Impact of the Learning Curve and the Time of Day on the Procedure in STEMI Patients Undergoing Primary PCI with Left Radial Approach

Abstract

PURPOSE: Since 2011 the primary setup of our catheterization lab has been changed to left radial, and nowadays approximately 95% of all procedures are performed with either left or right “wrist access.” Primary PCI in STEMI patients (pts) are the most demanding and operators need to
be well trained before they begin using the radial approach. The aim of the study was to establish whether the operator’s experience in left radial approach and the time of day when
the procedure was done had any influence on the success of the procedure, or on patient and operator safety in STEMI pts undergoing primary PCI with left radial approach.
METHODS: In this retrospective analysis we included 596 pts with STEMI, treated in our center from January 01, 2011 to June 01, 2014 with primary PCI with left radial
approach. We did not include pts treated with right radial or with femoral access. To analyze the learning curve variability we divided pts into 6 month period groups, with the total
of 7 groups. The second analysis was according to the time of day when pts arrived to the catheterization lab and so pts were divided into three groups (A: 8-16h, B: 16-24h and C:
24-8h). RESULTS: We found that fluoroscopy time was significantly longer and that a larger amount of contrast was used in the first year after changing the setup from femoral to left radial. During that time some of the operators were just finishing the training for the radial approach. Even so, the
procedure radiation dose was significantly higher in the first year and a half. On the other hand, there was no significant difference in procedure success, “door to balloon” time or total
procedure time in all analyzed groups. In the sub analysis we did not find that the time of day when the procedure was done had any significant influence on any of the analyzed parameters.
CONCLUSION: Fluoroscopy time, amount of contrast used and fluoroscopy dose are higher in STEMI pts treated with primary PCI in the first year after changing the setup of the catheterization lab to left radial. In time and with more operator experience, these measures can be expected to be significantly decreased.

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2A The Journal of InvasIve CardIology®
Transradial Approach in the World
New Zealand
Interventional Cardiology and the Transradial Approach
in New Zealand
Jim Stewart, Peter Barr, David Smyth, Andrew Kerr, Charmaine Flynn
Green Lane Cardiovascular Service, Auckland City Hospital, New
Zealand
New Zealand (NZ) is a country of 4.5 million people
located in the south Pacific, at the southern end of the so-
called “Polynesian triangle” (formed with Hawai’i to the
north and Easter Island to the east). Although the population
is small, it is spread over a land area that is a similar size to
Great Britain, with the majority living in the upper half of
the north island. According to the 2013 census, the ethnic
makeup of New Zealand is: European 74%, Maori 14.9%,
Asian 11.8%, Pacific peoples 7.4%, Middle Eastern/Latin
American/African 1.2%.
The health system provides free hospital care to all citi-
zens and residents, funded out of general taxation. Visits to
general practitioners and dentists generally attract a fee; pre-
scription drugs are purchased by a central buying agency on
behalf of the government, which attempts to get the lowest
price for pharmaceuticals and encourages the use of generic
agents once patents have expired. About 30% of the popu-
lation has private health insurance, which generally will not
cover acute conditions (since all patients can receive emer-
gency treatment at public hospitals). Coronary angiography
is undertaken in 11 public hospitals (PCI in 9) and 5 private
clinics; there are 5 cardiothoracic surgical centers located in
public hospitals (and 1 pediatric cardiothoracic center).
A comprehensive national cardiac registry, funded by the
Ministry of Health, was implemented in 2013, under the
auspices of the New Zealand branch of the Cardiac Society
of Australia and New Zealand. Since late 2013 all NZ public
hospitals that provide coronary angiography have complet-
ed the web-based CathPCI registry form for every coro-
nary angiogram perfor med. Complete data are available for
5 months from each of these centers, and are used in this
report.
The New Zealand interventional community adopted
radial access quite early (in the early 2000s) and almost all
centers are predominantly radial. Of the 5,894 coronary pro-
cedures recorded, 81.4% used radial artery access; the aver-
age number per center varied from 25 to 176 procedures
per month and the radial access rate averaged from 46.5% to
96.4%. Individual operators performing more than 20 pro-
cedures per month had radial access rates of 61% to 99%.
The highest volume operators (>30 procedures/month) had
radial access rates of greater than 80%.
Four of the 9 interventional centers had radial access rates
of greater than 90%. Radial access rates in patients admit-
ted with ST-elevation myocardial infarction (STEMI) was
79.5% for primary PCI and 71.4% for rescue PCI (n=42
for rescue PCI). In 2 centers, 100% of STEMI patients were
treated via the radial artery. Using multivariate analysis, the
strongest predictors of non-radial access were Maori ethnic-
ity and previous coronary surgery. Maori are recognized as
an ethnic group with high rates of vascular disease, diabetes
and renal dysfunction, which may influence choice of access
route (e.g. possible need for future dialysis access).
Although these are not randomized data (and it is possible
that those undergoing femoral procedures may have been a
higher risk cohort than those with radial procedures), they
support the information from randomised trials: all cause in-
patient mortality was lower (0.5% vs 2.1%, P<.0001), and
bleeding was reduced ([1.0% vs 3.5%, P<.0001], including
TIMI major bleeding 0.1% vs 0.4%). Interestingly, length of
stay was not significantly different between the groups.
In summary, radial access predominates in invasive cor-
onary procedures in New Zealand, with over 80% of cases
being performed radially. Nevertheless, there is still a high
degree of variability from one region to another, and from
one operator to another. Even within high volume opera-
tors, defined as >20 procedures/month, rates of radial access
vary from 61% to 99%.
Uruguay
Coronary Interventional Cardiology and Transradial
Approach in Uruguay
PA Vázquez, J Mayol, G Vignolo, I Batista, S Alonso, R Abreu, M
Dieste, R Lluberas, A Duran, C Pardiñas, T Dieste
Centro Cardiológico Americano, Montevideo, Uruguay
Uruguay is a country with an area of 176,220 km2 being
the second smallest of South America. Bounded on the north
and east by Brazil; west and southwest by Argentina. The
population is 3,407,000 inhabitants, and has not changed
significantly in the last 10 years. The economy has presented
sustained growth over the last 10 years and has multiplied by
4 its gross domestic product (GDP) in this period. It is the
Latin American country with the highest GDP per capita.
The life expectancy at birth was 77 years at the end of 2012
(from Worldbank Data 2014, http://www.worldbank.org/
en/country/uruguay).
Health is administered by the government in a national
system that provides coverage to all inhabitants of the coun-
try on equal terms (Integrated National Health System).
In turn, the high-tech and high-cost drugs are funded by a
non-state public institution called National Resource Fund
(FNR). Interventional cardiology (IC) is included within
this coverage, ensuring that all inhabitants have access.
IC has achieved a great development in our country,
mainly in coronary intervention. It is developed in only 6
centers all of high volume and with a high expertise of its
operators. Learning and specialty training is done through
residence in cardiology regime at the University of the Re-
public (UDELAR) and then as a fellowship training in any
of these 6 centers. The radial approach (RA) has been used
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vol. 27, supplemenT a, January 2015 3A
AimRADiAL 2014 AbstRActs
for over 15 years, at which time some centers already per-
formed the majority of the procedures by this approach. We
are proud to be pioneers in Latin America in the widespread
use of the technique and to have been boosters of the radial
approach in the region, training colleagues in our centers as
well as in their own countries. We have also promoted the
use of RA through multiple events of the Latin American
Society of Interventional Cardiology (SOLACI).
Data from the FNR show that between 2010 and 2013,
14,799 diagnostic catheterizations were performed in Uru-
guay, of which 14,023 (94.8%) were done by RA and 776
(5.2%) by femoral approach (FA). In that period 13,217 an-
gioplasties or percutaneous coronary interventions (PCI)
were performed, of which 12,594 (94.7%) were done by RA
and 623 by FA (4.3%). The following table shows the clini-
cally relevant variables that we found significantly associated
with the choice of vascular approach in our population.
Variable Radial Approach (%) P
Age (yrs) <51 51-60 61-70 >70
96.8 96.8 94.5 93.5 <.001
Gender Male Female
96.1 92.9 <.001
Diabetes No Yes
93.6 95.7 <.001
Renal function Normal R failure
No HD
HD
95.5 89.4 59.6 <.001
STEMI No Shock Shock
96.2 82.3 <.001
HD = hemodialysis; R failure = renal failure; STEMI = ST-elevation
myocardial infarction
Therefore, the most commonly used vascular approach
for coronary IC in Uruguay is RA in all scenarios, especially
in younger, non diabetic and male patients and in the ab-
sence of hemodialysis or shock.
Philippines
Transradial Approach to Coronary Interventions in
the Philippines
J. Edgar Villano, MD, FPCC, IFPSCCI, FACC, FSCAI.
Philippine Heart Center, Quezon City, Philippines
The Philippines has been among the dynamically emerg-
ing markets in the East Asia region with its sound economic
fundamentals and highly skilled workforce. With a total pop-
ulation of almost 99 million and a lower middle income lev-
el, the economy posted 7.2% GDP growth in 2013. Growth
momentum was maintained at 6% in the first half of 2014
and remained one of the fastest in the region.
