Safety and Efficacy of Transbrachial Access for Endovascular Procedures: A Single-Center Retrospective Analysis.

BACKGROUND: Endovascular procedures nowadays are generally performed via the femoral and radial artery. Although not routinely used by many, there is still an essential role for vascular interventions via brachial access. The technological advancement of endovascular devices leads to a significant increase of the variety of percutaneously treatable vascular pathology. The brachial artery approach nowadays is becoming crucial for complex procedures either as single access or in the context of mandatory double vascular approach for many complex interventions. OBJECTIVE: To evaluate the safety and efficacy of brachial artery access for diagnostic arteriography and endovascular interventions in different vascular territories in a single-center setting on the basis of a retrospective analysis of prospectively collected data in a large patient cohort. METHODS: Between 01/2013 and 09/2016, 11,274 endovascular procedures were performed in our hospital, 847 (7.5%) of them via brachial access, presenting the database for this study. All demographic, clinical, and periprocedural data were obtained prospectively and included in the computerized hospital records, and on this basis, a retrospective analysis was performed. RESULTS: While the radial access was the most used and constant for coronary and noncoronary interventions in our center (71%) in this period, the use of brachial access increased (from 4% to 12%) causing the femoral to decrease (from 27% to 16%). We used the brachial approach for diagnostic purposes in 162 patients (19%) and for head to toe endovascular interventions (including angioplasty, stenting, thrombolysis, or as adjunctive access) in 685 patients (81%). For 53 patients (6.2%), this was the only possible access for endovascular intervention. Overall access site-related complications occurred in 25 patients (2.9%), in 19 of them (2.2%) required surgical correction, for brachial artery thrombosis or pseudoaneurysm. The other six were managed conservatively. No permanent neurological deficits of the arm or severe bleeding were observed. Minor complications, mostly hematomas, occurred in 62 patients (7.3%), but they required no further treatment. CONCLUSION: Brachial artery access expands our capability to perform complex procedures by allowing us to reach arterial targets in all territories. Complications of brachial vascular access are gradually decreasing together with the decrease of the crossing profile of the devices used in practice. However, when they occur, they often require surgical treatment. The growing experience of the team not only while obtaining the access but also while achieving adequate hemostasis ("patent hemostasis") is of great importance for minimizing the complications.

Uneventful Follow-Up 2 Years after Endovascular Treatment of a High-Flow Iatrogenic Aortocaval Fistula Causing Pulmonary Hypertension and Right Heart Failure.

Iatrogenic aortocaval fistula is an extremely rare pathologic condition that often results in clinically significant left-to-right extracardiac shunt. In slow-progressing cases, chronic right-sided heart failure can occur and, in some patients, may persist for years. We present a patient with a long-standing aortocaval fistula that was causing high-flow left-to-right shunting, tricuspid regurgitation, severe pulmonary hypertension, and right-side heart failure. After undergoing complete endoscopic isolation of the aortocaval fistula, the patient experienced dramatic clinical improvement and continued to have excellent imaging and clinical resolution after 2 years of follow-up.

Comparison of standard renal denervation procedure versus novel distal and branch vessel procedure with brachial arterial access.

OBJECTIVES: We assessed a novel approach to percutaneous renal denervation for uncontrolled hypertension consisting of ablation beyond the proximal main renal artery (Y-pattern), including the primary branches, and compared it to the standard procedure applied only within the main vessel. We also assessed the safety and practicality of a brachial access approach. METHODS AND RESULTS: Renal denervation was performed on 119 consecutive patients (60 ±â€¯13 years). In 68 of the patients, femoral arterial vascular approach was used and in 51 brachial. In 80 patients treated with the standard ablation, 12.0 ±â€¯3.0 total ablations (both sides) were applied while 20.4 ±â€¯3.9 total ablations were delivered for the group of 39 patients with Y-pattern denervation (P < 0.001). Technically successful renal denervation was achieved in all patients. Office blood-pressure levels at baseline were 170 ±â€¯17/93 ±â€¯10 mm Hg for the standard group and 169 ±â€¯13/96 ±â€¯9 mm Hg for the Y-pattern group. No major adverse events occurred during the procedure or in the postprocedural in-hospital period. Renal denervation was associated with significant decreases in both office and ambulatory systolic and diastolic blood pressure in both groups. The reduction in 24-hour mean ambulatory systolic blood pressure at 6 months was significantly greater (P = 0.002) for the Y-Pattern group (-22.1 ±â€¯15.4 mm Hg) compared to the Standard group (-11.8 ±â€¯16.2 mm Hg). Changes in diastolic office and ambulatory pressure were also significantly greater at 6 months in the Y-pattern ablation group. Indices of blood pressure variability improved in both groups. CONCLUSION: Renal denervation using a Y-pattern ablation strategy combined with a greater number of lesions is safe and resulted in significant greater decreases in mean 24-hour ambulatory systolic and diastolic blood pressure compared to the conventional approach in this single-centre matched cohort study. Brachial artery access was shown to be feasible and safe for renal denervation.

