Faculty Bibliography

OBJECTIVES: The aim of our study is to assess the feasibility and safety of transradial intervention (TRI) of coronary ostial lesions using the Szabo technique. BACKGROUND: When performing TRI of coronary ostial lesions, precise stent positioning is of paramount importance. TRI has experienced increasing popularity in the U.S.; however, utilization of the Szabo technique has not been systematically evaluated in this setting. We report the results of ostial stent deployment using the Szabo technique for 2 experienced TRI operators and centers. METHODS: This was a retrospective analysis of 40 consecutive patients who underwent PCI from April 2009 to September 2011. All patients who underwent PCI via the transradial route with the Szabo technique for ostial lesions performed by experienced transradial operators (>200 cases/yr) were included. RESULTS: In our study of 40 patients with 41 coronary ostial lesions, overall procedural success rate was 100%. Stent dislodgement was seen in 1 patient. Clinical follow up was 100%, with a mean duration of 292.7+/-200 days. Target lesion revascularization (TLR) was seen in 2 patients (5%). One patient had an episode of transient ischemic attack (TIA) at 33 days after PCI; another experienced subacute stent thrombosis at 81 days while on dual antiplatelet therapy. MACE was 7.5% overall. CONCLUSION: In our study, treatment of coronary ostial lesions with the Szabo technique via TRI is associated with a high procedural success rate and a low MACE of 7.5%.

OBJECTIVE: The aim of our study is to assess the feasibility, safety, and rate of radial artery occlusion (RAO) using 7F sheathless guiding catheter in a large population undergoing transradial intervention (TRI). BACKGROUND: There is a frequent need for large bore guiding catheter to perform complex coronary interventions. Hydrophilic sheathless guiding catheters are not available in the US, therefore, we present the results of a multicenter study using the modified sheathless technique and readily available catheters. METHODS: Between December 2010 and February 2011, 116 consecutive patients from four tertiary US centers who underwent TRI using 7F sheathless guiding catheter were included in this study. RESULTS: In our study of 116 patients with 123 coronary lesions, 57 stenoses (49%) were complex interventions, which included patients with acute coronary syndromes, chronic total occlusion (CTO), bifurcation stenting, calcified lesions, left main artery, and saphenous venous graft interventions. Overall procedural success rate was 95%. At 7-day, there were six patients (5%) with RAO, of which two of the six had severe radial artery spasm during the procedure. At 30-day, the overall persistent RAO was only detected in three patients (2.5%), as three patients had return of antegrade radial artery flow. CONCLUSIONS: In our multicenter study of 116 consecutive patients, using 7F sheathless guiding catheter to perform TRI is associated with a high procedural success (95%) and a low 30-day RAO rate (2.5%).

Ostial lesions, including aorta-ostial lesions and Medina 001 bifurcation lesions, are known to create difficulty in precise stent placement. There are many techniques used to help in precise ostial stent placement; these include using multiple angiographic views to assist in placement, the use of the Ostial Pro device, the aorta flowing wire technique, Szabo (anchor-wire) techniques, the T-stent and small protrusion (TAP) technique, the cross-over 1-stent technique, and new dedicated ostial stents. In this review, we summarize these different techniques and show that there is no universal technique that allows for perfect ostial stent placement.