Health insurance coverage has increased largely in the
past five years from 42% in 2008 to 63% in 2013. The cost of
healthcare received in private medical providers is substantially
higher than the cost of care received in public facilities. Only
less than half of the average hospital bill is paid by the na-
tional health insurance provider PhilHealth, perhaps in part
because not everyone has PhilHealth coverage.
The pioneers of interventional cardiology in the Philip-
pines saw the need to gather interventional cardiologists in
the country to at least exchange notes in individual cathe-
terization laboratory exper iences and at most advance the
field of cardiovascular catheterization and interventions to
a level that would offer maximum benefit and safety for pa-
tients needing these procedures. Thus, on 12 January 1993,
the Philippine Society of Cardiovascular Catheterization
and Interventions (PSCCI), an affiliate society under the
umbrella of the Philippine Heart Association and Philippine
College of Cardiology, was formally organized with Dr. Dy
Bun Yok as its first president. Among the primary objectives
of the society are to: (1) develop, optimize, promote, and reg-
ulate the practice of diagnostic cardiac catheterization and
interventional cardiology in the Philippines; (2) to define the
basic criteria for training and accreditation of cardiologists
who wish to perform or continue to perform diagnostic and
interventional cardiology; (3) to support and supervise re-
search towards the improvement of the quality and safety of
cardiovascular catheterization and interventional procedures;
and (4) to develop procedures for self and peer assessment
of its members. Currently, the list of membership includes
137 adult interventional cardiologists with 44 Fellows and
21 Interventional Fellows. To date, there are 31 catheteriza-
tion laboratories in the Philippines with 17 of them in the
greater Metro Manila area. There are 2 more catheterization
laboratories opening in 2015. All catheterization laboratories
are in hospitals with facilities for open heart surgery. The
premiere training institution for cardiology in the country
is the Philippine Heart Center which has 3 top-of-the-line
cath lab machines and 1 hybrid operating room with more
or less 1,160 PCIs a year. In 2013, the total number of cor-
onary artery bypass graft surgeries at the Philippine Heart
Center was 619. One has to finish a 3-year training program
in internal medicine and a 3-year core curriculum in general
clinical cardiology before embarking in interventional car-
diology training. An aspiring training fellow also has to pass
both diplomate certifying examinations in internal medicine
and in adult cardiology before being accepted in the one
year interventional cardiology training program (2 years in
low volume centers). Some fellows pursue further training
in interventional cardiology in first world countries.
Most interventional cardiologists in the Philippines were
trained with the femoral access. But today, the radial artery
default access to coronary angiography and interventions is
gaining popularity and support within the local interven-
tional community. However, the rate of default transradial
approach still varies widely from one operator to another
across the country with an approximately 15% overall rate.
One private medical center has a TRA rate of 87%. The new
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training fellows are now being exposed to both radial and
femoral approaches.
Aside from less vascular and bleeding complications
requiring blood transfusions and even surgery, there is a
cost-effective benefit with the transradial approach as a re-
sult of early ambulation and discharge which can translate
to significant savings for the patient, especially in the Philip-
pine setting. Transradial procedures are now being done on
an outpatient basis in low risk patients and in those with no
other serious illnesses that require in-hospital monitoring.
The transradial approach to coronary interventions under-
scores efforts to further improve the quality of patient care
as well as enhance patient experience in terms of comfort,
safety, and cost.
Training and Learning Curve
Impact of the Learning Curve and the Time of Day
on the Procedure in STEMI Patients Undergoing
Primary PCI with Left Radial Approach
ID Gabric, H Pintaric, Z Babic, M Trbusic, T Krcmar, K Stambuk,
J Budimilic-Mikolaci, I Benko, O Vinter, I Zeljkovic, S Manola, V
Radeljic, D Planinc, D Delic-Brkljacic
University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
PURPOSE: Since 2011 the primary setup of our cathe-
terization lab has been changed to left radial, and nowadays
approximately 95% of all procedures are performed with
either left or right “wrist access.” Primary PCI in STEMI
patients (pts) are the most demanding and operators need to
be well trained before they begin using the radial approach.
The aim of the study was to establish whether the operator’s
experience in left radial approach and the time of day when
the procedure was done had any influence on the success of
the procedure, or on patient and operator safety in STEMI
pts undergoing primary PCI with left radial approach.
METHODS: In this retrospective analysis we included
596 pts with STEMI, treated in our center from January 01,
2011 to June 01, 2014 with primary PCI with left radial
approach. We did not include pts treated with right radial or
with femoral access. To analyze the learning curve variability
we divided pts into 6 month period groups, with the total
of 7 groups. The second analysis was according to the time
of day when pts arrived to the catheterization lab and so pts
were divided into three groups (A: 8-16h, B: 16-24h and C:
24-8h).
RESULTS: We found that fluoroscopy time was signifi-
cantly longer and that a larger amount of contrast was used
in the first year after changing the setup from femoral to
left radial. During that time some of the operators were just
finishing the training for the radial approach. Even so, the
procedure radiation dose was significantly higher in the first
year and a half. On the other hand, there was no significant
difference in procedure success, “door to balloon” time or to-
tal procedure time in all analyzed groups. In the sub analysis
we did not find that the time of day when the procedure was
done had any significant influence on any of the analyzed
parameters.
CONCLUSION: Fluoroscopy time, amount of contrast
used and fluoroscopy dose are higher in STEMI pts treated
with primary PCI in the first year after changing the setup
of the catheterization lab to left radial. In time and with
more operator experience, these measures can be expected
to be significantly decreased.
Transradial Approach in Iran
O Hashemi Fard
Chamran Hospital, Isfahan, Iran
PURPOSE: To assess use of the transradial approach in Iran
and its growth in recent years.
METHODS: Sampling from centers across the country
on the percentage of coronary angiographies and percutane-
ous coronary interventions done through radial route.
RESULTS: Although transradial approach usage has in-
creased four-fold in previous 4 years it still remains below 30%.
Hemostasis, Radial Artery Injury and Occlusion
New Retrograde Arterial Access for Repeat Radial Cath-
eterization in Case of Late Radial Artery Occlusion
AM Babunashvili
Center of Endosurgery, Moscow, Russia
PURPOSE: Late radial artery (RA) occlusion occurs in
3-9% of transradial interventions limiting our ability of same
RA repeat catheterization. The purpose of this study was to
examine feasibility and safety of new radial arterial access for
late radial artery occlusion (RAO) recanalization.
METHODS & RESULTS: We demonstrate the possi-
bility of retrograde RA recanalization, dilatation and resto-
ration of the lumen of occluded RA through new vascular
access – deep palmar arterial arch (branch from radial artery).
This new puncture point located in wrist portion of radial
artery distally of origin ramus palmaris superficialis just over
the bone trapezium that makes good platform for compres-
sion hemostasis of puncture site. We used this new approach in
14 cases of RAO. In all cases puncture of deep palmar arterial
arch was successful and in 12 cases RAO recanalization and
restoration of RA lumen for repeat transradial intervention
(TRI) was achieved. We used “Dotter-type” recanalization (4
cases), balloon dilatation after wire crossing (3 cases) or mixed
technique (5 cases). No major access site complications oc-
curred; there were minor hematomas around puncture site in
two cases without clinical consequences. In all 14 cases deep
palmar arch punction artery was patent at moment of patient
discharge (1-2 days later TRI).
CONCLUSIONS: New access through the deep palmar
arch (branch from distal RA) is feasible and safe. It provides
more space (enlarges distal postocclusion segment) for safe
and effective manipulation for further recanalization of
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RAO. Moreover, caliber of access artery allows us to use
same instruments for catheterization as we usually use in
traditional RA entry point.
Incidence of Radial Artery Injury After PCI for Non-
STEMI ACS and 9-Month Follow-Up Re-Catheter-
ization Assessed by Optical Coherence Tomography
R Miklik, J Kanovsky, M Poloczek, O Bocek, P Jerabek, T On-
drus, T Novakova, J Spinar, P Kala.
Internal Medicine and Cardiology, University Hospital Brno, Brno,
Czech Republic
PURPOSE: To study the frequency of an acute injury of
the radial artery (RA) caused during the percutaneous cor-
onary intervention (PCI) and during subsequent 9-month
follow-up re-catheterization (9M FU reCAG) in patients
treated for non-STEMI acute coronary syndrome (ACS).
We used frequency-domain optical coherence tomography
(FD-OCT, Ilumien, St. Jude Medical) for the assessment.
METHODS: Since Dec 2012, we have performed FD-
OCT of the RA in 100 patients admitted to the PCI center
for the non-STEMI ACS. None of these patients had had
radial PCI in the past. 49 of these subjects underwent 9M
FU reCAG and radial OCT examination. Having pulled the
6-French radial sheath (Radifocus introducer, Terumo, 7cm
long) 4-5cm back out of the artery, we used automated pull-
back (54mm) starting 7cm from the tip end of the sheath
with the manual injection of the contrast fluid. All the FD-
OCT recordings were assessed by two analysts, evaluating
intimal tear (not affecting media), acute dissection (affecting
media) and perforation occurrence of the RA.
RESULTS: Right after the index PCI procedure, we
found 2 cases of intimal tear and 1 dissection (all together
3% of patients), after the 9M FU reCAG there were 5 cases
of intimal tear, 4 dissections and 1 perforation in 9 of 49 ra-
dial arteries (18.4% patients). No occlusions were found. All
complications were without sequelae.
