Comparación de seguridad y efectividad entre los accesos radiales derecho e izquierdo en la intervención coronaria percutánea / Comparison of safety and effectiveness between the right and left radial artery approach in percutaneous coronary intervention

Introducción y objetivos: Existen pocos estudios que comparen los accesos por la radial izquierda (ARI) y por la radial derecha en intervenciones coronarias percutáneas (ICP) en población general y practicadas por cirujanos con diferentes grados de experiencia en intervencionismo. El objetivo de nuestro estudio es comparar la seguridad y el beneficio clínico con cada acceso en pacientes no seleccionados con síndrome coronario agudo (SCA) y angina estable (AE). Métodos: Para evitar los posibles sesgos de un estudio no aleatorizado, se usó la puntuación de propensión para comparar ambos accesos radiales. Se recogieron datos de 18.716 pares con AE y 46.241 con SCA sometidos a ICP con implante de stent entre 2014 y 2017, en 151 centros terciarios con cardiología intervencionista en Polonia (registro nacional de Polonia [ORPKI]). Resultados: No se encontraron diferencias en cuanto a mortalidad y complicaciones periprocedimiento en AE. El ARI se asoció con mayores dosis de radiación independientemente de la presentación clínica (AE, 1.067,0±947,10 frente a 1.007,4±983,5 mGy; p=0,001; SCA, 1.212,7±1.005,5 frente a 1.053,5±1.029,7 mGy; p=0,001). En los pacientes con SCA, el ARI se asoció con mayor cantidad de contraste (174,2±75,4 frente a 167,2±72,1ml; p=0,001). Además, en los pacientes con SCA y ARI, las complicaciones periprocedimiento como disección coronaria (el 0,16 frente al 0,09%; p=0,008), fenómeno de no reflow (el 0,65 frente al 0,49%; p=0,005) y hemorragia en el sitio de punción (el 0,09 frente al 0,05%; p=0,04) resultaron más frecuentes. No hubo diferencias en la mortalidad entre los 2 grupos (p=0,90). Conclusiones: Los resultados que se presentan podrían estar en relación con una menor experiencia en el ARI. Ambos accesos son seguros en los pacientes con AE, pero el ARI se asoció con una mayor frecuencia de complicaciones periprocedimiento de ICP en el SCA (AU)

Introduction and objectives: There is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in “real-world” patients with either stable angina or acute coronary syndrome (ACS). Methods: To overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry). Results: The rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0±947.1 mGy vs 1007.4±983.5 mGy, P=.001; ACS: 1212.7±1005.5 mGy vs 1053.5±1029.7 mGy, P=.001). More contrast was used in LRA procedures but only in ACS patients (174.2±75.4mL vs 167.2±72.1mL, P=.001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P=.008), no-reflow phenomenon (0.65% vs 0.49%, P=.005), and puncture site bleeding (0.09% vs 0.05%, P=.04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P=.90). Conclusions: Our finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients (AU)

Long-term mortality and follow-up after carotid artery stenting.

BACKGROUND: Carotid artery stenting (CAS) is an alternative to carotid endarterectomy for the prevention of stroke and transient ischemic attack (TIA). The high long-term mortality among patients who underwent CAS seems to be related to the high comorbidity burden, including coronary and peripheral artery disease. However, limited data on very long-term mortality (over four years) and predictors of death are available. AIM: We sought to investigate the very long-term survival after CAS and the impact of comorbidities on mortality at follow-up. METHODS: Data of 194 symptomatic and asymptomatic patients who underwent CAS with cerebral protection systems from December 2002 to March 2014 were analyzed. All cause mortality during long-term follow-up was assessed. Univariate and multivariate Cox regression analysis was used to find independent predictors of death. RESULTS: The median age of patients was 66 [interquartile range (IQR): 60-73] years and 78.9 % of patients were male. The median follow-up was 7.6 (IQR: 4.4-10.2) years. The all-cause mortality rate after 30 days, one year, four years, and at maximum follow-up was 0 %, 5.1 %, 17.5 % and 31.4 %, respectively. Out of 61 deaths, 37 (60 %) were cardio-cerebral vascular related deaths, 15 (25 %) non-cardiovascular deaths, and 9 (15 %) due to unknown reasons. Among cardio-cerebral vascular deaths, there were 12 fatal strokes, 18 fatal myocardial infarctions and seven other cardiac related deaths. Non-cardiac deaths were due mainly to cancer (9/15). Age and diabetes mellitus were independent predictors of all-cause death during long-term follow-up. CONCLUSIONS: The mortality rate during short and long-term follow-up after CAS was lower than reported in the literature. Age and diabetes mellitus were independent predictors of all-cause death. Further research is needed to confirm the potential association between those risk factors and decreased survival. Hippokratia 2016, 20(3): 204-208.

Mesh-covered embolic protection stent implantation in ST-segment-elevation myocardial infarction: final 1-year clinical and angiographic results from the MGUARD for acute ST elevation reperfusion trial

The MGuard, a bare metal stent covered with a polymer mesh, was designed to reduce distal embolization during percutaneous coronary intervention in ST-segment-elevation myocardial infarction. In the MGUARD for Acute ST Elevation Reperfusion trial, the primary end point of complete ST-segment resolution was significantly improved with the MGuard compared with control. We evaluated 1-year clinical and angiographic results.METHODS AND RESULTS:Patients with ST-segment-elevation myocardial infarction ≤12 hours undergoing primary percutaneous coronary intervention of a single de novo native lesion were randomized to the MGuard versus any commercially available metallic stent (39.8% drug-eluting). Clinical follow-up was performed through 1 year, and angiography at 13 months was planned in 50 MGuard patients. There was no difference in major adverse cardiac events (1.8% versus 2.3%; P=0.75) at 30 days between the groups. Major adverse cardiac events at 1 year were higher with the MGuard, driven by greater ischemia-driven target lesion revascularization (8.6% versus 0.9%; P=0.0003). Conversely, mortality tended to be lower with the MGuard at 30 days (0% versus 1.9%; P=0.04) and at 1 year (1.0% versus 3.3%; P=0.09). Late lumen loss at 13 months in the MGuard was 0.99±0.80 mm, and binary restenosis was 31.6%.CONCLUSIONS:In patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention, a trend toward reduced 1-year mortality was present in patients treated with the MGuard stent. Target lesion revascularization and major adverse cardiac events rates during follow-up were higher in the MGuard group than in the control stent group, and angiographic late loss of the MGuard was consistent with that expected from bare metal stents.

Advantages of MGuard coronary stent system.

Effectiveness of percutaneous coronary intervention (PCI) within thrombus containing lesions (ST-segment elevation myocardial infarction setting, degenerated saphenous venous grafts) is limited by the risk of occurrence of distal embolization and no-reflow phenomenon. Several pharmacological agents, as well as mechanical devices (i.e. manual aspiration catheters/mechanical thrombectomy, proximal and distal protection devices) were introduced, in the last years, to reduce the risk of angiographic complications during percutaneous coronary intervention and to improve myocardial reperfusion. Recently, the MGuard stent (Inspire MD, Tel Aviv, Israel), a bare-metal stent covered by micron level mesh, which allows to prevent distal embolization by blocking the atherothrombi prolapse through the stent struts during deployment has been introduced. This article discusses the data concerning safety and efficacy of mesh covered stent implantation in a ST-segment elevation myocardial infarction setting, as well as during percutaneous coronary intervention in saphenous venous grafts.