomatic radial artery occlusion.

A randomised comparison of transradial and transfemoral approach for carotid artery stenting: RADCAR (RADial access for CARotid artery stenting) study

AIMS Limited data exist on radial access in carotid artery stenting. This multicentre prospective randomised study was performed to compare the outcome and complication rates of transradial and transfemoral carotid artery stenting. METHODS AND RESULTS The clinical and angiographic data of 260 consecutive patients with high risk for carotid endarterectomy, treated between 2010 and 2012 by carotid stenting with cerebral protection, were evaluated. Patients were randomised to transradial (n=130) or transfemoral (n=130) groups and several parameters were evaluated. Primary combined endpoint: major adverse cardiac and cerebral events, rate of access-site complications. Secondary endpoints: angiographic outcome of the procedure, fluoroscopy time and X-ray dose, procedural time, crossover rate to another puncture site and hospitalisation in days. Procedural success was achieved in all 260 patients (100%), the crossover rate was 10% in the TR and 1.5% in the TF group (p<0.05). A major access-site complication was encountered in one patient (0.9%) in the TR group and in one patient (0.8%) in the TF group (p=ns). The incidence of major adverse cardiac and cerebral events was 0.9% in the TR and 0.8% in the TF group (p=ns). Procedure time (1,620 [1,230-2,100] vs. 1,500 [1,080-2,100] sec, p=ns) and fluoroscopy time (540 [411-735] vs. 501 [378-702] sec, p=ns) were not significantly different, but the radiation dose was significantly higher in the TR group (195 [129-274] vs. 148 [102-237] Gy*cm2, p<0.05) by per-protocol analysis. Hospitalisation days were significantly lower in the TR group (1.17±0.40 vs. 1.25±0.45, p<0.05). By intention-to-treat analysis there was a significantly higher radiation dose in the TR group (195 [130-288] vs. 150 [104-241], p<0.05), but no difference in major events (0.9 vs. 0.8, p=ns) and length of hospitalisation in days (1.4±2.6 vs. 1.25±0.45, p=ns). CONCLUSIONS The transradial approach for carotid artery stenting is safe and efficacious; however, the crossover rate is higher with transradial access. There are no differences in the total procedure duration and fluoroscopy time between the two approaches but the radiation dose is significantly higher in the radial group, and the hospitalisation is shorter with the use of transradial access by per-protocol analysis. By evaluating the patient data according to intention-to-treat analysis we found no difference in major adverse events and hospitalisation. In both groups, vascular complications rarely occurred.

Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropoliteal occlusions in critical limb ischemia

Successful angioplasty is one of the main factor of limb salvage during critical limb ischemia. In complex femoropopliteal to infrapopliteal occlusions, an anterograde recanalization attempt can fail in up to 20% of the cases. The purpose of this dual center pilot study was to evaluate the acute success and clinical impact of retrograde transpedal access for retrograde below‐the‐knee and femoropopliteal chronic total occlusions after failed anterograde attempt and to access the late complications at the puncture site.

Clinical predictors of mortality following rotational atherectomy and stent implantation in high‐risk patients: A single center experience

Our aim was to assess the procedural success and determine the clinical predictors of postprocedure mortality, following rotational atherectomy (RA) and stenting in high‐risk patients.

Impact of Center Experience on Patient Radiation Exposure During Transradial Coronary Angiography and Percutaneous Intervention: A Patient-Level, International, Collaborative, Multi-Center Analysis