CONCLUSION: Acute radial injury during the first-
time radial access PCI is very rare (3%). Only minor injuries
of no clinical importance were found. Chronic changes (in-
timal proliferation, fibrosis etc) of the artery are the subject
of our further research, but acute radial injuries after subse-
quent re-catheterizations are much more common (18.4%).
Both acute and chronic changes/injuries may play a role in
future utilization of these arteries for surgical purposes.
Supported by the Grant of the IGA Ministry of Health of
the Czech Republic no. NT/13830.
How Feasible is it to Reuse the Radial Artery for
Intervention
V Singh, P Kumar, A Sinha, A Gopal, K Vaibhav
Paras HMRI Hospital, Patna, India
BACKGROUND: We report our experience with reuse
of the same radial for repeat intervention- the safety, feasibil-
ity and further patency of this artery in follow-up.
METHODS: Data from patients undergoing coronary
angiography (CAG) and percutaneous coronary interven-
tion (PCI) at our center between Aug 1, 2013 to May 31,
2014 were analysed. Data was analysed in terms of total radi-
al CAGs requiring a repeat intervention (most often PTCA
to the culprit artery) and the safety and feasibility outcomes.
RESULTS: A total of 795 CAGs and 206 PCI were done
during this period. Out of the 771 CAGs that were done
using the radial route, 55 patients underwent PTCA to the
culprit lesion, not in the same sitting (next day in 34 patients,
between days 2-7 in 13 and after the first week in 8). In 51
of the 55 patients, the same radial access (right) could be
employed for a successful PTCA. The most frequent compli-
cations after the initial CAG in these patients were all local
[small hematoma in 6 patients (11.7%), superficial bruising
in 8 (15.7%) and local tenderness in 29 (56.8%) patients out
of 51]. The local tenderness in most of these patients (25 of
29) could be controlled with SOS analgesics. After the sec-
ond procedure (PTCA), hematoma was seen in 9 (17.6%),
superficial bruising in 17 (33.3%) and local tenderness in 44
(86.3%) of the 51 patients. Pain and tenderness necessitated
a short course of analgesics in 26 patients while 18 could
be managed with SOS analgesics. None of the hematomas
again was of any hemodynamic significance. Pain and local
tenderness were most marked in the patients who had re-
quired the procedures in quick succession. Three of these
51 patients required a third procedure, all within 48 hours
of the PTCA. In all of these, the same access was uniformly
employed and procedure could be completed successfully.
CONCLUSION: If measures are taken to ensure paten-
cy of the radial artery, it is feasible to employ it for repeat
procedures if required for future procedures. The only po-
tential problems is a slightly increased risk of local compli-
cations particulary superficial bruising which is self- limiting
and pain and tenderness at the local site which can be man-
aged with oral analgesics.
Technical Aspects
Placement of Amplatzer Vascular Plug 4 via Transradial
Approach in the Visceral Arteries
MP Edwards, RS Patel, SF Nowakowski, E Kim, R Lookstein,
AM Fischman.
Icahn School of Medicine at Mount Sinai, New York NY, USA
PURPOSE: To determine the technical success and ef-
fectiveness of placing the Amplatzer Vascular Plug 4 (AVP4)
in the visceral arteries from a transradial approach.
METHODS: A retrospective single center review from
April 2012-June 2014 was performed of 845 patients under-
going transradial intervention. Of these patients, AVP4 place-
ment from a radial approach was attempted in 20 patients
in 21 vessels. The technical success of placing the AVP4 and
effectiveness (as defined by complete vessel occlusion at the
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6A The Journal of InvasIve CardIology®
time of deployment and at follow-up) of the embolization
was evaluated. The Barbeau waveform, device size, emboli-
zation adjunct, catheter selection, sheath size, target vessel,
fluoroscopic time, and major and minor adverse events were
also recorded.
RESULTS: 21 vessels embolized included: gastroduo-
denal artery (GDA) (n=15), right gastric artery (n=2), left
hepatic artery (n=1), right inferior phrenic artery (n=1),
splenic artery (n=1), abdominal aortic Type I endoleak
(n=1). AVP4 diameters included: 6mm (n=10) and 8mm
(n=11). Technical success was 100%. 1 case required addi-
tional embolization for complete occlusion. Effective embo-
lization occurred in 15/18 (83%) vessels on follow-up DSA/
CT/MRI. Median follow-up interval was 23 days. 2 of 3
recanalized vessels were GDA and 1 included a small but
significantly reduced persistent endoleak in the abdominal
aneurysm. Mean fluoroscopy time was 28 minutes (range
8-40). Radial sheath size included: 4F (n=1), 5F (n=18) and
6F (n=1). There was no evidence of radial artery occlusion
or major or minor adverse events at 30 days.
CONCLUSION: AVP4 placement in the visceral ar-
teries via a transradial approach is technically feasible and
effective without complication.
The Incidence of Anatomical Variations from Wrist to
Aorta and their Impact on Transradial Interventional
Procedures
H Pejkov, B Zafirovska, O Kalpak, S Kedev
University Clinic for Cardiology, University Ss Cyril and Methodius
Medical Faculty, Skopje, Republic of Macedonia
PURPOSE: To assess the incidence of arterial anom-
alies from wrist to aorta and their impact on the success
of primary chosen transradial access site in a large ser ies of
patients.
METHODS: 10,502 consecutive patients from March
2011 to July 2013 were examined at the University Clinic
for Cardiology in Skopje. Preprocedural radial artery angi-
ography was performed in all patients. Clinical and proce-
dure characteristics, type of vascular anatomy variants and
transfer direction were analyzed. Primary endpoint of the
study was the occurrence of transradial approach failure due
to anatomical variants and need to crossover to another ac-
cess to finish the procedure. All other causes of TRA failure
were excluded. Secondary endpoints were presence of access
site bleeding complications and radial artery spasm.
RESULTS: From 10,502 consecutive transradial proce-
dures, anatomical variants were present in 1,114 (10.5%) pa-
tients. The most frequent variant was high-bifurcating radial
artery origin from the axillary and brachial arter ies in 733
(6.6%) patients, 105 (1.0%) had a full radial loop, 152 (1.4%)
had extreme radial artery tortuosity, 17 (0.16%) had hypo-
plastic radial artery, and 113 (1.0%) patients had tortuous
brachial, subclavian and axillary arteries. Anomalies of the
aortic arch (arteria lusoria) were found in 6 cases (0.05%).
From 1,114 patients with anatomic variants, failure in pri-
marily chosen access site occurred in 52 (4.7%). We had
successful crossing of anatomical variants in 1,062 patients
(95.3%). The presence of a complex radial loop in 23 (22%)
was the commonest cause of procedural failure. Access site
crossover due to spasm of the radial artery without anoma-
lies occurred in only 12 cases (0.01%). All other TRA pro-
cedures were successfully performed through the primary
chosen transradial access site with overall procedural success
rate of 99.4% in 10,450 patients.
CONCLUSION: Radial artery variations are relatively
common and a cause of transradial procedure failure even
for experienced radial operators. Pre-procedural radial ar-
tery angiography helps to delineate underlying variations
and successfully plan the strategy for crossing the anomaly.
High volume transradial centers with experienced transradi-
al operators have low transradial crossover rates due to ana-
tomical variations.
Transradial Percutaneous Coronary Interventions Using
a Sheathless Eaucath Guiding Catheter Compared to
Standard Guiding Catheter: a Randomized Study
E Tessitore, S Noble, F Rigamonti, S Bunwaree, M Righini, H
Robert-Ebadi, M Roffi, RF Bonvini
University Hospital of Geneva, Geneva, Switzerland
BACKGROUND: Guiding catheter (GC) characteris-
tics play an important role in the success of transradial (TR)
percutaneous coronary intervention (PCI). We compared TR
PCI with Sheathless Eaucath GC to standard GC in women
and patients with complex lesions requiring large bore GC.
METHODS: Between 2011 and 2013, we prospectively
randomized men with ostial or bifurcation lesions and all
women undergoing TR PCI at a single tertiary academic
center between standard 6 Fr in women and 7 Fr in men
GC (Medtronic) and the Sheathless Eaucath (Asahi Intecc,
Japan) GC (6.5 Fr in women and 7.5 Fr in men). The proce-
dures were performed by three trained radialists. Our prima-
ry endpoint was procedural success (successful PCI without
GC-induced coronary complications) and procedural safety
(absence of hematoma, radial occlusion assessed by duplex
scanning, PCI complications and vascular complications).
Secondary endpoint was the efficacy of the Sheathless Eau-
cath GC considering procedural time, amount of contrast
media, crossover to additional techniques (e.g. mother and
child technique) or to transfemoral approach.
RESULTS: We randomized 213 patients (110 (52%)
women and 103 (48%) men), who were treated using 116
Sheathless Eaucath GC and 117 standard GC for a total of
233 PCIs. The procedures were performed in the setting of
stable angina in 73% of the cases and acute coronary syn-
dromes in 27%. Lesion types were B2 and C in 60% of the
cases. PCI were performed for LAD (60%), LCX (22.5%)
and RCA (17.5%) lesions. In the standard GC group, despite
the use of the mother and child technique in 25%, crossover
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AimRADiAL 2014 AbstRActs
to the Sheathless Eaucath GC was necessary in 8.5% of the
cases in order to complete the PCI by TR approach. In 1.3%
of the cases (0.8% in the GC group and 1.7% in the Sheath-
less group) crossover to transfemoral approach occurred. No
PCI complications were directly related to the GC type. Ra-
dial occlusion was found overall in 3% of the cohort equally
distributed between both GC.
