Faculty Bibliography

BACKGROUND:Transpedal access is increasingly utilized for peripheral vascular catheterization. There is a paucity of data on the use of radial hemostasis devices as an alternative to manual compression for achievement of hemostasis after this approach. OBJECTIVE:To compare safety and efficacy of two hemostasis devices following transpedal catheterization for lower extremity revascularization for peripheral arterial disease. METHODS:A consecutive cohort of patients with bilateral Rutherford 2-5 disease who underwent transpedal catheterization for peripheral vascular interventions were retrospectively analyzed. In each patient, retrograde tibial artery access was obtained, a 4 French sheath was placed, and all revascularization was performed via tibial access. In all patients, a TR Band™ (Terumo Medical, n = 215) and/or VasoStat™ (Forge Medical, n = 99) were used to apply puncture site compression, following removal of the tibial sheath until hemostasis was achieved. Safety and efficacy of each device was compared. RESULTS:Puncture site hemostasis was achieved in all patients within 2 hours of sheath removal facilitating early discharge. Two access site pseudoaneurysms occurred within 30 days of revascularization, one of which followed TR Band™ placement and the other following VasoStat™ placement (P = 0.53). Each patient was successfully treated with ultrasound-guided thrombin injection. Loss of access site patency by duplex ultrasound occurred in 2 patients following the TR Band™ and a single patient following the VasoStat™ (P = 1.0). CONCLUSION/CONCLUSIONS:Both the TR Band™ and the VasoStat™ were effective in achieving hemostasis following transpedal catheterization with low rates of complications.

BACKGROUND: Atherosclerotic disease of the superficial femoral artery (SFA) is frequently seen and can be treated with percutaneous interventions, traditionally via femoral artery access. There are limited reports of transpedal artery access for peripheral artery interventions, but none to date describing routine primary transpedal artery approach for SFA stenting. METHODS: In this preliminary study, we report 4 patients who underwent successful endovascular SFA stenting using a single transpedal artery access via a new ultra-low profile 6 Fr sheath (Glidesheath Slender; Terumo Corporation). RESULTS: All patients underwent successful SFA stenting without complication. Procedure time varied from 51 to 72 minutes. The mean contrast amount used was 56 mL; mean fluoroscopy time was 21 minutes; mean radiation dose was 91 mGy. At 1-month follow-up, duplex ultrasonography showed that all pedal arteries had remained patent. CONCLUSIONS: Transpedal artery approach as a primary approach to SFA stenting appears feasible and safe. Comparative trials with standard percutaneous femoral approach are warranted.

Technological innovations have enabled higher success rates with percutaneous coronary intervention (PCI) of complex coronary lesions via the transradial approach. The orbital atherectomy system (OAS; Cardiovascular Systems, Inc) is the most recent innovation that abrades plaque using a rotation device for the facilitation of stent placement in heavily calcified lesions. Fifty patients with classic anginal symptoms and an abnormal stress test demonstrating ischemia underwent PCI using the coronary OAS. In all, 46 out of 50 patients received stents in the target lesion after orbital atherectomy. At follow-up, there were no major adverse cardiovascular events, including cardiac death, myocardial infarction, and need for target-vessel revascularization. Radial artery occlusion rate was 6% at 30 days. The use of the OAS via the radial approach may be a safe and feasible option to assist in the treatment of heavily calcified coronary lesions.

OBJECTIVE:To demonstrate the feasibility and safety of transpedal arterial access for lower-extremity angiography and intervention. BACKGROUND:Traditionally, the femoral artery is chosen for the initial access site in symptomatic peripheral artery disease (PAD), but this approach carries a substantial portion of the entire procedural complication risk. METHODS:80 patients were prospectively evaluated for the treatment of PAD between May and July 2014. All patients underwent peripheral angiography, and intervention if necessary. A pedal artery was the initial access site for all patients. Under ultrasound guidance, one of the pedal arteries was visualized and accessed, and a 4 Fr Glidesheath was inserted. Retrograde orbital atherectomy and balloon angioplasty were performed with a 4 Fr sheath or upsizing to a 6 Fr Glidesheath Slender (Terumo) for stenting as needed. Clinical and ultrasound assessment of the pedal arteries were performed before the procedure and at 1-month follow-up. RESULTS:Diagnostic transpedal peripheral angiography was performed in all 80 patients. 43 out of 51 patients (84%) who required intervention were successful using a pedal artery as the sole access site. No immediate or delayed access-site complications were detected. Clinical follow-up was achieved in 77 patients (96%) and access artery patency was demonstrated by ultrasound at 1 month in 100% of patients. CONCLUSION/CONCLUSIONS:The routine use of a transpedal approach for the treatment of PAD may be feasible and safe. Pedal artery access may also avoid many of the complications associated with the traditional femoral approach, but further study is needed.

