Faculty Bibliography

OBJECTIVES: The aim of this review is to discuss different methods of working through subclavian, innominate, and aortic arch anatomical challenges to increase the success rate of transradial approach (TRA). BACKGROUND: Anatomical challenges in the subclavian, innominate, and aortic arch regions are important reasons for failure of TRA. There is limited modern literature describing methods to overcome these challenges and reduce TRA failure. METHODS: A number of primary subclavian, innominate, and aortic arch anatomical challenges are identified and management techniques to overcome them are discussed. RESULTS: Subclavian, innominate, and aortic arch anatomical challenges can be divided into five subsets, including (1) tortuosity, (2) loop, (3) stenosis, (4) congenital aberrancy, and (5) combined challenges. In depth discussion with supportive examples for the identification and management of these challenges are provided. CONCLUSIONS: Despite lower rates of bleeding and vascular complications as compared to transfemoral approach, the adoption of TRA has been relatively slow in part due to frustration from operator failure during the learning curve. Anatomical challenges of subclavian, innominate, and aortic arch regions play an important role in TRA procedural failure. Using a simple, conceptual, framework to classify the anatomical or functional problem and then applying a logical approach to these challenges can facilitate management and augment operator success rates for TRA.

Coronary angiography is the gold standard for defining obstructive coronary disease. However, radiation exposure remains an unwanted hazard. Patients referred for coronary angiography with abdominal circumference <45 inches and glomerular filtration rate >60 ml/min were randomized to the fluorography (n = 25) or cineangiography (n = 25) group. Patients in the fluorography group underwent coronary angiography using retrospectively stored fluorography with repeat injection under cineangiography only when needed for better resolution per operator's discretion. Patients in the cineangiography group underwent coronary angiography using routine cineangiography. The primary end point was patient radiation exposure measured by radiochromic film. Secondary end points included the radiation output measurement of kerma-area product and air kerma at the interventional reference point (Ka,r) and operator radiation exposure measured by a dosimeter. Patient radiation exposure (158.2 mGy [76.5 to 210.2] vs 272.5 mGy [163.3 to 314.0], p = 0.001), kerma-area product (1,323 muGy.m(2) [826 to 1,765] vs 3,451 muGy.m(2) [2,464 to 4,818], p <0.001), and Ka,r (175 mGy [112 to 252] vs 558 mGy [313 to 621], p <0.001) were significantly lower in the fluorography compared with cineangiography group (42%, 62%, and 69% relative reduction, respectively). Operator radiation exposure trended in the same direction, although statistically nonsignificant (fluorography 2.35 muGy [1.24 to 6.30] vs cineangiography 5.03 muGy [2.48 to 7.80], p = 0.059). In conclusion, the use of fluorography in a select group of patients during coronary angiography, with repeat injection under cineangiography only when needed, was efficacious at reducing patient radiation exposure.

This report describes the technique of transradial renal angiography and interventions. We illustrate the approach using typical case images. We believe cranio-caudal approach to the renal artery for diagnostic and therapeutic catheterization offers advantages over the traditional femoral approach.

OBJECTIVE: We sought to study the clinical outcomes of bifurcation stenting in patients who presented with stent thrombosis segment elevation myocardial infarction (STEMI). BACKGROUND: Patients with STEMI are usually excluded from randomized bifurcation studies. There is limited information for bifurcation stenting in this population. METHODS: All STEMI patients who were randomized were retrospectively reviewed from DKCRUSH II (double kissing, double crush) database. DKCRUSH II is a multicenter, randomized study of provisional stenting (PS) versus the DK crush stenting techniques. A total of 370 patients with bifurcation lesions were randomized and of this group a total of 63 patients with STEMI were found. This group of STEMI included 30 patients in the PS group and 33 patients in the DK crush stenting group. RESULTS: There were no differences in terms of contrast used, procedure time, and fluoroscopy time. Procedural success rates were 97% in all patients with STEMI, with 100% in the PS group and 94% in the DK crush stenting group. During the procedure, there were two patients with less than TIMI 3 (thrombolysis in myocardial infarction) flow in the main vessel of the DK crush group However, TIMI 3 flow was 100% in the side branch for both groups. Cumulative 12-month major adverse cardiac event (MACE) was 22% in the whole STEMI group, whereas PS and DK crush groups were 23% versus 21%, respectively (P = NS). There were no differences in in-hospital, 6-month, and 12-month MACE in these two groups. At 6 and 12 months, there were two cardiac deaths in the PS group but without statistical significance when compared with the DK crush stenting group (7% vs. 0%, P = NS). CONCLUSION: Bifurcation stenting in patients with STEMI is safe and feasible. The immediate and midterm clinical outcomes were comparable between PS and DK crush stenting. (c) 2013 Wiley Periodicals, Inc.