Recanalization and stenting of total occlusions of the renal arteries for blood pressure control in resistant to treatment hypertension.

OBJECTIVE: To evaluate whether percutaneous recanalization and stenting of totally occluded renal arteries is feasible and might be justified as effective in reducing the blood pressure (BP) in some patients with preserved collateral renal flow. PATIENTS AND METHODS: Seven consecutive patients (3 women, 4 men) at average age of 42.8 years (range, 15-67 years) with resistant hypertension, high renin activity, renal artery occlusion and preserved subsegmental flow were included. RESULTS: Endovascular recanalization was successful in 6 of 7 attempted cases. One month after the procedure the 24-h ABPM in the successfully recanalized renal CTO patients showed impressive decrease in the BP average of 138.5/81.7 mm Hg compared to 167.1/95.1 mm Hg before the procedure. Significant decrease in the drug medication was achieved. During the 6-month follow-up, two of the patients had in-stent restenosis- both successfully treated with endovascular reintervention. Secondary patency was 100% for 18 months thereafter and the BP control was excellent without medication increase. CONCLUSIONS: The recanalization of total renal artery occlusions resulted feasible and safe in the described group of patients with resistant hypertension and high plasma rennin activity. The renal artery recanalization had a positive effect on lowering the plasma renin activity and BP control.

Timing of invasive strategy in diabetic and non-diabetic patients with non-ST-segment elevation acute coronary syndrome.

INTRODUCTION: Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). A history of diabetes mellitus (DM) is no doubt one of the factors that define a patient as being at a higher risk of having the syndrome. AIM: To compare early invasive strategy with selective invasive strategy indicated for patients with and without DM. PATIENTS AND METHODS: The study enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), and of these 52 (29.2%) had DM. Patients were randomly assigned to an early invasive strategy (these were scheduled to undergo coronary arteriography and percutaneous coronary intervention within 24 hours after admission) or to a selective invasive strategy (at first these were medically stabilized, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). The patients were followed up for a mean period of 22.8 +/- 14 months. RESULTS: In the follow up the diabetics allocated to an early invasive strategy were found to have a significantly lower angina recurrence incidence (p = 0.005), rehospitalization rate (p = 0.001), fewer arteriographies (p = 0.001) and coronary interventions (p = 0.001) and low cumulative incidence of MACE (p = 0.008) in comparison with the diabetics assigned to selective invasive strategy. We also found, using the Kaplan-Meier curves survival analysis, that the time to MACE in patients assigned to an early invasive strategy was significantly longer than that in the group of selective invasive strategy. In the follow-up of non-diabetics we found no significant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. In the selective invasive strategy group, however, the cardiovascular adverse events tended to occur earlier than in the early invasive strategy group. CONCLUSIONS: Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndrome is associated with a reduced MACE rate compared with the selective invasive strategy used in these patients. Early invasive strategy applied in diabetic patients is also associated with a significantly longer time to MACE. In non-diabetics the advantages of early over selective invasive strategy are not so clearly differentiated.

Successful fibrinolysis after acute left ventricular assist device thrombosis.

The Berlin Heart INCOR system (Berlin Heart AG, Berlin, Germany) is a left ventricular assist device that generates a laminar blood flow. One of our INCOR-implanted patients was admitted to the hospital with clinical data indicating device thrombosis. The flow through the pump was assessed by contrast injection into the inflow canula. Lack of flow through the pump was found. A decision was made to perform fibrinolysis, which was performed by a reteplase injection into the device's inflow canula. After the manipulation, a restoration of the flow through the pump was observed. The patient was discharged 9 days after the procedure with no complications.