Additional prognostic value of heart rate reserve over left ventricular contractile reserve and coronary flow velocity reserve in diabetic patients with negative vasodilator stress echocardiography by regional wall motion criteria.

AIMS: In diabetic patients, a blunted left ventricular contractile reserve (LVCR) and/or a reduced coronary flow velocity reserve (CFVR) identify patients at higher risk in spite of stress echocardiography (SE) negative for ischaemia. Cardiac autonomic dysfunction contributes to risk profile independently of inducible ischaemia and can be assessed with heart rate reserve (HRR). We sought to assess the added prognostic value of HRR to LVCR and CFVR in diabetic patients with non-ischaemic SE. METHODS AND RESULTS: Six-hundred and thirty-six diabetic patients (age 68 ± 9 years, 396 men, ejection fraction 58 ± 10%) with sinus rhythm on resting electrocardiogram underwent dipyridamole SE in a two-centre prospective study with assessment of wall motion, force-based LVCR (stress/rest ratio, normal value > 1.1), CFVR of the left anterior descending coronary artery (stress/rest ratio, normal value >2.0), and HRR (stress/rest ratio, normal value >1.22). All-cause death was the only considered endpoint. During a median follow-up of 39 months, 94 (15%) patients died. Independent predictors of death were abnormal CFVR [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.0-2.52, P = 0.05], reduced LVCR (HR 1.76, 95% CI 1.15-2.69, P = 0.009), and blunted HRR (HR 1.92, 95% CI 1.24-2.96, P = 0.003). Eight-year death rate was 9% for patients with triple negativity (n = 252; 40%), 18% for those with single positivity (n = 216; 34%), 36% with double positivity (n = 124; 19%), and 64% for triple positivity (n = 44; 7%) (P < 0.0001). CONCLUSION: Diabetic patients with dipyridamole SE negative for ischaemia still may have a significant risk in presence of an abnormal LVCR and/or CFVR and/or HRR, which assess the underlying myocardial, microvascular, and cardiac autonomic dysfunction. CLINICAL TRIALS: Gov Identifier NCT 030.49995.

Endovascular treatment of iliac and common femoral arteries disease by the transradial access: A prospective, feasibility study.

AIM: To report feasibility and safety of endovascular interventions on iliac and common femoral arteries, using the transradial access (TRA). METHODS: 100 consecutive patients (19 women; mean age 71, range 37-90years) with critical limb ischemia (30%) or claudication, and TASC A-D lesions in iliac or common femoral arteries, were prospectively enrolled, from January 2013 to June 2015, to be treated via the TRA. Exclusion criteria included no palpable radial arteries (RA) and the presence of a fistula for hemodialysis. Patients were evaluated for procedural technical success, in-hospital complications, and 30days clinical success (defined as improvement of at least one grade in the Rutherford classification of symptoms). RESULTS: A total of 131 iliac and common femoral arteries lesions were treated (58 in common iliac arteries, 38 in external iliac arteries and 35 in common femoral arteries). Ninety-two stents were deployed in 58 patients. Procedural technical success was achieved in 91% of the lesions; with 95% technical success rate in common iliac arteries, 87% in external iliac arteries and 89% in common femoral arteries; with 72% technical success rate in occlusions and 98% in stenosis. No in-hospital complications were observed. At 30days, 93 patients (93%) had an improvement of at least one category in the Rutherford classification of symptoms (clinical success rate 93%); 12 patients (12%) had an asymptomatic occlusion of the RA. CONCLUSIONS: TRA can be used to treat iliac and common femoral arteries lesions with a high grade of technical success and a low rate of complications.

Tailored use of transradial access for above-the-knee angioplasty.

PURPOSE: To report the results and complications of a single-center experience of above-the-knee angioplasty via transradial access (TRA). METHODS: In a prospective study, 110 consecutive patients (88 men; mean age 72 years, range 37-90) referred for critical limb ischemia (26, 24%) or claudication were eligible for lower limb angioplasty via TRA (patients with TASC D lesions of the superficial femoral artery and below-the-knee lesions were excluded). RESULTS: The majority of patients (84, 76%) were treated via a left TRA. A total of 170 lesions were addressed, of which 38 (22%) were occlusions; 113 stents were positioned in 82 patients. The overall technical success rate was 91%, with a 63% success rate in occlusions and a 98% success rate in stenoses; by location, the success rates were 91% in suprainguinal lesions and 90% in infrainguinal lesions. No hemorrhagic or local complications requiring surgery were observed. At 1-month follow-up, 101 patients had a downward shift of at least one category in the Rutherford classification of symptoms (clinical success rate 92%); 18 (16%) patients had occlusion of their access radial artery, but none had symptoms or discomfort. CONCLUSION: The present study demonstrates that TRA is a safe and effective approach for lower extremity arterial revascularization, at least for interventionists with longstanding experience in TRA and in selected anatomical subsets.