Transradial access for coronary interventions has grown substantially in the last few years. Currently, there is an increased interest in applying this approach to peripheral vascular interventions. This report reviews the current status of transradial peripheral interventions, and offers advice in terms of feasibility, equipment use, and technical challenges. (c) 2012 Wiley Periodicals, Inc.

Background: Stenting of coronary bifurcation lesions provides excellent immediate outcomes, with higher rates of major adverse cardiac events (MACE) at follow-up compared to lesions not at bifurcations. Final kissing balloon inflation (FKBI) after stenting these bifurcations, appears to improve angiographic results, although concerns have been raised regarding its effect on stent geometry. The impact of FKBI on MACE is not entirely clear. Methods: Pubmed, Cochrane, Embase and Google scholar databases were searched for the terms <>, <> and <>. 65 studies were retreived from the literature. 8 studies reported outcomes in cohorts with or without FKBI, using a 2-stent strategy. MACE, stent thrombosis and side branch restenosis outcomes were analyzed using Comprehensive meta-analysis software. Heterogeneity was assessed using the I-square statistic. Both random and fixed effects models were evaluated. Results: A total of 2871 patients were included in the analysis. A significant reduction in side-branch restenosis (O.R = 0.381, P = 0.0001, I-square = 69, random-effects model) as well as stent thrombosis (O.R = 0.371, P = 0.026, I-square = 9, fixed effect model) was noted in patients receiving FKBI, compared to those who did not. A significant reduction in 1 year MACE was noted in the cohort with FKBI, compared to control group (O.R = 0.395, P = 0.0001, I-square = 62, random effects model was used). Significant publication bias was noted (Egger's 2-tailed P = 0.0036) Conclusion: In patients with coronary bifurcation stenoses, undergoing PCI with two-stent strategy, a significant reduction in side branch restenosis, stent thrombosis as well as 1 year MACE, is observed if final kissing balloon inflation is performed

Vascular and bleeding complications are a known risk of cardiac catheterization. In this article, we report a neck hematoma after left-sided transradial cardiac catheterization, which is a known but rarely reported complication of this procedure.

BACKGROUND: Studies demonstrate an increase in radiation exposure with transradial approach (TRA) when compared with transfemoral approach (TFA) for coronary angiography. Given the learning curve associated with TRA, it is not known if this increased radiation exposure to patients is seen when procedures are performed by experienced operators. METHODS: We retrospectively evaluated 1,696 patients who underwent coronary angiography with or without percutaneous coronary intervention (PCI) by experienced operators at a tertiary center from October 2010 to June 2011. Experienced operators were defined as those that perform >75 PCIs/year with >95% of cases performed using the TRA or TFA approach for >/=5 years. The outcomes of interest were dose area product (DAP) and fluoroscopy time (FT). RESULTS: Of the 1,696 patients, 1,382 (81.5%) were performed by experienced femoral operators using TFA and 314 (18.5%) were performed by experienced radial operators using TRA. Most of these cases (65.4%) were diagnostic only (870 TFA and 240 TRA) with both DAP (6040 [3210-8786] vs 5019 [3377-6869] muGy.m, P = .003] and FT [6.2 [4.0-10.3] vs 3.3 [2.6-5.0] minutes, P < .001) significantly higher using TRA versus TFA. For procedures involving PCI, despite similar baseline patient, procedural and lesion characteristics, DAP and FT remained significantly higher using TRA versus TFA (19,649 [11,996-25,929] vs 15,395 [10,078-21,617] muGy.m, P = .02 and 22.1 [13.3-31.0] vs. 13.8 [9.8-20.3] minutes, P < .001). CONCLUSIONS: In a contemporary cohort of patients undergoing coronary angiography by experienced operators, TRA was associated with higher radiation exposure when compared with TFA.