OBJECTIVES: To provide new strategies and techniques for the successful recanalization of chronic total occlusions (CTOs) with the sole use of the CrossBoss catheter. In addition, some common CTO scenarios are illustrated in detail. BACKGROUND: CTOs are one of the most challenging complex coronary lesion subsets to intervene upon. Even with the innovation of specialized catheters, the success rate of antegrade recanalization remains low. METHODS: Between June and December 2013, a retrospective analysis of 50 consecutive patients who presented with a planned percutaneous intervention (PCI) of a CTO was performed. In all patients, the CrossBoss catheter was used. No additional reentry devices were necessary. Procedural success was defined as <20% residual stenosis and TIMI-3 distal blood flow of the treated vessel at the end of the procedure. RESULTS: The majority of the patients were male (72%), with an average age of 68 years. Thirty percent of patients presented with prior CTO-PCI failure. The average fluoroscopy time was 45.9 minutes and the average amount of contrast use was 273.8 mL. No patient suffered a coronary perforation from the CrossBoss catheter. CONCLUSIONS: With increased experience using the CrossBoss catheter, the antegrade success rate of CTOs can be improved. Some tips include identifying the likely course of the artery with the aid of retrograde injection, proper guidewire selection and manipulation, and redirecting the CrossBoss catheter if there is substantial deviation from the original path.

OBJECTIVES/OBJECTIVE:To evaluate the use of extension catheters in transradial intervention of complex coronary lesions. BACKGROUND:Complex percutaneous coronary intervention (PCI) via transradial approach remains a challenge for many interventionalists, primarily due to the difficulty in obtaining adequate guide catheter support. METHODS:A retrospective case series identified 54 patients who presented for PCI of complex coronary lesions. A lesion was defined as complex if it contained severe calcification, proximal tortuosity, chronic total occlusion, or was located distal to a previously implanted stent. After identifying the complex lesions, a conversion to femoral approach was considered, but an attempt via the transradial approach with the use of an extension catheter was chosen as the initial strategy. Specific cases highlighting this approach are illustrated in detail. RESULTS:The average age of the patients was 72 years old, with male predominance (55%). The success rate of completing the transradial intervention with the help of an extension catheter was 96%. Stent delivery failed due to severe tortuosity and calcification in only 2 cases. The coronary artery involved was either the left anterior descending (n = 25), the left circumflex (n = 10), the right coronary artery (n = 14), or a saphenous vein graft (n = 5). There were no coronary dissections evident from use of the extension catheter. CONCLUSION/CONCLUSIONS:In the treatment of complex coronary lesions via the transradial approach, the use of an extension catheter may assist in improving successful intervention and decrease the frequency of crossover to a femoral approach.

OBJECTIVES/OBJECTIVE:Currently, there are limited data on mortality or predictors of survival for patients admitted to the coronary care unit (CCU). The purpose of this study was to provide data on mortality in the modern-day CCU and to better define factors influencing patient survival. METHODS:A survey was conducted of all patients admitted to CCUs in New York City metropolitan academic hospitals in 2011, followed by a retrospective analysis comparing clinical data from 59 nonsurvivors with those from 897 survivors at two representative institutions. RESULTS:The weighted average mortality in the CCU across all hospitals was 5.6% (range 2.2-9.2%). The average age of the patients admitted to the CCU was 67 years, with 68% being male. Acute coronary syndromes accounted for 57% of all CCU admissions. Survival was worse in patients admitted for cardiac arrest (P=0.000), sepsis (P=0.002), primary respiratory failure (P=0.031), and systolic heart failure (P=0.003). Excluding patients who were made 'do not resuscitate' during their CCU stay, patients receiving treatments such as defibrillation after in-CCU cardiac arrest, right heart invasive monitoring, mechanical ventilation, inotropic support, emergent dialysis, or placement of an intra-aortic balloon pump had higher rates of in-CCU mortality. The most frequent causes of death were intractable cardiogenic shock, brain death, respiratory failure, multiorgan failure, or hypotension. CONCLUSION/CONCLUSIONS:This study provides additional mortality information for the modern-day CCU and should help identify factors that may predict survival.

BACKGROUND:Contrast-induced nephropathy (CIN) continues to be a common cause of acute renal failure in high-risk patients undergoing radiocontrast studies. However, there is still a lack of consensus regarding the most effective measures to prevent CIN. METHODS:ONE HUNDRED EIGHTEEN PATIENTS WITH DIABETES MELLITUS AND/OR RENAL INSUFFICIENCY, SCHEDULED FOR CORONARY ANGIOGRAPHY OR INTERVENTION, WERE RANDOMLY ASSIGNED TO ONE OF FOUR TREATMENT GROUPS: intravenous (IV) 0.9% NaCl alone, IV 0.9% NaCl plus N-acetylcysteine (NAC), IV 0.9% sodium bicarbonate (NaHCO(3)) alone or IV 0.9% NaHCO(3) plus NAC. All patients received IV hydration as a preprocedure bolus and as maintenance. Iso-osmolar contrast was used in all patients. CIN was defined as an increase of greater than 25% in the serum creatinine concentration from baseline to 72 h. RESULTS:The overall incidence of CIN was 6%. There was no statistically significant difference in the incidence of CIN among the groups. There was a CIN incidence of 7% in the NaCl only group, 5% in the NaCl/NAC group, 11% in the NaHCO(3) only group and 4% in the NaHCO(3)/NAC group (P=0.86). The maximum increase in serum creatinine was 14.14±12.38 μmol/L in the NaHCO(3) group, 10.60±29.14 μmol/L in the NaCl only group, 9.72±13.26 μmol/L in the NaCl/NAC group and 0.177±15.91 μmol/L for the NaHCO(3)/NAC group (P=0.0792). CONCLUSION/CONCLUSIONS:CIN in high-risk patients may be effectively minimized solely through the use of an aggressive hydration protocol and an iso-osmolar contrast agent. The addition of NaHCO(3) and/or NAC did not have an effect on the incidence of CIN.