Background The adoption of the transradial (TR) approach over the traditional transfemoral (TF) approach has been hampered by concerns of increased radiation exposure—a subject of considerable debate within the field. We performed a patient‐level, multi‐center analysis to definitively address the impact of TR access on radiation exposure. Methods and Results Overall, 10 centers were included from 6 countries—Canada (2 centers), United Kingdom (2), Germany (2), Sweden (2), Hungary (1), and The Netherlands (1). We compared the radiation exposure of TR versus TF access using measured dose‐area product (DAP). To account for local variations in equipment and exposure, standardized TR:TF DAP ratios were constructed per center with procedures separated by coronary angiography (CA) and percutaneous coronary intervention (PCI). Among 57 326 procedures, we demonstrated increased radiation exposure with the TR versus TF approach, particularly in the CA cohort across all centers (weighted‐average ratios: CA, 1.15; PCI, 1.05). However, this was mitigated by increasing TR experience in the PCI cohort across all centers (r=−0.8; P=0.005). Over time, as a center transitioned to increasing TR experience (r=0.9; P=0.001), a concomitant decrease in radiation exposure occurred (r=−0.8; P=0.006). Ultimately, when a centers balance of TR to TF procedures approaches 50%, the resultant radiation exposure was equivalent. Conclusions The TR approach is associated with a modest increase in patient radiation exposure. However, this increase is eliminated when the TR and TF approaches are used with equal frequency—a guiding principle for centers adopting the TR approach.

Transradial and transulnar access for iliac artery interventions using sheathless guiding systems: A feasibility study

Our aim was to evaluate the acute success and complication rates of the transradial and transulnar access for iliac artery stenting using sheathless guiding systems.

Rotational atherectomy of undilatable coronary stents: Stentablation, a clinical perspective and recommendation

AIMS Our aim was to examine procedural viability and midterm outcomes following the use of rotational atherectomy (RA) on malapposed, crippled, otherwise non-salvageable metallic stents (i.e., stentablation [SA]), and convey important procedural pointers for practitioners encountering such situations. METHODS AND RESULTS Data on twelve SA subjects were analysed. The primary endpoint was procedural success: effective ablation of the malapposed stent and successful implantation of a new device. Major adverse cardiac events (MACE) and all-cause death at six months following the index procedure were examined as a secondary endpoint. All twelve patients underwent successful SA and novel stent implantation, with sufficient salvage of coronary anatomy (residual stenosis <30%). At six-month follow-up, however, MACE amounted to 50% and all-cause mortality to 25% in the inspected subjects. CONCLUSIONS We found that, although feasible as an acute salvage option, SA distinctively increases post-procedural midterm MACE and mortality rates. This places emphasis on the importance of avoiding eventual SA situations, underlining the importance of ample lesion preparation prior to stent implantation.

Catheter-induced brachial artery dissection during transradial angioplasty.

The transradial approach is becoming a very popular technique in coronary and peripheral interventions because of its low vascular complication rate and improved patient comfort. Reported complications during the transradial approach are radial artery spasm, perforation, occlusion and formation of pseudoaneurysms. The kinking of the diagnostic catheter during catheter manipulation in a severely tortuous subclavian artery can occur very easily, and catheter movements at this point can cause barchial and subclavian artery dissection. We report a case of brachial and subclavian artery dissection during transradial diagnostic angiography, treated by angioplasty and stenting.

Retrograde transpedal stenting of the tibioperoneal trunk in critical limb ischemia.

Management of critical limb ischemia (CLI) requires a combined treatment approach: optimal medical therapy and revascularization procedures are both essential for favorable outcome. With the development of endovascular interventions these new modalities took the primary role in limb revascularization, especially in CLI patients, where the culprit lesion is often located below the knee (BTK) level, making the surgical procedure unfeasible. In our present case report, we demonstrate a successful percutaneous recanalization of a surgically non‐treatable tibioperoneal trunk occlusion. The procedure was performed with dual access from anterograde and retrograde transpedal approach, and modified “V stenting” technique was used. We describe feasibility of bail out stenting using retrograde posterior tibial artery access after failed retrograde guidewire externalization. Our report discusses the feasibility, safety, and efficacy of the retrograde approach applying 4F compatible devices.

Retrograde subintimal recanalization of a radial artery occlusion after coronary angiography using the palmar loop technique

We report interventional management of critical hand ischemia after transradial coronary angiography. The radial artery occlusion was confirmed by Doppler ultrasound and digital subtraction angiography. The radial artery was opened using retrograde recanalization technics through the palmar arch. After guidewire passage the proximal occlusion site was stented with balloon expandable drug eluting stent, and the distal segment underwent balloon angioplasty. The report discusses the potential risks and advantages of angioplasty in the treatment of a symptomatic radial artery occlusion and the retrograde recanalization technique via the palmar arch.