CONCLUSIONS: The use of Sheathless Eaucath GC in
TR PCI was feasible, safe and effective compared to standard
GC. Crossover to Sheathless Eaucath GC after standard GC
failure allowed successful TR PCI to be performed in most
patients of the studied population (i.e. women, men requir-
ing large bore GC).
Complex PCI
A Case of Embolic Inferior Wall Myocardial Infarction
Secondary to a Thrombus in the Right Coronary Sinus
of Valsalva Originating from the Left Atrial Append-
age. A Complex Case Tackled via Radial Approach
AS Ahmed, A Alqaqa’a, IC Gilchrist
Penn State Milton Hershey Medical Center and College of Medi-
cine, Heart and Vascular Institute, Hershey PA, USA
CASE: An 84-year-old woman with hypertension pre-
sented with epigastric pain lasting for three hours. Her
heart rate was 35-45 beats per minute, blood pressure was
190/80. She had normal cardiac and pulmonary exam. She
had no electrolyte derangement and a normal Troponin-I.
EKG showed a junctional rhythm at rate of 40 and 2 mm
inferior ST elevations with lateral ST depressions. She was
taken emergently to the catheterization lab. Coronary angi-
ography was performed via a right radial access. Attempts to
engage the right coronary artery (RCA) were unsuccessful
despite using multiple guide catheters. The left coronary sys-
tem showed no angiographic evidence of coronary artery
disease with left to right collaterals. Contrast injection in the
right coronary sinus suggested ostial total occlusion of the
RCA. Probing of a coronary wire near the potential ostium
location was associated with an accelerated idioventricular
rhythm and resolution of ST elevation. The RCA was then
easily engaged with angiography showing a smooth vessel
and abrupt termination of the distal PL2 branch. Left ven-
triculogram showed inferior and posterior-basal hypokine-
sis. A CT angiogram showed aortic root thrombus (21x16
mm) with extension into the right coronary sinus and a large
left atrial appendage (LAA) thrombus. Subsequent EKGs
demonstrated paroxysmal atrial fibrillation. A brain MRI
showed multiple embolic cerebral infarcts.
DISCUSSION: Coronary artery embolism is a known
etiology for acute coronary syndromes. There are very few
reports in the literature about ascending aortic thrombi
causing coronary sinus compromise and coronary artery
occlusion leading to acute. Initial attempts to engage the
RCA were unsuccessful secondary to the large thrombus in
the right coronary sinus completely obliterating the ostium.
Contrast injection in the right coronary sinus dislodged part
of the thrombus and revealed the RCA ostium. Attempts to
pass the coronary wire resulted in distal embolization of the.
The ascending aortic thrombus has likely originated in the
LAA secondary to undiagnosed atrial fibrillation. Other ev-
idence of systemic emboli was detected on further workup.
CONCLUSION: This case shows clear association be-
tween coronary artery embolism with a well-documented
right coronary artery sinus and LAA thrombus. It reflects
the importance of a thromboembolic etiology of MI and its
influence on therapeutic strategies. It also demonstrates that
such a complex case can be successfully performed through
radial access.
Transradial Approach and Distal Buddy-in-Jail Tech-
nique: a Series of 28 Cases
V Vangoisse, A Guédès, L Gabriel, C Hanet, E Schroeder
CHU Mont Godinne UCL, Yvoir, Belgium
BACKGROUND: Difficult coronary anatomies mixing
tortuosity, bending, lesions and vessels calcifications added to
plurifocal long and or severe stenosis are challenging cases,
often addressed either by CABG surgery or “aggressive“ PCI
strategies, using large guiding catheters, atherectomy devic-
es and adjunctive materials like mother and child catheters.
Transradial access is often denied due to requirement of
large bore catheters. We developed a new technique around
the buddy wire technique, using a distal “Buddy-in-Jail “
technique. The technique traps a buddy wire during a distal
stenting. The technique thereafter allows additional stenting
of proximal lesion(s) over either the jailed or the free wire.
The added support of a jailed wire allows use of 5 or 6 Fr
catheters even for tough anatomies. We report here our pre-
liminary experience.
METHODS: From December 2011, difficult cases were
recruited from 498 consecutive PCIs (ad hoc 423). We grad-
ed the diseased vessel anatomy according to a local score for
ease of angioplasty. The score uses patient, aorta, coronary
and lesions characteristics. A score of 3 or less is for easy
cases, 4 to 6 for intermediate difficulty and more than 7 for
tough cases.
RESULTS: The technique was applied to stent 28 pa-
tients, 6 LM/LAD/diagonal tree, 5 LM/CX tree, 16 RCA
and one SVG. 20 cases were ad hoc procedures. The mean
population age was 69 ± 10 y (min 39, max 89), included
4 female and 24 male patients with a mean BMI of 28 ± 5.
All cases except one were performed through right TRA
(16) or left TRA (11). 5 Fr guiding catheters were used for
19 and 6 Fr GC for 9. Of the 28 cases, 3 were intermediate
(mean 5.67), 25 were scored as difficult, score of 9.20 ±
1.55. All cases were successful and uneventful except for one
case of myocardial suffusion treated medically (post CABG
patient). The suffusion was related to a wire used as anchor
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AimRADiAL 2014 AbstRActs
8A The Journal of InvasIve CardIology®
in a non-treated vessel. Mean volume of contrast was 226
± 90, mean fluoroscopy time was 11 ± 11 min and mean
DAP was 173 ± 76 Gy/cm2. The trapped wire was used for
proximal stenting(s) in 10 cases and the free wire was used
for the remaining 18.
CONCLUSION: The Distal Buddy-in-Jail technique
allowed successful stent delivery in difficult anatomies with-
out requiring large catheters or special material. The tech-
nique should safely be integrated in the available solutions
for tough PCI.
Evaluation of the Safety and Efficacy of the Novel
Svelte™ Acrobat Integrated Delivery System via a
Radial Approach with 5-French Catheters
FS Devito, PB Andrade, CEF Silva, MP Menezes, A Abizaid, JR
Costa, RA Costa, AMR Sousa
Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brasil
PURPOSE: To evaluate the safety and efficacy of the
Svelte Acrobat Integrated Delivery System (IDS) via a radial
approach with 5-French catheters. The direct stenting (DS)
system enables easy delivery, deployment, and post-dilatation
of a cobalt-chromium stent.
METHODS: Patients with coronary artery disease
(CAD) were prospectively enrolled at three centers in Sao
Paolo, Brazil to undergo PCI with DS via a radial approach
using 5-French catheters. The primary endpoint was IDS
success, which was defined as DS without post-dilatation
and final stenosis <20% with TIMI 3 flow.
RESULTS: Fifty consecutive patients with 55 lesions
were included. The procedural success was 98%. The device
could not cross the lesion in 2 cases, so DS success was 96%.
Fifty lesions met the primary study objective; thus, IDS suc-
cess was 91%. The procedure duration was 21 min (SD = 9);
fluoroscopy time, 437 sec (SD = 280); and contrast volume
per vessel, 103 cm3 (SD = 33). The final residual stenosis,
by quantitative coronary angiography, was 3.4% (SD = 4).
The reduced need for additional catheters resulted in a 20%
procedural cost saving. There were no bleeding or vascular
complications. At 8 months, the event-free survival was 84%.
CONCLUSIONS: DS using the Svelte Acrobat IDS via
a radial approach and low-profile catheters is safe and effi-
cacious in select CAD patients, and its use is associated with
potential procedural cost savings.
Total Wrist Access for Primary Percutaneous Coro-
nary Intervention: A Real World Single Center regis-
try of 2624 Consecutive Patients with Acute STEMI
O Kalpak, S Antov, J Kostov, H Pejkov, I Spiroski, M Boshev, I
Vasilev, B Zafirovska, S Kedev
University Clinic for Cardiology, Skopje, Republic of Macedonia
PURPOSE: Transradial access for primary percutaneous
coronary intervention (TRA PPCI) in patients with acute
ST elevation myocardial infarction (STEMI) is associated
with reduced complications and mortality rate. However,
there is a paucity of data regarding total transition towards
radial or wrist access for PPCI. Our center completely trans-
ferred access strategy to default TRA for all interventions.
METHODS: From January 2010 to December 2013,
2,624 consecutive all-comers STEMI patients underwent
PPCI within first 12 hours of symptoms onset. TRA was
used as the first choice default access strategy by all 7 ex-
perienced high volume radial operators. Interventions were
done according to international guidelines with or with-
out thrombus aspiration according to operator’s decision.
Primary outcomes were: access site transfer rate, secondary
outcomes were mortality and major adverse cardiovascular
events rates (MACE: death, reinfarction, stroke target vessel
revascularisation) at 30 days and 6 months.
