Readmissions to Hospital After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Factors Associated with Readmissions.

BACKGROUND: Readmissions after PCI are a burden to patients and health services that are not well understood. METHODS: A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses. RESULTS: A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day readmission rate varied from 3.3%-15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6-50.4% at 12 months and 26.3-71% beyond 48 months. The pooled proportion of patients with cardiac cause for readmissions ranged from 4.6%-75.3%. The range of rates of 30-day readmissions for reinfarction/stent thrombosis, heart failure, chest pain and bleeding were 2.5%-9.5%, 5.9%-12%, 6.7-38.1% and 0.7-7.5%, respectively. Meta-analysis suggests that female gender (RR 1.25(1.20-1.30), I2 = 65.2%), diabetes (RR 1.22(1.20-1.25), I2 = 0%), heart failure (RR 1.43(CI 1.28-1.60), I2 = 92.8%), renal failure (RR 1.50(1.45-1.55), I2 = 0%), chronic lung disease (RR 1.34(1.26-1.44), I2 = 87.5%), peripheral artery disease (RR 1.20(1.15-1.25), I2 = 46.5%) and cancer (RR 1.35(1.15-1.58), I2 = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively. CONCLUSIONS: We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department.

Impact of access site selection and operator expertise on radiation exposure; a controlled prospective study.

BACKGROUND: Published data relating to arterial access site selection and radiation exposure during coronary procedures suggest radial access may lead to increased radiation exposure, but this is based on poorly controlled studies. We sought to measure radiation exposure to patients and operators during elective coronary angiography (CA) according to access site, with other procedure related variables controlled for. We also investigated the specific effect of operator expertise in relation to radiation exposure. METHODS: 100 consecutive patients undergoing first time elective CA were recruited prospectively. An expert transradial (TR) and an expert transfemoral (TF) operator performed 25 cases each via their default route. A trainee cardiologist with intermediate experience in both access sites performed 25 cases via each route. Angiographic projections were standardised and optimised radiation protection was utilised for all procedures. The primary endpoints were operator and patient exposure, quantified by effective dose (ED) and dose area product (DAP) respectively. Secondary endpoints included fluoroscopy time (FT) and time to patient ambulation. RESULTS: The trainee operator recorded higher values for radiation exposure in radial and femoral cases when compared to the expert operators. There were no significant differences in radiation exposure during CA to operator or patient according to access site when standardised by operator experience. For the trainee, ED for TR and TF procedures was 8.8 ± 4.3 µSv and 8.5 ± 6.5 µSv (P = .86) and DAP was 25.4 ± 4.8 Gycm(2) vs 25.2 ± 8.3 Gycm(2) (P = .9). For the expert TR and TF operators, ED was 6.4 ± 4.7 µSv vs 6.1 ± 5.6 µSv (P = .85) and DAP was 21.7 ± 6.5 Gycm(2) vs 22.4 ± 8.0 Gycm(2), (P = .74). There was no significant difference in FT in relation to access site. Time to ambulation was significantly longer with TF access. CONCLUSION: The use of TR access has no adverse effect on radiation exposure or FT for diagnostic CA, but does allow for quicker ambulation compared to TF access. The magnitude of radiation exposure is related to operator expertise for both access sites. The results of previous studies reflect the effect of uncontrolled patient and operator variables and not access site selection.

Don't rule out retroperitoneal bleeding just because the angiogram was done from the radial artery.

The use of radial artery for vascular access for cardiac catheterization and intervention has gained increasing acceptance over the last few years as result of the lower risk of vascular complications compared to use of the femoral artery. The strong evidence showing that major bleeding (commonly access site related) is an independent predictor of mortality in acute coronary syndrome patients undergoing intervention has only accelerated this change. This case highlights that although the risk of access site complications is reduced with the radial approach there remains a risk of spontaneous bleeding elsewhere due to the use of multiple potent antiplatelet and anticoagulant therapy in the treatment of acute coronary syndromes. Early recognition of bleeding is of the utmost importance as delay increases the likelihood complications of bleeding including death.

Starting a transradial programme: how to go about it?

Since the introduction of the use of the radial artery as the means of access for coronary angiography by Campeau in 1989 and for angioplasty by Kiemeneij and Laarman in 1993, this artery is increasingly becoming the preferred route of access for percutaneous coronary intervention. The two main driving forces behind this have been the colossal advances in technology that led to miniaturization of catheters and the excellent results achieved with regard to vascular complications, despite the aggressive use of multiple potent antiplatelet and anticoagulant agents during percutaneous coronary interventions. More and more interventional centers are in the process of setting up a transradial program to adopt the transradial approach. This article concentrates on the practical aspects of setting up a transradial program and offers practical advice on how to go about it.

Percutaneous left and right heart catheterization in fully anticoagulated patients utilizing the radial artery and forearm vein: a two-center experience.

BACKGROUND: Stopping oral anticoagulants prior to cardiac catheterization is associated with an increased risk of thromboembolism. Performing the procedures via the femoral artery and vein without interruption of anticoagulation is associated with a high rate of major access site complications. The transradial technique for left heart catheterization is safe in fully anticoagulated patients but few data are available on the percutaneous right and left heart catheterization utilizing a combination of the radial artery and antecubital vein in this group of patients. METHODS: We report our experience in 28 consecutive patients that underwent left and right heart catheterizations via this percutaneous arm approach without interruption of anticoagulation. These were compared to 31 consecutive non-anticoagulated patients that underwent the procedure via a conventional femoral artery and vein approach. RESULTS: Arterial and venous accesses were achieved and complete angiographic and hemodynamic data obtained in all patients. There were no access site complications in the anticoagulated patients despite an International normalized ratio (INR) of 2.5 +/- 0.5. Procedural duration was longer in the anticoagulated group of patients, but fluoroscopy time and patient radiation dose were similar in both groups. CONCLUSION: Our experience suggests that left and right heart catheterization can be safely performed in most fully anticoagulated patients using this technique with a low bleeding and thromboembolic risk and no increase in radiation exposure.

Deep vein thrombosis in the arm following transradial cardiac catheterization: an unusual complication related to hemostatic technique.

Transradial cardiac catheterization is an increasingly popular technique mainly because of the low vascular complication rate. We report a case of arm deep vein thrombosis that may be related to a common puncture site hemostasis technique. This complication supports the use of specific unilateral compression hemostatic systems following transradial procedures.