Faculty Bibliography

BACKGROUND:Use of a universal diagnostic catheter may decrease procedural time and catheter-exchange related spasm when compared with a dual-catheter strategy. The aim of this study was to identify preprocedural predictors of failure to complete a coronary angiogram with a universal catheter alone. METHODS:Consecutive patients (n = 782) who underwent a right transradial/transulnar coronary angiogram with a single operator were retrospectively reviewed. Multivariable predictors of failure to complete the procedure with a universal catheter alone were identified using logistic regression analysis and presented as odds ratio (OR) and 95% confidence interval (CI). RESULTS:Of the study population (n = 558), a total of 216 (38.7%) required exchange to a coronary-specific catheter (44.4% for right coronary artery alone, 25.5% for left coronary artery alone, 30.1% for both) and 342 (61.3%) underwent angiography with a universal catheter alone. Patients who required a catheter exchange were more likely to have the following characteristics compared with patients who underwent an angiogram with a universal catheter alone: age >75 years (27.3% vs 16.4%; P<.01), female sex (34.3% vs 23.1%; P<.01), diabetes mellitus (50.0% vs 38.3%; P<.01), hypertension (88.0% vs 74.6%; P<.001), and chronic kidney disease (29.2% vs 17.8%; P<.01). After multivariable adjustment, age ≫75 years (OR, 1.92; 95% CI, 1.21-3.04), female sex (OR, 1.94; 95% CI, 1.20-3.14), hypertension (OR, 2.08; 95% CI, 1.22-3.57), and chronic kidney disease (OR, 1.58; 95% CI, 1.01-2.46) predicted failure of a universal catheter alone to complete angiography. CONCLUSION/CONCLUSIONS:Consideration may be given to use an initial dual-catheter strategy if one or more of the following are present: elderly age, female sex, hypertension, and chronic kidney disease.

BACKGROUND:Improved equipment and techniques have resulted in transition from surgical bypass to endovascular intervention to treat superficial femoral artery (SFA) chronic total occlusions (CTO). A change in access site to radial (TRA) or tibiopedal (TPA) artery for the treatment of these SFA CTO has been reported. The feasibility, efficacy and safety of these two access sites for treatment of SFA CTO have not been reported. METHODS:We performed an as treated analysis of 184 SFA CTO interventions in 161 patients from 01/2014 to 09/2016 using either primary TRA or TPA (operator discretion) at two institutions. Primary end point was 30 day major adverse event (MAE) - death, amputation or target vessel revascularization, secondary endpoint was success of procedure. RESULTS:Primary TRA was used in 46 patients with 47 CTO lesions .Primary TPA was used in 115 patients with 137 CTO lesions. Primary crossing success rate was higher with TRA compared to TPA (74% vs 54%, P = 0.01). Dual TRA-TPA was required in 72 prior uncrossed lesions resulting in a crossing and procedural success of 99% and 96% respectively. The overall crossing and procedural success rate using either of these approaches was 99% and 98% respectively. The 30 day MAE was 5% in TRA arm, 0% in TPA arm and 2% in dual TRA-TPA arm, P = 0.08. All access sites were patent, confirmed by ultrasound. CONCLUSION/CONCLUSIONS:The treatment of SFA CTO is feasible and safe using both TRA or TPA approach providing high success rates and no access site complications.

