Initial Experience Using the Transradial Approach for Endovascular Treatment of Vascular Pathologies: Safety and Feasibility

Background Endovascular treatment of vascular pathologies through the transradial approach has been increasingly used and has demonstrated a low rate of complications. Objective To report our initial experience in the endovascular treatment of cerebrovascular diseases with the transradial approach and to determine its safety and feasibility. Methods Consecutive patients who underwent the transradial approach for endovascular treatment of aneurysms and vascular malformations were reviewed at a single institution. Technical success, fluoroscopy time, and access-related complications were analyzed. Results Eight patients underwent endovascular treatment with the transradial approach. One arteriovenous fistula, one superficial temporal artery aneurysm, three arteriovenous malformations, and four aneurysms were treated successfully. The radial artery was successfully approached and a 6-F sheath was used in all the cases. Navigation of guiding catheters (5 and 6 F) was done without complications. The most commonly approached artery was the right internal carotid artery, followed by the right vertebral artery. Postoperative vasospasm was identified in three patients. Mean fluoroscopy time was 34.7 minutes. Conversion to transfemoral approach was not required. No postoperative complications were reported. Conclusions In our initial experience, the transradial approach is a safe and feasible alternative for the endovascular treatment of cerebrovascular pathologies.

Robot-assisted carotid artery stenting: outcomes, safety, and operational learning curve

OBJECTIVE Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution. METHODS A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period. RESULTS A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively). CONCLUSIONS Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.

809 Frequency and determinants of haemoglobin drop without overt bleeding in patients undergoing transcatheter aortic valve replacement

Aims Post-procedural bleedings have a significant impact on mortality in patients undergoing transcatheter aortic valve replacement (TAVR). Unfortunately, the source of these bleedings is often undetermined, causing difficulties in diagnosis and related treatment. Furthermore, the frequency and determinants of ‘non-overt’ bleeding are largely lacking in TAVR studies. Accordingly, in this analysis, we aimed to assess the frequency and determinants of haemoglobin drop without overt bleeding in patients undergoing TAVR. Methods Patients undergoing TAVR at Magna Graecia University in Catanzaro from September 2008 to November 2020 were included in this study. Post-procedural haemoglobin (Hb) drop was calculated subtracting the lowest value observed after the procedure to the one obtained at admission (Hb drop). The association between baseline clinical and procedural variables with Hb drop was investigated with a linear regression model. Results Out of 407 patients undergoing TAVR at our institution, 119 (29.2%) were excluded because experiencing overt bleeding, red blood cells transfusion, were treated with only balloon angioplasty, or for procedural unsuccess. Among the 288 patients included in the final analysis, 239 (83.0%) were older than 74 y.o., 148 (51.4%) were female, 94 (32.6%) were diabetics, and 69 (24.0%) had CKD. All the patients were deemed at intermediate/high operatory risk and treated using the transfemoral approach. After TAVR, Hb significantly decreased (12.6 ± 1.6 g/dL to 9.7 ± 1.3 g/dL, P < 0.001), with an absolute mean reduction of 2.9 ± 1.23 g/dL 126 patients (43.8%) had Hb drop ≥ 3 g/dL, while 11 (3.8%) had Hb drop ≥ 5 g/dL. The table below summarizes the determinants of Hb drop. Among them, the new generation of self-expandable and balloon-expandable devices were associated with a lower post-procedural Hb drop compared to the previous generation of self-expandable devices, alongside, higher body mass index and hypertension. Conclusions Post-procedural reduction of Hb without overt bleeding or RBC transfusion is frequent, involving almost half of the patients undergoing TAVR. The introduction in clinical practice of new-generation valve devices is significantly associated with a reduction of this adverse event. However, further and thorough investigation should be accomplished to reclassify this large part of patients into a well-defined category.