RESULTS: Crossover from default radial was low 5.4%
(144 patients). We treated 98.7% (2,589) patients by wrist
access and only 1.3% (35) patients with transfemoral access
(TFA). Access site transfer occurred towards left radial in
2.6 % (69 patients), ulnar 1.6 % (40 patients) and in only
1.3 % (35 patients) towards TFA. Secondary outcomes at
30 days were: MACE rate of 6.6% (174 patients), mortality
rate of 5.0% (131 patients). At six months MACE rate was
8.6% (226), mortality rate was 5.6% or additional 16 deaths
were observed.
CONCLUSION: Default TRA strategy is associated
with low crossover rate in experienced high volume radial
center. Total wrist access for STEMI interventions is linked
with low mortality and MACE rate in unselected all-comers
cohort.
A New Over-the-Wire Support Catheter for Radial
Treatment of CTOs: The Prodigy Balloon
S Moualla, RR Heuser
St. Luke’s Medical Center, Phoenix AZ, USA
Chronic total occlusion (CTO) interventions continue
to be challenging for interventionists despite the advent of
multiple devices and techniques. The anchoring balloon tech-
nique has been described for several years as an aid in opening
CTOs using the antegrade approach. The anchoring balloon
technique in radial CTO intervention is effective but limited
because the over-the-wire balloons are too long and can result
in barotrauma to the origin of the treated vessel. We introduce
a shorter length and tip and less traumatic elastomeric balloon
to aid in support for treating CTOs.
METHODS: We have utilized the Prodigy balloon in 5
radial cases; 4 right coronary artery CTOs and 1 circumflex
CTO.
RESULTS: All procedures were successful. All cases
were done with less than 40 min of fluoro time. Three pa-
tients were discharged 4 hrs after procedure (outpatient).
CONCLUSION: The Prodigy support catheter may be
an improvement in anchor ing techniques to aid in complex
PTCA and CTO intervention. The device has been particu-
larly effective in radial CTO cases.
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AimRADiAL 2014 AbstRActs
Bioresorbable Vascular Scaffold Implantation in a
Real World Population Using the Radial Approach as
a Default Route
N Salvatella, H Tizón, F Miranda
Hospital del Mar, Parc de Salut Mar-IMIM, Barcelona, Spain
PURPOSE: To assess the feasibility and early safety of
bioresorbable vascular scaffolds (BVS) implantation, includ-
ing complex disease in a real-world setting using the radial
approach as the default vascular route.
METHODS: Single center registry (inclusion October
2012-June 2013), lesions deemed suitable for BVS implan-
tation, at operator’s discretion. Patient and lesion charac-
teristics and procedural data were recorded. Procedural and
in-hospital outcomes are described.
RESULTS: 124 patients (133 procedures, 143 lesions). Age
61 ± 10 years, 57% of patients were diabetic, 34% had mul-
tivessel disease. The most frequent indication for the procedure
was acute coronary syndrome. The left anterior descending
was the vessel most frequently treated, 5 lesions (3.5%) were
located on a bypass graft. The median lesion length was 24
mm (range 7-85, interquartile range: 15.5-32.5). 58% lesions
involved a branch of at least 1.5 mm, 11 lesions (8%) were
chronic total occlusions, 17 (12%) were ostial lesions, 8 lesions
(6%) were restenotic. 21 lesions (15%) were moderately or se-
verely calcified. 2 lesions (1.1%) involved the left main. 74%
lesions were ACC/AHA type C. Radial approach was used
for 97% of the procedures (of these, 98% 6Fr sheath, 2% 7Fr
sheath). In 17% cases an extra support PTCA wire was used.
85% lesions were predilated. Cutting balloon was used for 43%
lesions. Rotational atherectomy was used for 4 lesions (2.8%).
The average number of BVS/lesion was 1.4. In 29% lesions,
there was overlapping of BVS. Postdilation with a non-compli-
ant balloon was performed in 85% cases. IVUS guidance was
used in 22%. Success delivery of the scaffold 97%. In-hospital
outcomes: No cases of acute stent thrombosis of in-hospital
death. Periprocedural MI requiring prolongation of hospital-
isation n=6 (4.5%). No vascular complications requiring pro-
longation of hospitalisation, transfusion or surgery.
CONCLUSIONS: It is feasible to implant BVS via a radial
approach in a real-world setting, including lesions of a wide
range of complexity, with a high device delivery success and
favourable in-hospital outcomes.
Bleeding and Anticoagulation
The Impact of Bleeding at Different Sites and Risk
of Subsequent Mortality and Major Adverse Cardio-
vascular Events Following Percutaneous Coronary
Intervention: A Systematic Review and Meta-Analysis
CS Kwok, MA Khan, SV Rao, T Kinnaird, M Sperrin, I Buchan,
MA de Belder, PF Ludman, J Nolan, YK Loke, MA Mamas
Cardiovascular Institute, University of Manchester, Oxford Road,
Manchester, UK
PURPOSE: To evaluate the impact of bleeding at dif-
ferent sites on mortality and major adverse cardiovascular
events (MACE) in contemporary percutaneous coronary in-
tervention (PCI).
METHODS: We conducted a systematic review and
meta-analysis of PCI studies that evaluated site-specific
peri-procedural bleeding complications and their impact on
MACEs and mortality outcomes. We searched MEDLINE
and EMBASE to identify relevant studies and random effects
meta-analysis was used to estimate the risk of adverse out-
comes with site-specific bleeding complications.
RESULTS: We identified 25 relevant studies with
2,400,645 patients who underwent PCI. Both non-access
site (RR 3.70 95%CI 2.92- 4.69) and access site-related
bleeding complications (RR 1.65 95%CI 1.37-1.99) were
independently associated with an increased risk of peri-pro-
cedural mortality. There were differences in the prognostic
impact of non-access site related bleeding events on mortali-
ty outcomes according to the source of anatomical bleeding.
There were significant increases in mortality for gastroin-
testinal bleed (RR 2.78 95% CI 1.25-6.18), retroperitoneal
bleed (RR 7.55 95% CI 2.33-24.45) and intracranial bleed
(RR 22.71 95% CI 12.53-41.15), but not femoral bleed
(RR 2.17 95% CI 0.07-69.22). The risk of MACE was not
significantly increased with intramyocardial bleed (RR 1.65
95% CI 0.66-4.13) and gastrointestinal bleed (RR 1.23 95%
CI 0.55-3.05) but did increase with the composite of in-
tramyocardial bleed, pericardial bleed or cardiac tamponade
(RR 2.96 95% CI 1.07-8.17).
CONCLUSIONS: Site-specific bleeding complications
following PCI are independently associated with increased
mortality and the prognostic impact of bleeding complica-
tions on mortality depends on the anatomical site.
Impact of Access Site on Bleeding and Ischemic Events
in Patients with Non-STEMI Treated with Prasugrel
at the Time of Percutaneous Coronary Intervention
or as Pretreatment at the Time of Diagnosis: the
ACCOAST Access Sub-Study
I Porto, L Bolognese, D Dudek, P Goldstein, C Hamm, JF Tan-
guay, J Ten Berg, P Widimsky, E Brown, L LeNarz, DL Miller, G
Montalescot, for the ACCOAST Investigators.
Cardiovascular and Neurological Dept, Azienda Ospedaliera Arez-
zo, Arezzo, Italy
PURPOSE: Radial artery access for angiography and
percutaneous coronary intervention (PCI) in acute coronary
syndromes has been associated with lower r isk of bleeding
and reduced mortality in both observational and random-
ized studies, although less consistently in non-ST-segment
elevation myocardial infarction (NSTEMI) than in STEMI.
METHODS: We evaluated the impact of access site on
clinical outcomes of NSTEMI patients from the ACCOAST
study. The ACCOAST study evaluated a prasugrel loading
dose of 60 mg given at the start of PCI versus a split loading
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AimRADiAL 2014 AbstRActs
10A The Journal of InvasIve CardIology®
dose of 30 mg given immediately at the time of diagnosis of
NSTEMI (prior to coronary angiography), followed by 30
mg given at the start of PCI. In the study, choice of access
site was at the investigator’s discretion.
RESULTS: Patients who received radial (vs femoral) ac-
cess in the overall cohort were younger, more often from
Western Europe, and had lower GRACE and CRUSADE
bleeding risk scores. TIMI major bleeding in the PCI co-
hort through 7 days was significantly higher in those patients
with femoral access than with radial access (21 [1.34%] vs 5
[0.42%]; HR [95%CI] 3.19 [1.20, 8.47], P=.014). Baseline
characteristics of the PCI cohort are presented by access site
in the Table.
Variable Radial
(n=1191)
Femoral
(n=1571)
P-value
Age ≥75 years, % 15.6 18.2 .074
Female, % 22.6 25.0 .149
Western Europe, % 56.9 52.9 .016
CRUSADE score,
mean±SDa
33.5±12.0 35.0±11.8 .002
GRACE score,
mean±SDb
118.9±26.7 121.6±26.4 .010
Prior CABG, %c2.4 7.7 <.001
Prior PCI, %d14.4 18.9 .002
PPI use at base-
line, %
46.6 35.6 <.001
Baseline characteristics of PCI patients in the ACCOAST study for
radial vs femoral access site. PPI= proton pump inhibitor.
an = 1131 and 1509; bn = 1132 and 1539; cn= 1187 and 1565;
dn=1187 and 1565 for Radial and Femoral, respectively.