Background: Use of a universal diagnostic catheter may decrease procedural time and catheter exchange-related spasm compared to a dual catheter strategy. The aim of this study is to identify demographic and clinical predictors of failure to complete an invasive coronary angiogram with a universal catheter alone. Methods: A retrospective review was performed of consecutive unique patients who underwent a right transradial or transulnar diagnostic coronary angiogram between January 2015 and June 13, 2017 by a transradial operator who routinely starts with a universal catheter (n=624). Patients were excluded if a universal catheter was not initially used (n=84). Multivariable predictors of failure to complete the procedure with a universal catheter alone were identified using logistic regression analysis and presented as odds ratio (OR) [95% confidence interval (CI)]. Results: Of patients who met study criteria, 317 (58.7%) underwent angiography with a universal catheter alone and 223 (41.3%) required exchange to a coronary-specific catheter (53.2% for right coronary artery alone, 20.1% for left coronary artery alone, 25.2% for both). Patients who required a catheter exchange were more likely to be age >75 years (24.7% vs 14.8%, p<0.005), female (34.4% vs 20.1%, p<0.005), height <64 inches (35.3% vs 25.5%, p=0.016), with diabetes mellitus (47.9% vs 36.7, p=0.010), with hypertension (85.2% vs 74.4%, p=0.003), or with chronic kidney disease (25.9% vs 17.2%, p=0.017). After multivariable adjustment, age >75 years (OR 2.02 [1.29-3.17]), female sex (OR 2.11 [1.42-3.15]), diabetes mellitus (OR 1.54 [1.06- 2.24]), and hypertension (OR 1.96 [1.23-3.12]) independently predicted failure of a universal catheter alone to complete angiography. Conclusion: In patients undergoing a right transradial or transulnar coronary angiogram, consideration may be made to use a dual catheter strategy over a universal catheter strategy if one or more of the following characteristics are present: elderly age, female sex, diabetes mellitus, hypertension. A prospective study is needed to determine if catheter selection based on these pre-procedural characteristics can decrease access crossover rate, procedural time, radiation exposure, and contrast use

Lack of health insurance is associated with adverse clinical outcomes; however, association between health insurance status and outcomes in patients presenting with ST-elevation myocardial infarction (STEMI) is unclear. Using the Nationwide Inpatient Sample data from 2003 to 2014, hospitalizations with STEMI in patients 18 years of age and older were extracted. Based on health insurance status, patients were categorized into insured and uninsured groups. The primary outcome measure was in-hospital mortality. Adjusted analysis using inverse probability weighting with multivariable regression was performed to identify independent predictors of in-hospital mortality. Of 2,710,375 patients included in the final analysis, 220,770 patients were uninsured. Unadjusted in-hospital mortality was lower in uninsured patients (5.1% vs 9.3%; p <0.001). Adjusted analysis showed that lack of health insurance was associated with the worst in-hospital mortality (odds ratio [OR] = 1.77, 95% confidence interval [CI] 1.72 to 1.82; p <0.001). Other independent predictors of in-hospital mortality were low household income (OR = 1.08, 95% CI 1.07 to 1.09; p <0.001), acute stroke (OR = 2.87, 95% CI 2.80 to 2.95; p <0.001), acute kidney injury (OR = 2.60, 95% CI 2.57 to 2.64; p <0.001), cardiac arrest (OR = 8.88, 95% CI 8.77 to 8.99; p <0.001), cardiogenic shock (OR = 5.81, 95% CI 5.74 to 5.88; p <0.001), requirement of pericardiocentesis (OR = 10.54, 95% CI 9.64 to 11.52; p <0.001), gastrointestinal bleeding (OR = 1.41, 95% CI 1.38 to 1.54; p <0.001), and pneumonia (OR = 1.43, 95% CI 1.41 to 1.45; p <0.001). The multivariate model demonstrated good statistical discrimination (c-statistic = 0.89). In conclusion, lack of health insurance is independently associated with increased in-hospital mortality in patients presenting with STEMI.

Background: Patients undergoing Transcatheter aortic valve replacement (TAVR) for symptomatic aortic stenosis (AS) have a high prevalence of coronary artery disease (CAD) and it adversely impacts long term outcomes of patients undergoing TAVR. However, the strategies for treatment of CAD prior to TAVR are more heterogenous and no consensus exists whether a "complete revascularization" (CR) strategy is superior to "incomplete revascularization" (ICR) strategy. We aimed to assess the prognostic effect of concomitant CAD, stratified by completeness versus the incompleteness of revascularization, on the oneyear clinical outcomes. Methods: A systemic search of database, including, Pubmed, Web of Science, Google scholar and Cochrane Database were performed by two independent reviewers to identify relevant studies. Studies were included comparing complete versus incomplete revascularization with PCI for CAD in patients undergoing TAVR. The primary outcome was one year all cause mortality. We also evaluated the outcome stratified by residual syntax score (less than 8 versus more than 8). Results: Seven studies were included in the analysis. The prevalence of CAD was 45.9% in our pooled sample. The one year all-cause mortality was comparable between the 2 groups (19.7% in CAD group and 17.3% in no CAD group, OR=1.08, [CI 0.79,1.49], I25 0%). Five studies reported data on complete versus incomplete revascularization. There was no difference in one year all-cause mortality among two groups (18.8% in CR group versus 27.7% in ICR group, OR=0. 58, [CI 0.20,1.70], I2= 86%). The one year all cause mortality was also not different between patients with a residual syntax score less than 8 and more than 8 (18.3% vs 36%, respectively, OR=0.29, [CI 0.08,1.11], I25 77%). Conclusion: The presence of CAD, incomplete revascularization strategy, and residual unrevascularized CAD burden are not associated with decreased survival in patients with AS and CAD undergoing TAVR. (Figure Presented)

