The Clinical Impact of Access Site Selection for Successful Thrombolysis and Intervention in Acute Critical Lower Limb Ischaemia (RAD-ALI Registry).

Background: Acute limb ischaemia (ALI) is of great clinical importance due to its consequent serious complications and high comorbidity and mortality rates. The purpose of this study was to compare the acute success and complication rates of CDT performed via transradial, transbrachial, and transfemoral access sites in patients with acute lower limb vascular occlusion and to investigate the 1-year outcomes of CDT and MT for ALI. Methods: Between 2008 and 2019, 84 consecutive patients with ALI were treated with CDT in a large community hospital. Data were collected and retrospectively analysed. The primary ("safety") endpoints encompassed major adverse events (MAEs), major adverse limb events (MALEs), and the occurrence of complications related to the access site. Secondary ("efficacy") endpoints included both technical and clinical achievements, treatment success, fluoroscopy time, radiation dose, procedure time, and the crossover rate to an alternative puncture site. Results: CDT was started with radial (n = 17), brachial (n = 9), or femoral (n = 58) access. CDT was technically successful in 74/84 patients (88%), but additional MT and angioplasty and/or stent implantation was necessary in 17 (20.2%) and 45 cases (53.6%), respectively. Clinical success was achieved in 74/84 cases (88%). The mortality rate at 1 year was 14.3%. The cumulative incidence of MAEs and MALEs at 12 months was 50% and 40.5%, respectively. After conducting multivariate analysis, history of Rutherford stage IIB (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.58-8.41; p = 0.0025), occlusion of the external iliac artery (HR, 27.52; 95% CI, 2.83-267.33; p = 0.0043), being a case of clinically unsuccessful thrombolysis (HR, 7.72; 95% CI, 2.48-23.10; p = 0.0004), and the presence of diabetes mellitus (HR, 2.18; 95% CI, 1.01-4.71; p = 0.047) were independent predictors of a high MAE mortality rate at 12 months. For MALEs, statistically significant differences were detected with the variables history of Rutherford stage IIB (HR, 4.30; 95% CI, 1.99-9.31; p = 0.0002) and external iliac artery occlusion (HR, 31.27; 95% CI, 3.47-282.23; p = 0.0022). Conclusions: Based on the short-term results of CDT, acute limb ischaemia can be successfully, safely, and effectively treated with catheter-directed thrombolytic therapy with radial, brachial, or femoral access. However, radial access is associated with fewer access site complications. A history of Rutherford stage IIB, occlusion of external iliac artery, unsuccessful thrombolysis, and the presence of diabetes mellitus were independently associated with an increased risk of MAEs. A history of Rutherford stage IIB and external iliac artery occlusion are independent predictors of MALEs.

Superficial temporal artery access for carotid artery stenting: A case report.

Percutaneous intervention of patients who suffer from generalized vascular disease is often a great challenge due to the limited accessibility of the access gates. We discuss the case of a 66-year-old man who presented with critical right internal carotid artery (ICA) stenosis after previous hospitalization due to stroke. In addition to arteria lusoria, the patient had known bilateral femoral amputation, occlusion of the left ICA and significant three-vessel coronary artery disease. After unsuccessful common carotid artery (CCA) cannulation from the right distal radial artery access, we successfully performed the diagnostic angiography and the planned right ICA-CCA intervention using superficial temporal artery (STA) puncture. We showed that STA access can be used as an alternative and additional access site for diagnostic carotid artery angiography and intervention when standard access sites alone are insufficient.

Impact of Diabetes Mellitus on Early Clinical Outcome and Stent Restenosis after Carotid Artery Stenting.

Background: Diabetes mellitus is closely related to both the severity of carotid disease and its outcome after revascularization. Carotid artery stenting (CAS) has emerged as a viable alternative to surgical endarterectomy but little is known about the impact of diabetes after CAS. Methods: A consecutive cohort of 1940 patients undergoing CAS in two institutions was divided into two groups, diabetics and nondiabetics, and major cerebrovascular events (MACCEs) were analyzed at 30 days post-CAS and at 1 year follow-up. Results: There were 730 patients with diabetes, with significantly higher BMI, hypertension, chronic dialysis, and dyslipidemia frequency (p < 0.05). There was no significant difference between the two groups in terms of early and late MACCEs (composite of transient ischemic attack, major stroke, myocardial infarction, and death), with an early rate of 3.5% nondiabetics vs. 5.3%, p = 0.08 and 2.4 nondiabetics vs. 2.3% diabetics, p = 0.1 at 12 months. Overall stroke/death rate in the asymptomatic patients was 2.4%, and the restenosis rate was higher in the diabetes population (2.3% vs. 1%, p = 0.04). Conclusion: The presence of diabetes was associated with an acceptable increased periprocedural risk for CAS, but no further additional risk emerged during longer term follow-up. Diabetes may precipitate the rate of early in-stent restenosis.