BACKGROUND: The sheathless approach to transradial percutaneous coronary intervention (PCI) has recently gained popularity among interventionalists. However, technical problems and lack of approved equipment in the United States has limited its applicability. We describe a new approach, balloon-assisted sheathless transradial intervention (BASTI) that can ease the use of 5 Fr sheathless guiding catheters and decrease complication rates. METHODS: Twenty-seven consecutive patients undergoing staged elective PCI were enrolled. Radial artery access was obtained using the BASTI method - inflation of a compliant coronary balloon at the tip of the guiding catheter was used to ease the transition of the catheter into the skin. The guidewire and coronary balloon were reused during the PCI. Each of the patients had clinical postprocedure follow-up at radial compression device release, and at 1 day, 7 days, and 30 days. Major adverse cardiac events and access-site complications, including radial artery occlusion (RAO), were documented. RESULTS: In this consecutive series, we successfully attempted (27/27) BASTIs. There were no difficulties in obtaining radial artery access with the 5 Fr sheathless guiding catheter. Two patients had balloon rupture during initial radial artery access, but were successfully re-attempted with a higher balloon inflation pressure. All patients then underwent successful coronary intervention. There were no adverse events or procedure-related complications at any time period during follow-up. CONCLUSION: BASTI is a feasible alternative to conventional techniques and may reduce vascular access-site complications and patient morbidity in a cost-effective manner.

Transradial catheterization (TRC) has been associated with a lower incidence of major access site related complications as compared to the transfemoral approach. With the increased adoption of transradial access, it is essential to understand the potential major and minor complications of TRC. The most common complication is asymptomatic radial artery occlusion, which rarely leads to clinical events, owing to the dual collateral perfusion of the hand. Adequate anticoagulation, appropriate compression techniques, and smaller sheath size can minimize the risk of radial artery occlusion. Hand ischemia with necrosis has never been reported during TRC with thorough pre-examination of intact collateral circulation. Radial artery spasm is relatively common, and can result in access and procedural failure. It can be prevented by the use of vasodilator cocktails and hydrophilic sheaths. Radial artery perforation can lead to severe forearm hematoma and compartment syndrome if not managed promptly. Careful observation, prompt detection of the hematoma, and management with a pressure bandage dressing are critical to avoid serious complications. Pseudoaneurym and arteriovenous fistula are rare complications, which can likely be managed conservatively without surgical intervention. Nerve injury occurring during access has been reported. Close observation for improvement is necessary, although symptoms usually improve over time. In summary, to prevent access site complications, avoidance of multiple punctures, gentle catheter manipulation, use of guided compression, coupled with careful observation for adverse warning signs such as hematoma, loss of pulse, pain, are critical for safe and effective TRC. (c) 2011 Wiley Periodicals, Inc

Previous studies have shown that the right radial approach encounters more tortuosity than the left radial approach during transradial coronary angiography. The objective of this study was to compare the procedural difficulty of the right and left radial approaches in the modern era with dedicated transradial catheters. One hundred ninety-three patients scheduled for transradial coronary angiography with normal Allen test results and without histories of coronary artery bypass grafting were randomized to the right or left radial approach. The choice of catheter was left to the discretion of the operator, with the preferred catheter being a dedicated transradial Optitorque catheter. The primary end point was procedural difficulty, defined as (1) hydrophilic or coronary wire use for tortuosity, (2) stiff wire use for the coronary engagement, (3) multiple catheters used, or (4) nonselective injection. The clinical characteristics were similar between the 2 groups. Procedural success was achieved in 98 of 101 (98%) in the right radial group and 91 of 92 (99%) in the left radial group. Procedural difficulty, fluoroscopy time, and contrast use were similar between the 2 groups. The use of a single catheter was more common in the right radial group (73% vs 18%, p <0.001). In conclusion, procedural success and difficulty were similar in the comparison groups. The right and left radial approaches are feasible and effective to perform coronary angiography and intervention

Although the provisional stenting technique to treat coronary bifurcation lesions is the preferred method, many bifurcation lesions still require a two-stent technique to optimize the result and clinical outcome. This manuscript summarizes the tips and tricks of bifurcation stenting with cases illustrations. As interventionists are encountering more complex and difficult cases, one may find the tips and tricks in this manuscript helpful in daily practice

Radial artery pseudoaneurysm is an extremely rare complication associated with transradial catheterization. We report 2 cases of pseudoaneurysm of the radial artery that were successfully treated using the Terumo TR band. We believe that the safety, efficiency, speed and minimal invasiveness of this method make it feasible for use as a treatment for peripheral pseudoaneurysm in such patients