Background: Transcatheter aortic valve replacement (TAVR) has been recognized as the treatment of choice for patients with severe aortic stenosis who are considered high or prohibitive risk for surgery. The scope of TAVR has been evaluated in low to intermediate risk population, however, these studies are mostly observational and few in number. We aimed to evaluate the outcomes in low to intermediate risk patients with severe aortic stenosis who underwent TAVR compared to surgical aortic valve replacement (SAVR). Methods: A systemic search of database, including, Pubmed, Web of Science, Google scholar and Cochrane Database were performed by two independent reviewers to identify relevant studies. Studies were included comparing TAVR versus SAVR in patients with low to intermediate risk. The primary outcome was 30 day mortality and secondary outcomes were one year mortality, myocardial infarction, stroke, major or life threatening bleeding, permanent pacemaker implantation, paravalvular regurgitation and acute kidney injury. Results: Nine studies were included in the analysis. There were no significant differences in 30 day (OR, 0.83 [CI 0.63,1.10], I²= 0%) and one year (OR, 0.92 [CI 0.78,1.09], I²=0%) mortality between TAVR and SAVR group. There were also no significant differences in myocardial infarction (OR, 0.65 [CI 0.40,1.05], I²=0%), and a stroke rate (OR, 0.83 [CI 0.64,1.07], I²=0%) between the two groups. However, the rate of permanent pacemaker implantation (OR, 3.97 [CI 2.12,7.45], I²=83%) and moderate to severe paravalvular regurgitation (OR, 6.04 [CI 3.80,9.61], I²=0%) were more in TAVR group and acute kidney injury (OR, 0.50 [CI 0.31,0.78], I²=65%) and major and life threatening bleeding (OR, 0.29 [CI 0.15,0.55], I²=86%) were more in SAVR group. Conclusion: TAVR and SAVR has a similar rate of mortality, stroke and myocardial infarction rate. TAVR has more number of permanent pacemaker implantation and paravalvular regurgitation rates and SAVR have more number of life threatening bleeding and acute kidney injury

Background: Femoral artery access remains the most frequent access site for cardiac catheterization in the United States Vascular access related complications (VAC) are the Achilles heal of femoral access and are associated with increased mortality and morbidity. A micropuncture [21 gauge (G)] needle with a 0.018" or 0.021" guidewire has been available, with the potential advantage of smaller failed or posterior puncture and hence a presumed lower incidence of VAC. The literature remains divided from a standpoint of comparative VAC outcomes between the 2 strategies of arterial access, and imprecise in view of small sample size of individual datasets. We performed a systematic review and meta-analysis to compare the incidence of VAC between Micropuncture access versus standard access. Methods: A systematic search of database, including, Pubmed, Web of Science, Google scholar and Cochrane Database were performed by two independent reviewers to identify relevant studies. Studies were included comparing Micropuncture access versus standard needle access. The primary outcome was composite of VAC including bleeding, hematoma, pseudoaneurysm, acute limb ischemia, vascular perforation and arteriovenous fistula. Results: Three studies, including 3745 patients were included in the analysis. 21 G needle was used in Micropuncture group in all three studies and 18 G needle was used in the standard group in two studies and 19 G needle in one study. Two studies included patients who underwent percutaneous coronary intervention and one study with patients who underwent lower extremity arterial intervention. The rate of access site complication was 4.9% in the Micropuncture needle group and 2.27% in the standard needle group. There was no significant difference in vascular access site complication between the two groups (OR, 0.99 [CI 0.50, 1.99], I²556%). Conclusion: Femoral access using Micropuncture needle did not reduce the incidence of access site complications as compared to standard needle. Appropriately powered randomized controlled trials are needed to evaluate the safety and potential efficacy of Micropuncture needle technique

