Feasibility and Safety of Early Repeat Transradial Access Within 30 Days of Previous Coronary Angiography and Intervention.

Transradial approach (TRA) is the default access site for diagnostic angiography and intervention in many centers. Repeat ipsilateral radial artery access late after index procedure has been associated with failures. It is unknown whether early (≤30 days) and very early (<24 hours) repeat radial access is technically feasible and safe. Study population consisted of consecutive patients undergoing repeat (≥2) procedures within 30 days in a high-volume TRA center. Transradial access failure and resulting femoral approach was categorized as primary (no repeat attempt) or secondary (crossover). Timing of repeat access and reasons for failure were recorded. From November 2012 to December 2014, repeat catheterization by TRA was performed twice in 573 of 626 patients (92%) (median delay 4 [2 to 9] days), 3 times in 29 of 38 (76%) patients (median delay 15 [5 to 26] days), and 4 times in 1 patient within 21 days. When repeat catheterization occurred during the first 24 hours following the index procedure, 53% and 75% of patients had second and third procedures using the same ipsilateral radial artery, respectively. Primary radial failure occurred in 5.8% for second attempt and 13% for a third attempt, whereas crossovers were noted in 2.7% and 2.6%, respectively. Main reasons for failed re-access of ipsilateral radial artery were related either to operator's reluctance to repeat attempt (primary failure) or to issues with puncture site (crossover). In a high-volume TRA center, patients who required repeat catheterization within 24 hours and within the first 30 days had the same radial artery re-accessed in the majority of cases.

Comparison of radiation exposure during transradial diagnostic coronary angiography with single- or multi-catheters approach.

OBJECTIVE: To compare radiation exposure during transradial diagnostic coronary angiography (DCA) using standard single- or multi-catheters with different shapes. BACKGROUND: Transradial DCA can be performed using single- or multi-catheters to canulate left and right coronary ostia. To date, it remains unknown whether there are differences in radiation exposure between the two strategies. METHODS: From November 2012 to June 2014, 3,410 consecutive patients who underwent transradial DCA were recruited. Groups were based on the initial diagnostic catheter used and were dichotomized between single- and multi-catheters approach. All crossovers were excluded. The multi-catheters approach (Multi) group consisted of Judkins left and right catheters, whereas the single-catheter (Single) group included Amplatz, Barbeau, or Multipurpose catheters. Fluoroscopy time (FT) as a surrogate end-point for total radiation exposure and kerma-area product (KAP; patient radiation exposure) were collected as radiation exposure parameters. RESULTS: A single-catheter strategy was used in 439 patients, while 2,971 patients had a multi-catheters approach. There was no significant difference in FT between groups (2.86 ± 1.48 min for Multi vs. 2.87 ± 1.72 min for Single, P = 0.13). The multi-catheters approach was associated with a significant 15% reduction in KAP (3,599 ± 2,214 cGy · cm2 vs. 3,073 ± 1,785 cGy · cm2 , P < 0.0001) compared to the single-catheter approach. When pooling all patients, mean FT was 2.86 ± 1.51 min. Mean KAP was 3,141 ± 1,854 cGy · cm2 . Reference levels in our institution in both groups were below international diagnostic reference levels. Overall both FT and KAP decreased by 15% and 19%, respectively, over the 2-year study period. CONCLUSIONS: Compared to a single-catheter approach, a multi-catheters approach with standard Judkins catheters for DCA significantly reduced patient radiation exposure. Whether single catheter designed for DCA by radial approach can further reduce radiation exposure compared to Judkins catheters remains to be compared in randomized studies. © 2016 Wiley Periodicals, Inc.

Meta-Analysis of Effects of Bivalirudin Versus Heparin on Myocardial Ischemic and Bleeding Outcomes After Percutaneous Coronary Intervention.