In propensity adjusted analysis in PCI patients, the effect
of access site lost statistical significance [HR=2.36, P=.089];
similar results were seen for all patients. The results of the
impact of access site will be presented at the meeting sepa-
rately for PCI and all patients including predefined STEE-
PLE and GUSTO definitions for bleeding.
CONCLUSIONS: For PCI patients, femoral access was
associated with significantly more TIMI major bleeds, how-
ever, the effect was attenuated after adjustment.
Safety and Efficacy of Intracoronary Thrombolysis in
STEMI Setting with Large Burden Thrombus
H Tizon-Marcos, F Miranda, N Salvatella, M Garcia, B Vaquer-
izo, D Arzamendi, A Serra, J Bruguera
Hospital del Mar, Barcelona, Spain
PURPOSE: Large burden thrombus in STEMI setting
confers a poor prognosis. Even with double antiplatelet thera-
py and thrombus aspiration, distal embolisation and non-reflow
are common. Intracoronary thrombolysis may be an effective
and safe treatment option in patients with STEMI.
METHODS: Retrospective review of all patients with
STEMI and large burden thrombus that were treated with
intracoronary thrombolysis in the period 2006-2014.
RESULTS: 36 patients with STEMI were treated with
intracoronary thrombolysis (age 61.4±13.5, 33% females, 95%
received loading dose of double antiplatelet therapy). In 47% of
cases the RCA was the culprit artery, 25% LCx, 14% LAD, 14%
secondary branches. Initial TIMI Flow Grade (TFG) was 0 in
81% of cases. Initial TIMI Thrombus Grade (TTG) was 4 (22%)
and 5 (78%). Radial access was used in 89% of patients. During
the procedure, heparin was given (median 33.6UI/kg (31.9-
36.7). Thrombolytic therapy used was TNK (78%) and rTPA
(22%) with dosage 33.7U/kg (31.9-36.7) and 0.36±0.9U/kg,
respectively. Glycoprotein IIb/IIIa inhibitors were used in 20%
of cases. Thrombectomy was used in 89% of cases. 80% of pa-
tients received at least one stent. Distal embolisation occurred
in 31% of cases. ST resolution of at least 50% of initial ST
elevation was observed in 69% of patients. Final TFG was ≥2
in 94% of cases, TTG decreased to ≤2 in 94% of patients and
final myocardial blush grade was ≥2 in 71% of cases. During
admission, TIMI major bleed was observed in 8% of cases, TIMI
minor bleed in 8% and vascular access bleed non requiring in-
tervention in 8%. Two patients died during hospitalization due
to mechanical complications of STEMI. TIMI major bleed was
associated with higher heparin and fibrinolytic dosage.
CONCLUSIONS: Intracoronary thrombolytic therapy
may be an effective reperfusion therapy in selected patients
with STEMI and large thrombus. The safety of this therapy
may be related to weight adjustment of the thrombolytic
agent and heparin dosage, and to vascular access.
Non-Coronary Intervention
Surefire Catheter Deployment via a Transradial Approach:
Feasibility and Technical Outcomes
DM Biederman, RS Patel, E Kim, FS Nowakowski FS, RA
Lookstein, AM Fischman
Icahn School of Medicine at Mount Sinai, Dept of Radiology, New
York NY, USA
PURPOSE: The Surefire catheter (Surefire Medical) is
an anti-reflux microcatheter (ARM) recently introduced for
more precise and directed infusion of selective internal radi-
ation therapy (SIRT) and trans-arterial chemoembolization
(TACE). We present our initial experience of deploying this
novel ARM via a transradial approach (TRA).
METHODS: Patients who underwent SIRT or TACE
with the ARM via TRA were retrospectively reviewed. In
all cases, a Barbeau Test was performed. A 5 Fr Glidesheath
(Terumo) was placed in the left radial artery using ultrasound
guidance. Following sheath placement, a standard solution of
3000U heparin, 2.5mg verapamil and 200mcg nitroglycerin
was administered intra-arterially. A 5 Fr guiding catheter with
minimum 0.054 inner lumen diameter was used to perform
diagnostic angiography of the visceral and hepatic arteries. The
ARM was advanced to the target hepatic artery through the
guiding catheter over a 0.016 Fathom wire (Boston Scientific).
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AimRADiAL 2014 AbstRActs
SIRT/TACE infusion was administered in the target vessel
under real time fluoroscopy. A TR band (Terumo) was used
for hemostasis. Technical success, fluoroscopy time (FT),
major and minor post adverse events and procedural details
were recorded.
RESULTS: From November 2013 to June 2014, 13 pa-
tients, mean age of 62.8 ± 10.9 years, underwent SIRT/
TACE for liver tumors in which the ARM was deployed
via TRA (6 SIRT, 7 TACE). Tumor pathology included:
HCC (n=9), neuroendocrine (n=2), leiomyosarcoma (n=1),
angiosarcoma (n=1). Technical success was 92.3% (12/13).
The failure which occurred was secondary to a replaced
left hepatic artery originating from the left gastric artery,
creating an oblique, tortuous angle which was exaggerated
when entering via TRA. Subsequently the case was success-
fully completed via a femoral approach. In the 12 success-
ful cases, 100% of the intended therapeutic radiation dose/
chemotherapy was delivered without evidence of reflux on
real time fluoroscopy. Median (interquartile range) FT and
radiation dose were 18.3 (16.4) min and 248 (325) Gy-cm2
respectively. There were no post-procedural major or minor
adverse events. Patients were followed for a median (inter-
quartile range) of 21 (20.5) months and did not exhibit any
signs of non-target chemo/radio-embolization.
CONCLUSION: The Surefire ARM can be safely de-
ployed via a transradial approach. Pre-procedural cross-sec-
tional imaging studies (CT/MRI) should be used to analyze
patient specific differences in anatomy to guide the decision
between radial or femoral approach.
Outpatient Transradial Hemodynamic Assessment of
Mechanical Aortic Valve Prosthesis Using a Coronary
Fractional Flow Reserve Guidewire
K Challa, M Vidovich
University of Illinois at Chicago, Chicago IL, USA
PURPOSE: To describe an outpatient transradial hemo-
dynamic assessment of a mechanical aortic valve prosthesis
using a coronary fractional flow reserve (FFR) guidewire in
a patient who is fully anticoagulated with warfarin.
METHODS: Procedure was done as an outpatient on
a patient fully anticoagulated without the need for heparin
bridging. Right heart catheterization was completed via
right brachial vein access and a 5 French Arrow Balloon
Tipped catheter. Left heart catheter ization was completed
via right radial access. The guide catheter used was a Bar-
beau Guide, which was zeroed in the left ventricle. Simul-
taneous left ventricle and aortic pressure were collected
with a coronary FFR guidewire. Baseline hemodynamics
in addition to hemodynamics with dobutamine infusion
were collected.
RESULTS: There was a mean gradient of 31.23mmHg
at baseline and mean gradient of 48.73mmHg with infu-
sion of dobutamine 40mcg/kg/min. Right-sided pressures
were within normal limits with the exception of pulmonary
capillary wedge pressure of 16. The patient had no bleeding
complications.
CONCLUSION: We have demonstrated a total radial
approach to mechanical aortic valve prosthesis gradient as-
sessment. This was an outpatient evaluation in a patient who
was fully anticoagulated on warfarin. We were able to avoid a
heparin bridge and also avoided transseptal and/or percuta-
neous left ventricle apical puncture. Additionally, we avoid-
ed the potential complication of catheter entrapment with
using pigtail catheters to assess left ventricle hemodynamics.
Finally, FFR assessment allowed for a direct and accurate
measurement of left ventricle and aortic pressures.
Transradial Access for Above-The-Knee Angioplasty
R Lorenzoni, A Iannielli, C Lisi, M Lazzari, F Bovenzi
Cardiovascular Department, San Luca Hospital, Lucca, Italy
PURPOSE: To report the results and complications of
a single-center experience of above-the-knee angioplasty
(ATK) via transradial access (TRA).
METHODS: In a prospective study, 120 consecutive pa-
tients (94 men; mean age 71 years, range 37-90) referred for
critical limb ischemia (31, 26%) or claudication with ATK
lesions (excluding patients with TASC D lesions of the su-
perficial femoral artery) were eligible for lower limb arterial
angioplasty via TRA.
RESULTS: The majority of patients were approached
via left TRA (92, 77%) and with a sheathless catheter (94,
78%; Sheathless PV, Asahi). A total of 188 lesions were ad-
dressed, of which 43 (23%) were occlusions; 121 stents (73 in
suprainguinal lesions; sinusSuperFlex-518, OptiMed) were
positioned in 92 patients. Overall technical success (<30%
residual stenosis) was achieved in 170 (90%) lesions, with
a 63% success rate in occlusions and a 99% success rate in
stenoses; with a 91% success rate in suprainguinal lesions
and a 90% in infrainguinal lesions. No hemorrhagic or local
complications requiring surgery were observed. At 1-month
follow-up, 111 patients had a downward shift of at least one
category in the Rutherford classification of symptoms (clin-
ical success rate 92%); 18 (15%) patients had occlusion of
their access radial artery, but none had symptoms or dis-
comfort. However, the rate of radial artery occlusion fall to
5% when the patent hemostasis technique was systematically
applied.