Background: Lack of health insurance is associated with adverse clinical outcomes; however, effects of health insurance status on outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) is unclear. Methods: Using the Nationwide Inpatient Sample (NIS) data from 2003-2013, hospitalizations with STEMI in patients 18 years of age and older were extracted. Depending on their primary payer status, patients were categorized into insured and uninsured groups. The primary study outcome measure was in-hospital mortality. Adjusted analysis using inverse-probability weighting with multivariable regression was performed to evaluate the independent predictors of in-hospital mortality. Results: Of 4,812,009 patients included in the final analysis, 4,426,747 (92%) patients were insured, whereas 385,262 (8%) patients were uninsured. Unadjusted in-hospital mortality was lower in uninsured patients (5% vs 9.5%; P=0.0005). Uninsured patients presented with STEMI at a younger age and with fewer diagnosed comorbidities. Independent predictors of in-hospital mortality were lack of health insurance (O.R=1.36, 95% C.I [1.34-1.39], P=0.0005), low household income (O.R=1.12, 95% C.I [1.11-1.3], P=0.0005), acute cerebrovascular accident (O.R=2.94, 95% C.I [2.89-3.00], P=0.0005), acute kidney injury (O.R=2.67, 95% C.I [2.64-2.69], P=0.0005), cardiac arrest (O.R=8.66, 95% C.I [8.58-8.75], P=0.0005), cardiogenic shock (O.R=5.31, 95% C.I [5.26-5.37], P=0.0005) requirement of pericardiocentesis (O.R=10.86, 95% C.I [10.15-11.62], P=0.0005), gastrointestinal bleeding (O.R=1.42, 95% C.I [1.39-1.44], P=0.0005), mechanical circulatory support (O.R=1.30, 95% C.I [1.29-1.32], P=0.0005) and pneumonia (O.R=1.45, 95% C.I [1.43-1.47], P=0.0005). The multi-variate model demonstrated good statistical discrimination (c-statistic=0.89). Conclusion: Lack of health insurance is independently associated with increased in-hospital mortality in patients presenting with STEMI

Background: Transradial access (TRA) as compared to transfemoral access (TFA) for percutaneous coronary intervention (PCI) is being increasingly popular because of fewer vascular complication rate and early ambulation. TF approach is the preferred approach for CTO-PCI because it allows the use of large catheters with better passive support. TRA utilization in CTO-PCI is increasing. We aimed to evaluate the safety and procedural outcomes of the TRA versus TFA for PCI of CTO. Methods: A systematic search of database, including, Pubmed, Web of Science, Google scholar and Cochrane Database were performed by two independent reviewers to identify relevant studies. Studies comparing TRA versus TFA in patients undergoing CTO-PCI were included. The primary outcome measure was procedural success rate and secondary outcomes studied were total procedure time, fluoroscopy time, contrast volume, access-site complications and other in-hospital major procedural complications. Random-effects model was used and publication bias was calculated. Results: Eleven studies, including 5120 patients were included in the analysis. The procedural success rate was significantly higher in the TRA group as compared to TFA group in the unadjusted pooled analysis (OR, 1.37 [CI 1.11, 1.68], I²=37%), however, the adjusted analysis showed no significant difference between the two groups (OR, 1.26 [CI 0.67, 2.4], I²=61%). Access-site complication rate was lower in the TRA group as compared to TFA group (OR, 0.32 [CI 0.15, 0.69], I²=10%). Total procedure time (WMD, -0.33 minutes [CI -13.54, 12.88], I²=90%), fluoroscopy time (WMD, -2.59 minutes [CI -9.73, 4.54], I²=88%) and the contrast volume (WMD, 7.17 ml [CI -27.02, 41.36], I²=79%) were comparable between the two groups. The rate of other procedural complications was also comparable between the two groups (OR, 0.71 [CI 0.38, 1.32], I²=25%). There was no evidence of publication bias for the primary outcome measure, (Begg-Mazumdar (p=0.61) and Egger's (p=0.87) rank correlation test). Conclusion: TRA is safe and feasible in patients with PCI of CTO with similar procedural success rate and is associated with a lower vascular complication rates as compared to TF approach