10 van Leeuwen aimradial20170922 ACRA study

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International Chair on Interventional Cardiology and Transradial Approach

This document summarizes a study on the anatomy of the palmar arches and their relationship to outcomes after transradial catheterization. The study found: 1) The superficial palmar arch was incomplete in 46% of patients based on angiography, while the deep palmar arch was complete in all patients. 2) Non-invasive tests (MAT and Barbeau) to assess palmar arch patency had low diagnostic accuracy compared to angiography. 3) Incompleteness of the superficial palmar arch was associated with smaller vascular dimensions and more distal collateral flow but did not impact long-term hand function. 4) The study concludes non-invasive palmar arch tests should be abandoned

ACRA
Anatomy Study
Maarten van Leeuwen
Ínterventional cardiologist
September 22, 2017
A comprehensive anatomic and functional assessment of the vasculature of the hand
and relation to outcome after transradial catheterisation

I do not have any potential conflict of interest to report
Potential conflicts of interest

Background
• Palmar arches
1. Most important conduits for digital blood supply
2. Incompleteness may increase the risk for hand ischemia in case of RAO
3. Incompleteness in post-mortem studies highly variable
4. Anatomic studies in life patients are lacking
Hamon, Eurointervention 2013
Brezezinski, Anesth Analg. 2009
Valgimigli, J Am Coll Cardiol. 2014
• MAT and Barbeau
1. Non-invasive patency testing of the palmar arches
2. Recommended to apply before radial access and harvest
3. Not related with acute ischemic complications of the hand

Methods
Primary objective
To determine the rate of palmar arch incompleteness and to
compare this to the test results of the MAT and Barbeau
Secondary objectives
The effect of palmar arch incompleteness on digital vascular
supply and upper extremity function

Demographic characteristics
Age 63 (±11)
Male 164 (76%)
Length (cm) 175 (±8)
Weight (kg) 85 (±17)
Cardiovascular history
Previous MI 46 (21%)
Previous PCI 62 (29%)
Previous CABG 2 (1%)
Peripheral artery disease 10 (5%)
Previous radial access 84 (39%)
Previous femoral access 51 (24%)
Cardiovascular risk factors
Current smoking 38 (18%)
Hypertension 112 (52%)
Hypercholesterolemia 87 (41%)
DM 45 (21%)
BMI (kg/m2) 27 (24-30)
Family history CVD 75 (36%)
Procedure
PCI 101 (47%)
Procedural time (min) 34 (20-50)
Procedural success 210 (98%)
RA spasm 32 (15%)
Pain score (VAS) 0 (0-3)
Baseline characteristicsNon-invasive Invasive (angiograp
n=234 n=215
MAT Palmar arch incomp
Normal (0-5 s) 52% SPA
Intermediate (6-10 s) 27% DPA
Abnormal (>10 s) 22% SPA and DPA
Barbeau Additional arterial c
Type A 36% Interosseus collate
Type B 51% Persistent median
Type C 9% SPA-DPA anastom
Type D 4% SPA-RA connectio

Palmar arch completeness
Ruengsakulrach
J Thorac Card Surg. 2001
54%
46% 0% 0%

Palmar arch patency
Non-invasive vs. invasive assessment
Poor diagnostic accuracy (57-
62%)

SPA completeness
Yes No p-value
Vascular dimensions (mm)
RA 2.51 (±0.4) 2.64 (±0.4) 0.017
UA 2.45 (±0.5) 2.23 (±0.4) 0.002
SPA 1.87 (±0.4) 1.66 (±0.4) <0.001
DPA 1.27 (±0.3) 1.32 (±0.3) 0.17
Collateral Flow (s)
UA-Digit 1 3.8 (3.0-5.2) 4.6 (3.4-5.9) 0.08
RA-UA 1.1 (0.8-1.6) 1.3 (0.9-1.8) 0.22
Palmar arch patency
Vascular and flow characteristics
other characteristics
Distal interosseus collaterals 44% 65% 0.002

Palmar arch incompleteness
Long-term upper extremity dysfunction

Digital vascular supply is preserved in all patients by the palmar arches
(DPA 100%, SPA 54%)
MAT and Barbeau are related with SPA incompleteness, however
diagnostic accuracy is low
Loss of hand function is not related to palmar arch incompleteness at
long-term follow-up
Clinical message:
MAT and Barbeau should be abandoned to prevent
acute ischemia of the hand
Conclusions
Rademakers
Neth Heart J 2012

ACRA Perfusion study
- Digital perfusion and palmar arch incompleteness (LDPI)
- Digital blood pressure and palmar arch incompleteness (Nexfin)
Hirado study
- Functional and ischemic stress testing in patients with RAO
(TcPO2 and capillary lactate)
Upcoming

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This study compared aortic valve area (AVA) measurements from Doppler echocardiography (AVAEcho) and multidetector computed tomography (MDCT) (AVACT) in 269 patients with aortic stenosis. The study aimed to determine if AVACT was superior to AVAEcho in assessing hemodynamic correlations, predicting survival outcomes, and resolving discordant assessments of aortic stenosis severity. The study found that while AVACT measurements of the left ventricular outflow tract were larger than AVAEcho, leading to slightly higher calculated AVA values, AVACT did not improve correlations with transvalvular gradients, concordance between gradient and AVA, or prediction of mortality compared to AVAEcho. Both AVAEcho and AV

Yeh RW - Femoral vs radial: evidence - 201507

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | A Trans-Radial Approach of Cardiac Catheterization f...