CONCLUSION: The present study demonstrates that
TRA can be a safe and effective approach for lower extremity
arterial revascularization, at least in selected anatomical subsets.
Transradial Approach Facilitates Same-Day Discharge
for Transarterial Chemoembolization to Treat Hepato-
cellular Carcinoma
R Posham, RS Patel, RA Lookstein, FS Nowakowski, E Kim,
AM Fischman
Interventional Radiology – Mount Sinai Hospital, Icahn School of
Medicine, New York NY, USA
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AimRADiAL 2014 AbstRActs
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PURPOSE: Transradial access (TRA) was evaluated as
a method to help facilitate same-day discharge for patients
undergoing transarterial chemoembolization (TACE) to
treat unresectable hepatocellular carcinoma (HCC).
METHODS: Retrospective review of 21 continuous
patients selected for same-day TACE to treat HCC from
Feb 2014 to Jul 2014, with 12/21 patients treated via TRA.
Criteria for same-day TACE included Child-Pugh A or B,
and ECOG performance status 0 or 1. A Barbeau test was
performed using a pulse oximeter on the ipsilateral thumb
to confirm dual circulation and patency of the palmar arch.
Ultrasound evaluation of the radial artery was performed to
ensure adequate vessel size. Contraindications to TRA in-
cluded RA < 2mm and Barbeau D waveform. Following
arterial puncture, a hydrophilic 5 Fr Glidesheath (Terumo
Interventional Systems) was placed. A medication solution
of 3000 U heparin, 2.5 mg verapamil, and 200 mcg nitro-
glycerin was given to minimize vascular complication. At
the end of the procedure a TR band (Terumo) was used
to compress the puncture site for approx. 60-90 min using
patent hemostasis technique. Procedural details, technical
success, 30-day major and minor adverse events, fluoroscopy
time, and post-procedural time to discharge were evaluated.
RESULTS: Technical success via TRA was obtained in
100% of cases, with no major or minor adverse events at 30-
days. Average fluoroscopy time under TRA was 25.1 min.
TRA TACE patients were discharged on average approxi-
mately 2 hours after being transferred to the recovery room
and were able to ambulate immediately.
CONCLUSION: TRA appears to be feasible and safe
in HCC patients undergoing same-day TACE, and facili-
tates same-day discharge by minimizing post-procedural
discharge times and allowing nearly immediate ambulation.
Nursing Aspects
Nursing Initiated Radial Artery Occlusion Screening
Quality Improvement Program
KA Durham, P Arman, DS Griza, BS Speiser, AR Shroff, AK
Ardati, N Barman, MI Vidovich
Jesse Brown VA Medical Center, Chicago IL, USA
PURPOSE: Radial artery occlusion (RAO) is a known
complication following transradial catheterization. Although
RAO has been thought to be asymptomatic, detailed eval-
uation of the hand circulation pre- and post-transradial car-
diac catheterization is rare. Determining if specific variables
influence RAO, along with a definitive method of screening
for RAO, will provide a more reliable post-catheterization
complication rate.
METHODS: A total of 73 patients were prospectively
screened for arterial patency before transradial catheteriza-
tion using the modified Allens and Barbeau test along with
arterial ultrasound evaluation. Any abnormalities in vascular
integrity were communicated to the interventional cardiol-
ogists before the procedure. At the time of submission, 63
subjects returned for follow-up and underwent evaluation
for RAO by the methods listed above.
RESULTS: Post-procedure changes in the modified Al-
len or Barbeau test results in the ipsilateral access wrist were
noted in 3 patients, but there were also changes noted in
10 patients in the non-accessed contralateral radial artery.
By ultrasound, the average diameter of the accessed artery
decreased in 24 patients, increased in 18 patients and did not
change in 20 patients. There were no cases of radial artery
occlusion in any of the follow up patients.
Value Pre-transradial cathe-
terization in arm of access
Value Post-transradial cath-
eterization in arm of access
Right radial
AP diameter
0.267
(0.13-0.37)
Right radial
AP diameter
0.259
(0.14-0.36)
Le radial AP
diameter
0.242
(0.2-0.28)
Le radial AP
diameter
0.242
(0.15-0.28)
Right radial
velocity
52.43 Right radial
velocity
53.01
Le radial
velocity
54.22 Le radial
velocity
56.78
CONCLUSION: There are numerous methods of assess-
ing the radial artery before and after cardiac catheterization.
Inconsistencies in the results of the modified Allen/Barbeau
tests in both the accessed and non-accessed arteries challenge
the practicality of these tests for routine screening of vascular
integrity. Objectively evaluating vascular status before and after
transradial catheterization with open communication between
the research/nursing staff and the interventional cardiologists
elevates the quality of care and safety of the procedure.
Patient Satisfaction with Radial and Femoral Access
in Interventional Radiology: A Bedside Post-Proce-
dure Assessment Utilizing iPad Technology
VV Patil, RA Lookstein, RS Patel, E Kim, FS Nowakowski, M
Ort, D Scasserra, N Lamberson, AM Fischman
Icahn School of Medicine at Mount Sinai, New York NY, USA
PURPOSE: To determine the feasibility of post-proce-
dure patient satisfaction assessment using iPad technology
after radial and femoral access for interventional radiology
(IR) procedures.
METHODS: In this single-center study performed at
a high-volume academic medical center, 21 patients un-
dergoing arterial IR procedures were given post-procedure
surveys via a bedside iPad in the IR recovery unit. Patient
demographic data as well as information regarding the type
of procedure performed were recorded. The survey included
semi-quantitative assessments of intra- and post-procedural
access site pain levels (1-no pain, 10-severe pain). Survey
data was analyzed using SPSS Statistics 21 (IBM Corp).
RESULTS Of the 21 patients, 8 (38%) had common
femoral artery access (CFA) and 13 (62%) had radial artery
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vol. 27, supplemenT a, January 2015 13A
AimRADiAL 2014 AbstRActs
access (RAA) for their arterial procedure. The RAA patients
reported an access site-specific intra-procedure pain score
average of 3.1 (median = 2) and 2.1 post-procedure (me-
dian = 1). The CFA patients reported an access site-specific
intra-procedural pain score of 2.9 (median = 1.5) and 1.5
post-procedure (median = 1). 12 patients reported having
had both types of access in the past. Of those 12 patients, 8
preferred RAA and 1 preferred CFA access. 3 patients re-
ported no preference between RAA and CFA access.
CONCLUSION: Post-procedure survey data acquired
via iPad is feasible in a recovery unit setting. Early pilot data
gathered in this setting indicates patient preference for ra-
dial access despite higher intra- and post-procedure access
site-specific pain scores.
Radial Approach and Controversies
Radial Artery Remodeling After Primary PCI Assessed
by OCT
J Kanovsky, T Novakova, R Miklik, T Ondrus, M Poloczek,
O Bocek, J Spinar, P Kala
Internal Medicine and Cardiology, University Hospital Brno, Brno,
Czech Republic
PURPOSE: Transradial approach (TRA) in percutane-
ous coronary interventions (PCI) is preferred in many cath-
labs for its safety and comfort for the patient. Generally, the
number of transradial catheterizations (TRC) is increasing
worldwide comparing to transfemoral approach. Clinically
significant complications in radial artery (RA) itself are ex-
tremely rare. Extent of subclinical damage of RA after TRC
remains unclear due to lack of data on this topic. Optical
coherence tomography (OCT) is the most sensitive method
available for the evaluation of the vessel wall layers on close
to microscopic level in vivo.
METHODS: We included 30 consecutive patients in this
study. The patients were admitted to our department due to
the diagnosis of non-ST elevation myocardial infarction. The
early transradial coronary angiography revealed culprit vessel
lesion indicated for ad hoc PCI. Immediately after PCI, we
performed OCT of radial artery from the zone of the sheath
tip proximally. The length of the record was 53mm. After
9 months, follow-up OCT of RA was performed and the
intimal thickness and lumen area were compared to base-
line OCT record. The local ethics committee approved the
project and all the patients signed an informed consent with
the procedure.
RESULTS: Out of 30 patients, 28 records had technical
quality allowing us to assess vessel wall reliably. The mean
intimal thickness was 0.066 ± 0.012 mm in baseline OCT
and 0.082 ± 0.014 mm in follow-up OCT(P=.0023). The
mean lumen area was 7.12 ± 1.83 mm in baseline OCT and
6.30 ± 1.78 mm in follow-up OCT(P=.18).
CONCLUSION: The transradial PCI changes the
structure of the RA, even after only one TRA procedure.
The intimal layer is significantly thickened in 9 months after
the first TRC. However, there was no significant effect on
vessel lumen area. This observation needs to be analyzed in
larger group of patients, especially in view of the fact that
the number of surgical revascularization using RA is con-
stantly increasing.
Supported by the Grant of the Ministry of Health of the
Czech Republic no. NT/13830.
The Arteria Radialis Complications and Upper Extremity
Dysfunction Post-PCI Study (ARCUS)
R Koopman, A Ljsselmuiden, CAJ Holtzer, M Kofflard
Albert Schweitzer Hospital, Dordrecht, The Netherlands
BACKGROUND: The impact of access site complica-
tions on upper extremity function after transradial percu-
taneous coronary intervention (TR-PCI) is poorly under-
stood. Nonetheless, TR-PCI is quickly becoming the golden
standard for many intervention cardiologists, without know-
ing the consequence it has on upper extremity function.