Bivalirudin is an alternative to unfractionated heparin (UFH) anticoagulation during percutaneous coronary intervention. Previously, we have reported clinical benefit on major bleeding in favor of bivalirudin compared with UFH monotherapy but inconclusive results on mortality. Controversial data have been reported in the last 2 years. We conducted an updated meta-analysis including randomized trials and observational studies, which evaluated ischemic and bleeding outcomes for bivalirudin compared with UFH-only during percutaneous coronary intervention. We included 18 observational studies and 12 randomized trials published from 2003 to 2015. Primary outcomes were major adverse cardiovascular events within 30 days including death, myocardial infarction, and urgent revascularization and stent thrombosis, major bleeding, and transfusion. Overall, we found a significant risk reduction with bivalirudin for major bleeding (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49 to 0.71, p <0.0001) and for transfusion (OR 0.79, 95% CI 0.66 to 0.95, p = 0.01) and similar risk for major adverse cardiovascular events (OR 0.98, 95% CI 0.86 to 1.12, p = 0.80). However, there was a substantial increased risk of stent thrombosis associated with bivalirudin (OR 1.52, 95% CI 1.11 to 2.08, p = 0.009). No impact on mortality was found. Meta-regression analyses on major bleeding suggested that bivalirudin was more effective than UFH at doses >60 IU/kg and independent of radial access. In conclusion, compared with UFH monotherapy, bivalirudin remains associated with less bleeding risk but higher stent thrombosis risk. Further study remains required to define its role in current antithrombotic armamentarium.

Efficacy and safety of preoperative intra-aortic balloon pump use in patients undergoing cardiac surgery: a systematic review and meta-analysis.

BACKGROUND: Intra-aortic balloon pump (IABP) can be used prior to coronary artery bypass graft surgery (CABG) in high-risk patients. Whether this technique remains safe and effective in contemporary practice is controversial. OBJECTIVE: We have completed a systematic review and meta-analysis of randomized trials and observational studies to evaluate the safety and benefits of IABP prior to CABG surgery. METHODS: We searched PubMed, EMBASE, Cochrane Library databases, with cross-referencing of relevant articles for studies assessing the impact of IABP prior to and after isolated CABG. Two investigators independently sorted the potentially relevant studies, and three extracted data. The assessed outcomes included in-hospital and 30-day mortality, IABP-related complications and length of intensive care unit and hospital stay. RESULTS: From 1977 to 2015 we included 11 randomized controlled trials (n=1293) (RCTs) and 22 observational studies, including a total of 46,067 patients. Analyses from RCTs suggested that IABP prior to CABG was associated with a significant reduction in hospital mortality (odds ratio (OR) 0.20; 95% confidence interval (CI): 0.09-0.44; P<0.0001) and 30-day mortality compared to no preoperative IABP (OR 0.43, 95% CI: 0.25-0.76; P=0.003). IABP prior to CABG was also associated with shorter intensive care unit (weighted mean difference (WMD) -1.47day; 95% CI: -1.82 to -1.12day; P<0.00001) and hospital length of stay (WMD -3.25days; 95% CI: -5.18 to -1.33days; P=0.0009). However, there were significant bias and limitations among included studies. Furthermore, results for similar outcomes from observational studies remained inconclusive. CONCLUSIONS: In contemporary practice, evidence showing clinical benefit for preoperative IABP in high-risk patients remains limited and requires further validation in an appropriately sized multicenter randomized trial.

The Transradial Approach and Antithrombotic Therapy: Rationale and Outcomes.

This article reviews antithrombotic strategies for percutaneous coronary interventions according to the access site and the current evidence with the aim of limiting ischemic complications and preventing radial artery occlusion (RAO). Prevention of RAO should be part of the quality control of any radial program. The incidence of RAO postcatheterization and interventions should be determined initially using the echo-duplex and then frequently assessed using the more cost-effective pulse oximetry technique. Any evidence of higher risk of RAO should prompt internal analysis and multidisciplinary mechanisms to be put in place.