Actual perspective on off-pump transapical artificial chord implantation

Mitral valve repair (MVR) is undisputedly associated with better clinical and functional outcomes than any other type of valve substitute. Conventional mitral valve surgery in dedicated high-volume centers can assure excellent results in terms of mortality and freedom from mitral regurgitation (MR) recurrence but requires cardiopulmonary bypass (CPB) and cardioplegic heart arrest. Trying to replicate the percentage of success of surgical MVR is the aim of all new transcatheter mitral dedicated devices. In particular transapical beating-heart mitral valve repair by artificial chordae implantation with transesophageal echocardiography (TEE) guidance is an expanding field. The safety and feasibility of the procedure have already been largely demonstrated with Neochord and more recently with Harpoon systems. Wang et al. present the outcomes of the first-in-human experience using a novel artificial chordae implantation device, the Mitralstitch system. Despite a quite small cohort of only 10 patients treated, 1-year results are satisfying and comparable to the early experience with former devices (4 patients with moderate or more MR recurrence). The comparison with surgical MVR is still unfavorable and requires further studies and significant procedure improvement. However, the device permits the treatment of anterior and posterior leaflets prolapse and performs quite easily edge-to-edge reparation. It will be interesting to evaluate longer follow-up in larger cohorts of patients as well as the possibility to shift to the transfemoral approach.

Interventional Treatment of Access Site Complications During Transfemoral TAVI: A Single Center Experience

Introduction: Transcatheter aortic valve implantation (TAVI) has rapidly developed over the last decade and is nowadays the treatment of choice in the elderly patients irrespective of surgical risk. The outcome of these patients is mainly determined not only by the interventional procedure itself, but also by its complications.Material and Methods: We analyzed the outcome and procedural events of transfemoral TAVI procedures performed per year at our institution. The mean age of these patients is 79.2 years and 49% are female. All the patients underwent duplex ultrasonography of the iliac arteries and inguinal vessels before the procedure and CT of the aorta and iliac arteries.Results: Transfemoral access route is associated with a number of challenges and complications, especially in the patients suffering from peripheral artery disease (PAD). The rate of vascular complications at our center was 2.76% (19/689). Typical vascular complications (VC) include bleeding and pseudoaneurysms at the puncture site, acute or subacute occlusion of the access vessel, and dissection or perforation of the iliac vessels. In addition, there is the need for primary PTA of the access pathway in the presence of additional PAD of the common femoral artery (CFA) and iliac vessels. Balloon angioplasty, implantation of covered and uncovered stents, lithoplasty, and ultrasound-guided thrombin injection are available to treat the described issues.Conclusion: Interventional therapy of access vessels can preoperatively enable the transfemoral approach and successfully treat post-operative VC in most of the cases. Training the heart team to address these issues is a key focus, and an interventional vascular specialist should be part of this team.

Abstract 1122‐000175: Comparison of Transradial Artery Versus Transfemoral Artery Access Mechanical Thrombectomy at a Comprehensive Stroke Center

Introduction : The transradial approach (TRA) is being increasingly adopted by neuro‐interventionists and has emerged as an alternative to the traditional transfemoral approach (TFA) for mechanical thrombectomy (MT). We aim to compare various time, technical and outcome parameters in patients who undergo MT via TRF vs. TRA approach. Methods : We performed a retrospective chart review of patients who underwent MT at a comprehensive stroke center from 7/2016 to 12/2020. We compared patients who underwent MT via TRA vs. TRF with respect to time from angio suite arrival to puncture, first pass, second pass and recanalization; time from puncture to first pass, second pass and recanalization; time from arrival to the emergency department (ED) to puncture, first pass, second pass and recanalization; the number of passes, rate of switching, achievement of TICI≥2b score, functional independence (3‐month mRS≤2), 3‐month mortality and neurological improvement (improvement in NIHSS by ≥4 points) on day 1 and 3. A binary logistic regression analysis was performed, controlling for age, sex, NIHSS, type of anesthesia (general vs. moderate), laterality, and location of clot (internal carotid or middle cerebral artery), ASPECTS≥6, presenting mean arterial pressure, blood glucose, Hb A1C, LDL, intravenous alteplase. Results : 217 patients met our inclusion criteria. The mean age was 64.09±14.4 years. 42 (19.35%) patients underwent MT through the TRA approach. There was a significantly higher rate of conversion from TRA approach to TRF approach (11.90% vs.2.28%; OR, 105.59; 95% CI,5.71‐1954.67; P 0.002), but no difference in various time, technical and outcome parameters, as shown in the table. Conclusions : Our study demonstrates no significant difference between TRA and TRF approaches with respect to various time, technical and outcome parameters, with a notable exception of a significantly higher rate of conversion from TRA to TRF approach.