TRIACCESS Study: Randomized Comparison Between Radial, Femoral, and Pedal Access for Percutaneous Femoro-popliteal Artery Angioplasty.

BACKGROUND: The aim of this randomized study was to compare the success and complication rates of different access sites for the treatment of superficial artery stenosis. METHODS AND RESULTS: A total of 180 consecutive patients were randomized in a prospective study to treat symptomatic superficial femoral artery stenosis via radial (RA), femoral (FA), or pedal artery (PA) access. Technical success was achieved in 96.7%, 100%, and 100% of the patients in the RA, FA, and PA groups, respectively (p=0.33). Secondary access sites were used in 30%, 3.3%, and 30% of the patients in the RA, FA, and PA access groups, respectively (p=0.0002). Recanalization for chronic total occlusion was performed in 34/36 (94.4%), 30/30 (100%), and 46/46 (100%) patients in the RA, FA, and PA groups, respectively (p=0.17). The X-ray dose was significantly lower in the PA group than that in the RA and FA access groups (63.1 vs 162 vs 153 Dyn, p=0.0004). The cumulative rates of access site complications in the RA, FA, and PA groups were 3.3% (0% major and 3.3% minor), 16.7% (3.3% major and 13.3% minor), and 3.3% (3.3% major and 0% minor) (p=0.0085), respectively. The cumulative incidence of MACEs at 6 months in the RA, FA, and PA groups was 5%, 6.7%, and 1.7%, respectively. The cumulative incidence of MALEs at 6 months in the RA, FA, and PA groups was 20%, 16.7%, and 9.2%, respectively (p=0.54). CONCLUSION: Femoral artery intervention can be safely and effectively performed using radial, femoral, and pedal access, but radial and pedal access is associated with a lower access site complication rate and hospitalization. Pedal access is associated with a lower X-ray dose than that with radial and femoral access.

Superficial temporal artery access for percutaneous coronary artery stenting during the COVID-19 pandemic: a case report.

BACKGROUND: The COVID-19 pandemic creates new challenges for healthcare, including invasive cardiology. CASE SUMMARY: We discuss the case of a 65-year-old man who presented with non-ST segment elevation myocardial infarction combined with bilateral pneumonia. The patient had known severe iliac artery lesions with prior interventions and bilateral subclavian artery occlusions. After unsuccessful femoral artery access, the diagnostic angiography and the right coronary artery percutaneous coronary intervention were successfully performed from ultrasound-guided lower superficial temporal artery access. DISCUSSION: We showed that superficial temporal access can be used as an alternate access site for diagnostic coronary angiography and intervention when standard wrist and femoral access sites are not readily accessible.

Distal Radial Artery Access for Superficial Femoral Artery Interventions.

PURPOSE: To compare the acute success and complication rates of distal radial (DR) vs proximal radial (PR) artery access for superficial femoral artery (SFA) interventions. MATERIALS AND METHODS: Between 2016 and 2019, 195 consecutive patients with symptomatic SFA stenosis were treated via DR (n=38) or PR (n=157) access using a sheathless guide. Secondary access was achieved through the pedal artery when necessary. The main outcomes were technical success, major adverse events (MAEs), and access site complications. Secondary outcomes were treatment success, fluoroscopy time, radiation dose, procedure time, and crossover rate to another puncture site. RESULTS: Overall technical success was achieved in 188 patients (96.4%): 37 of 38 patients (97.3%) in the DR group and 151 of 157 patients (96.2%) in the PR group (p=0.9). Dual (transradial and transpedal) access was used in 14 patients (36.8%) in the DR group and 28 patients (18.9%) in the PR group (p<0.01). Chronic total occlusions were recanalized in 25 of 26 DR patients (96.1%) and in 79 of 81 PR patients (92.6%) (p=0.57). The crossover rate to femoral access was 0% in the DR group vs 3.2% in the PR group (p=0.59). Stents were implanted in the SFA in 15 DR patients (39.4%) and in 39 patients (24.8%) in the PR group (p=0.1). The contrast volume, fluoroscopy time, radiation dose, and procedure time were not statistically different between the DR and PR groups, nor were the rates of access site complications (2.6% and 7.0%, respectively). The cumulative incidences of MAE at 6 months in the DR and PR groups were 15.7% vs 14.6%, respectively (p=0.8). CONCLUSION: SFA interventions can be safely and effectively performed using PR or DR access with acceptable morbidity and a high technical success rate. DR access is associated with few access site complications.