OBJECTIVE: To assess the magnitude of this morbidity
with regards to the upper extremity surrounding TR-PCI.
Secondary objectives are to provide insight in the conse-
quences for diminished function, prognostic factors, finan-
cial costs and to identify patients who might benefit from
early referral and treatment.
METHODS: This is a multi-center prospective cohort
study containing 490 patients presenting for TR-PCI in an
experienced center. All patients will, after baseline examina-
tions be treated with the intent of using the radial artery for
access. After intervention patients will undergo follow-up
after 24 hours, 2 weeks, 1 and 6 months.
RESULTS: The main study parameter is a binary score
of upper extremity dysfunction after 2 weeks as compared
to baseline. A positive score is defined as either a ≥1 point
increase in either the symptom-severity score or the func-
tional-status score of the Levine-Katz (Boston) question-
naire or at least 2 of the following decreased scores, 2 weeks
after TR-PCI: (1) ≥15% decrease in the “Disabilities of the
Arm, Shoulder and Hand” outcome measure. (2) ≥2 points
increase in Visual Analogue Scale pain score with regard to
the upper extremity. (3) Absent signal when evaluating the
radial artery using Doppler ultrasound. (4) ≥10% decrease
in active range of motion goniometry of the upper extrem-
ity with a minimum decrease of 10o. (5) Strength: a) ≥60N
decrease in palmar grip strength compared to baseline; b)
≥12N decrease in pinch grip strength compared to baseline;
c) ≥15% decrease in isometric strength of flexion and ex-
tension of the elbow and flexion and extension of the wrist.
(6) At least one filament decrease in sensibility of the hand
using Semmes-Weinstein filaments according to WEST. (7)
≥1cm increase at volumetry of the hand, using the Figure
of eight-method. (8) ≥1cm increase at volumetry of the
forearm, measured circumferentially. The secondary study
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AimRADiAL 2014 AbstRActs
14A The Journal of InvasIve CardIology®
parameters will be divided in cardiac and upper extremity
related endpoints and will be used to answer the secondary
objectives.
CONCLUSION: Preliminary results show a trend to-
wards slight hand-dysfunction after TR-PCI. However TR-
PCI has great advantages compared to the femoral route
and a slight risk of upper extremity dysfunction might be
acceptable in certain patients. More research is needed to
investigate the impact and magnitude of this morbidity.
The Impact of Gender, Syndrome and Vascular Access
Site on Clinical Outcomes Following Percutaneous
Coronary Intervention
CS Kwok, E Kontopantelis, V Kunadian, S Anderson, K Ratib, M
Sperrin, A Zaman, PF Ludman, MA De Belder, J Nolan, and MA
Mamas on behalf of the British Cardiovascular Intervention Society
and the National Institute for Cardiovascular Outcomes Research.
Cardiovascular Institute, University of Manchester, Manchester, UK
PURPOSE: To determine the impact of gender, syn-
drome and vascular access site on clinical outcomes after
percutaneous coronary intervention.
METHODS: We studied the impact of gender, access
site and clinical syndrome on 30-day mortality, major ad-
verse cardiovascular events (MACE) and bleeding compli-
cations in 412,122 patients who underwent PCI between
2007 to 2012 in the United Kingdom.
RESULTS: We found that use of radial access increased
over time and the proportion of patients with radial access
was greater in men (24% in 2007 to 64% in 2012) com-
pared to women (21% in 2007 to 58% in 2012). Use of
transradial access was independently associated with lower
30-day mortality (OR 0.80 95% CI 0.73-0.89; OR 0.82
95% CI 0.71-0.94) in-hospital MACE (OR 0.82 95% CI
0.76-0.90; OR 0.75 95% CI 0.66-0.84) and major bleed-
ing (OR 0.54 95% CI 0.44-0.66; OR 0.26 95% CI 0.20-
0.33) respectively. For stable angina, radial access was not
associated with a significant reduction 30-day mortality but
bleeding rates were significantly lower for the radial group
(Men: OR 0.45 95% CI 0.25-0.80; Women: OR 0.13 95%
CI 0.06-0.30). For men, there was significantly reduced
risk of events among NSTEMI patients with radial access
(30 day mortality OR 0.77 95% CI 0.66-0.90, in-hospital
MACE OR 0.81 95% CI 0.70-0.94, in-hospital bleeding
OR 0.50 95% CI 0.36- 0.70) and STEMI (30 day mortality
OR 0.80 95% CI 0.70-0.91, in-hospital MACE OR 0.69
95% CI 0.61-0.79, in-hospital bleeding OR 0.59 95% CI
0.44-0.78). For women with NSTEMI, TRA was not asso-
ciated with decreased 30-day mortality, although significant
reductions with radial access for MACE (OR 0.67 95% CI
0.54-0.82) and bleeding (OR 0.19 95% CI 0.12-0.29) were
observed. TRA was independently associated with reduced
30-day mortality (OR 0.71 95% CI 0.59-0.86), in-hospital
MACE (OR 0.80 95% CI 0.66-0.97) and major bleeding
(OR 0.38 95% CI 0.27-0.54) in women undergoing PCI
for STEMI. Similarly TRA in men was independently as-
sociated with decreased rates of 30-day mortality, in-hospi-
tal MACE and major bleeding in men undergoing PCI for
STEMI.
CONCLUSIONS: Transradial approach should be the
preferred access site choice for PCI especially in women
who have the greatest risk of bleeding across all indications.
Arrhythmias in STEMI Treated with Transradial PCI
T Novakova, J Kanovsky, M Mikolaskova, A Pleskova, T Ondrus,
R Miklik, M Poloczek, J Spinar, P Kala
Internal Medicine and Cardiology, University Hospital Brno, Brno,
Czech Republic
PURPOSE: Acute myocardial infarction with ST seg-
ment elevation (STEMI) is an emergency that needs urgent
transfer of the patient to the catheterization center and im-
mediate treatment with primary percutaneous coronary in-
tervention (PPCI). The transradial approach performed by
skilled operator allows us to significantly decrease the time
of necessary immobilization of the patients. The effect of
early mobilization and transradial approach on arrhythmias
incidence during hospitalization remains unclear.
METHODS: 100 consecutive patients (pts) admitted to
our center with STEMI diagnosis in 2013 were included in
the project. All the patients were connected to the 12-lead
continuous monitoring system immediately after PPCI pro-
cedure. 12-lead ECG was recorded for 24 to 48 hours. We
compared the arrhythmias incidence with our STEMI pa-
tients’ data from 2005-6. The comparison group was treated
solely with transfemoral PPCI.
RESULTS: Records of 80 patients were suitable for anal-
ysis from 100 included pts. The incidence of arrhythmias was
found as follows: 2nd block (AVB) 0.0%, 3rd degree AVB
7.50%, non-sustained ventricular tachycardia (VT) 35.0%,
sustained VT 1.25%, ventricular fibrillation (VF) 3.75%. No
patient needed temporary pacing in the group. We used the
group of consecutive patients with STEMI diagnosis from
years 2005-2006 as reference data. In this second group, all
the patients were treated with transfemoral PPCI. In the
comparison group there was incidence of 2nd degree AVB
1.81% (P =NS), 3rd degree AVB 7.50% (P=.019), sustained
VT 1.81% (P=NS) and VF 4.35% (P=NS). 4.71% of pts
needed temporary pacing (P=.046).
CONCLUSION: The transradial approach for PPCI
didn’t increase the incidence of serious arrhythmias in the
STEMI patients, except the 3rd degree AV block. Howev-
er, the number of patients needed temporary pacing was
significantly lower in the radial group. The transradial ap-
proach in the hands of skilled operator and early mobiliza-
tion is safe and noninferior to transfemoral access regarding
the incidence of serious arrhythmias during the hospital-
ization phase.
Supported by the grant of Ministry of Health of the
Czech Republic NT13767-4.
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vol. 27, supplemenT a, January 2015 15A
AimRADiAL 2014 AbstRActs
Radial Lounge and Same-Day Discharge
Radial Makes Anything Possible: Outpatient CTO
Treatment
S Moualla, RR Heuser
St. Luke’s Medical Center, Phoenix AZ, USA
PURPOSE: Economic considerations make outpatient
PCI an important consideration in many stable patients. With
radial access, new antiplatelet agents and experience, many if
not all stable PCI patients can be discharged several hours af-
ter the procedure. At our center, we estimate that half of our
PCIs can be performed as outpatient with annual savings of
over $250,000. With improvement in equipment and expe-
rience with outpatient PCI, we can also perform outpatient
radial chronic total occlusion (CTO) intervention.
METHODS: Five consecutive radial CTO cases were
performed: age 51-78, 4 males and 1 female, 3 right coronary
arteries (RCAs) and 2 circumflex.
RESULTS: All cases were performed via antegrade ap-
proach and were successful and discharged within 3 hours
on ticagrelor.
CONCLUSION: With CTOs, we preferentially utilize
the radial approach particularly in RCAs. If there are no col-
laterals, we don’t use contralateral injections. If contralateral
injection is needed or contralateral intervention performed,
we prep the right groin and/or use 5 Fr catheters or utilize
the contralateral radial. In this small series we were able to
discharge consecutive CTO cases the same day.
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