Cost analysis of a coaching intervention to increase use of transradial percutaneous coronary intervention

Background The transradial approach (TRA) to cardiac catheterization is safer than the traditional transfemoral approach (TFA), with similar clinical effectiveness. However, adoption of TRA remains low, representing less than 50% of catheterization procedures in 2015. Peer coaching is one approach to facilitate implementation; however, the costs of this strategy for cardiac procedures such as TRA are unclear. Methods We conducted an activity-based costing analysis (ABC) of a multi-center, hybrid type III implementation trial of a coaching intervention designed to increase the use of TRA. We identified the key activities of the intervention and determined the personnel, resources, and time needed to complete each activity. The personnel cost per hour and the activity duration were then used to estimate the cost of each activity and the total variable cost of the implementation. Fixed costs related to designing and running the implementation were calculated separately. All costs are reported in 2019 constant US dollars. Results The total cost of the coaching intervention implementation was $374,863. Of the total cost, $367,752 were variable costs due to travel, preparatory work, in-person coaching, post-intervention evaluation, and administrative time. We estimated fixed costs of $7112. The mean marginal cost of implementing the intervention at only one additional medical center was $52,536. Conclusions We provide granular cost estimates of a conceptually rooted implementation strategy designed to increase the uptake of TRA for cardiac catheterization. We estimate that implementation costs stemming from the coaching approach would be offset after the conversion of approximately 409 to 1363 catheterizations from TFA to TRA. Our estimates provide benchmarks of the expected costs of implementing evidence-based, but expertise-intensive, cardiac procedures. Trial registration ISRCTN, ISRCTN66341299. Registered 7 July 2020—retrospectively registered

A feasible alternative to transfemoral artery access for endovascular revascularization in acute ischemic stroke in cases with difficult vessel anatomy

Endovascular treatment in acute ischemic stroke is usually performed via a transfemoral approach. Catheterization can be problematic in cases with difficult anatomy: unfavorable arch type, vessel tortuosity and ostial stenosis, aorta coarc‑ tation, iliac artery occlusion. The aim of this review is to describe the place of another arterial approach in the manage‑ ment in acute ischemic stroke: direct common carotid

Outcomes of Radial Versus Femoral Approach in Patients with St Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Aim of the work To compare transradial and transfemoral approaches in 1ry and rescue PCI for STEMI. Methods This prospective observational study was done at Alexandria University Hospital and International Cardiac Center from January 2020 to August 2020 by recruiting every patient had met our inclusion criteria (the third universal definition of MI) admitted to the coronary care unit after doing primary or rescue PCI 200 patients were involved. Exclusion criteria were (Thrombophilia and thrombocytopenia, known hematological abnormalities, and patients with known sever peripheral vascular disease. Randomization made by a computer-generated program into two equal parallel groups that were randomly assigned to either Radial access approach or femoral access approach for primary or rescue PCI. Chest pain to time of first medical contact (FMC), and the procedural time were computed. Coronary angiography and PCI procedure were described including materials used and the intra-procedure complications. MACE (Major Adverse Cardiac Events) or other hemodynamic complications were documented. All the patients were contacted for follow up to 6 months after the procedure by interviewing with the patients via telephone or the responsible physician to determine the outcomes procedure. Results The distribution of demographic variables and risk factors were similar among 200 patients in the radial and femoral groups. There had been significant differences between the groups concerning the primary end point MACE after 6 months in favor of radial group patients with p value (0.004), there was significant deference between the two studied groups concerning the total bleeding complication with higher risk in femoral group 11% compared to radial group 3% with P value (0.02). Despite the nearly equal mean time from pain to FMC (9.01 hours in radial group and 9.2 hours in femoral group), the total procedural time was significantly longer in radial group compared to femoral group with (p value 0.037). However the rate of non-culprit vessel revascularsation was significantly higher in radial group 17% compared to 6% in femoral group with p value of (0.015). In-hospital stay was significantly shorter in the radial group patients P value (0.02). Conclusion Transradial approach is safe, and effective with a high procedural success rate as the transfemoral approach but with lower risk for bleeding vascular complications and other access site complications as hematoma especially for patients where aggressive antiplatelet and anticoagulation therapy is needed, or patients who are expected to suffer from access site complications as those who need rescue PCI. Transradial approach has major additional advantages of decreasing the incidence of MACE compared to transfemoral approach. Transradial approach has another advantages of decreasing the in hospital stay.