Direct transpedal pressure measurement during transpedal below-the-knee interventions in critical limb ischemia.

AIM: The aim of this study was to assess the feasibility of the distal pressure measurement during transpedal below-the-knee interventions in chronic limb-threatening ischemia (CLTI) and to assess the hemodynamic response after percutaneous transluminal angioplasty. METHODS: The clinical and angiographic data of 137 consecutive patients treated via transpedal access in CLTI (Rutherford 4-6) were evaluated. Distal pedal pressure (PP) at the end of the pedal sheath was measured and the pedal-to-aortic pressure index (PAPI) was also calculated before and after the intervention. RESULTS: Good angiographic results was achieved in 131 patients (95.6%) in the femoro-popliteal and at least in one below-the-knee artery. Significant differences were found in PP and PAPI between before- and after-intervention values (103.2 ± 41.6 mmHg vs. 138.2 ± 37.8 mmHg and 0.74 ± 0.29 vs. 1.03 ± 0.34), respectively. Post-procedural PP and PAPI were significantly higher in patients who underwent good and borderline/unsuccessful intervention 141.7 [135.8-147.6] versus 82.6 [33.8-131.5] mmHg and 1.05 [1-1.1] versus 0.53 [0.2-0.8], respectively. PP's are significantly different in various Rutherford classification groups. Among the studied parameters, postprocedural PAPI was found to have the best discriminatory power to predict 3-month amputation (c-statistic: 0.749, 95% CI: 0.546-0.952, p = .016, sensitivity: 57.1%, specificity: 92.3% using the cut-off criterion ≤0.58). Major adverse event was detected in 17 patients at 3 months follow up (12.4%), including 7 major amputations (5.1%). CONCLUSION: Transpedal pressure and pedal-to-aortic pressure index significantly increased during transpedal below-the-knee angioplasty and final pressure and index correlates significantly with limb salvage.

Approach to Tibiopedal Retrograde Revascularization of Below-The-Knee Peripheral Arterial Diseases With or Without Transradial Guidance Peripheral Angiography.

OBJECTIVE: We sought to compare the use of transradial peripheral angiography to guide retrograde revascularization of below-the-knee (BTK) lesions using tibiopedal access (TPA). BACKGROUND: Tibiopedal retrograde revascularization of BTK lesions is an emerging technique in peripheral interventions. METHODS: We performed an observational cohort study of 194 consecutive adult patients with critical limb ischemia (CLI) who underwent endovascular intervention for BTK diseases using peripheral angiography and primary TPA access with vs without transradial (TR) guidance at 2 centers (New York, USA and Budapest, Hungary). The primary endpoints were procedure success, 30-day major adverse event rate, 30-day access-site complication rate, and 30-day access-site patency rate by ultrasound. Secondary endpoints were periprocedural complications, fluoroscopy time, procedure length, and crossover rate to femoral access. RESULTS: There were 78 patients in the TR-guidance group and 116 patients in the non-TR guidance group. Overall procedure success rates with TR guidance vs without TR guidance were 97% and 98%, respectively. Fluoroscopy times (732.8 ± 615.7 seconds vs 769.8 ± 565.8 seconds; P=NS) and procedure times (46.5 ± 24.4 minutes vs 55.4 ± 12.6 minutes; P=NS) were similar in the TR-guidance group vs the non-TR guidance group, but contrast volumes were higher in the TR-guidance group (100.0 ± 60.1 mL vs 43.8 ± 10.2 mL in the non-TR guidance group; P<.05). There was no difference in 30-day major adverse events, other than higher amputation rate in the TR-guidance group (15.3%), which was attributed to severe baseline complex CLI status in this patient group. There was 1 case of arteriovenous fistula, 1 case of pseudoaneurysm, and 1 case of tibiopedal artery occlusion at 30 days in the group without TR guidance. There were 3 cases (3.8%) of radial artery occlusion in the TR-guidance group. CONCLUSIONS: The treatment of CLI with BTK lesions is feasible and safe, with a high procedural success rate and low access-site complication rate using the TPA approach regardless of whether or not TR guidance is utilized.