International Chair on Interventional Cardiology and Transradial Approach

[123doc] - bai-giang-sieu-am-tim-3d-trong-danh-gia-va-can-thiep-cac-benh-ly-v...

Thọ Văn

3D echocardiography plays an important role in assessing and intervening in valve diseases. It can evaluate valve anatomy in detail, guide interventional procedures such as MitraClip and balloon valvuloplasty, and monitor outcomes. Real-time 3D TEE is especially useful for quantifying mitral regurgitation and measuring the mitral valve area during balloon valvuloplasty. 3D imaging also helps with patient selection and guidance for transcatheter aortic valve implantation.

CLEARFLOW Impact of Related Blood Charite

clearflow

Mri in corellation to surgery

Shoulder Library

The document summarizes a study on arthroscopic remplissage for recurrent anterior shoulder instability. 48 patients underwent remplissage in addition to Bankart repair, with a mean follow-up of 37 months. The failure rate was 6.3%, and 93.7% were satisfied without restrictions. Scores on the ASES, Rowe, and Oxford scales all significantly improved post-operatively without loss of range of motion. The study concludes remplissage enhances Bankart repair for managing instability, with good results and no effect on shoulder movement.

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PCI & AimRadial 2018 | Innovation in Cardiovascular Medicine - Tim A. Fischell

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes Tim Fischell's presentation on innovation in cardiovascular medicine. It discusses Fischell's history of medical device innovations, including the Arrow-Fischell sheath, brachytherapy devices, stents, and the AngelMed Guardian system. It provides guidance on developing new ideas into real innovations, including evaluating intellectual property, regulatory pathways, prototype testing, and clinical trials. Fischell emphasizes the importance of understanding unmet clinical needs and having a team approach to translating ideas into impactful new technologies.

PCI & AimRadial 2018 | A novel stent concept for South America - Ramses Galaz

International Chair on Interventional Cardiology and Transradial Approach

This document discusses opportunities for developing and manufacturing medical devices in Latin America, including coronary stents with an estimated $500M annual market. It outlines the roadmap needed to design, test, manufacture, and gain regulatory approval for a novel stent concept, including requirements for structure and flow, deployability and patency, and clinical performance. Design considerations are discussed such as structural rigidity, flexural rigidity, surface finish, and hemodynamic simulations. The potential for low-cost manufacturing and animal studies are also mentioned.

PCI & AimRadial 2018 | Biomechanics of biodegradable stents: a primer for car...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | Radial vs Femoral: Review of the Evidence in 2018 - Ia...

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes the evidence from multiple randomized clinical trials that support a Class IA recommendation for the use of radial artery access (TRA) over femoral artery access (TFA) for cardiac catheterization procedures. The data show that TRA is associated with lower rates of major vascular complications and major bleeding compared to TFA, with numbers needed to treat of 21 and 47 respectively. TRA may also reduce mortality in patients with acute coronary syndrome, with a number needed to treat of 100. Both the 2018 AHA guidelines and ESC/EACTS guidelines were updated to strongly recommend a radial-first approach in light of the overwhelming data demonstrating benefits of TRA over TFA.

PCI & AimRadial 2018 | Best practices in same day discharge - Ivo Bernat

International Chair on Interventional Cardiology and Transradial Approach

This document discusses best practices for same day discharge after cardiac procedures. It provides an overview of the history and evidence supporting same day discharge. Key points include: - Same day discharge has been shown to be safe and effective in studies dating back to the 1990s. - Dedicated lounges and infrastructure improve outcomes for same day discharge by allowing for close monitoring and care in the immediate post-procedure period. - The author's hospital has successfully performed over 7,000 same day discharge procedures over 10 years using a dedicated radial lounge with trained nursing staff who provide care and arrange discharge. Complication rates are low with their protocol.

PCI & AimRadial 2018 | Even the big boss fail - Zoltán Ruzsa

International Chair on Interventional Cardiology and Transradial Approach

This document describes a case of critical hand ischemia treated through multiple endovascular interventions over several years. Initially, the patient underwent brachial artery recanalization and stenting from left radial access, but presented two days later with stent thrombosis. A second procedure recanalized the stent and treated a brachial dissection with another stent. However, two years later the patient returned with re-occlusion of arm vessels and iliac arteries. Further interventions were needed to recanalize stenosed iliac and brachial arteries over time. In conclusion, long term patency of arm interventions is unknown, and stent CTO recanalization in the arms poses similar challenges to the legs.

PCI & AimRadial 2018 | Contemporary Transradial Access Practices: Results of ...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | A Growing Population in the Cath Lab: Patient Identifi...

International Chair on Interventional Cardiology and Transradial Approach

This document discusses expanding the FDA indication for protected PCI procedures using the Impella heart pump. Key points include: 1. A study of 891 patients found that those with mildly/moderately reduced ejection fraction (LVEF >35%) undergoing protected PCI had favorable outcomes similar to those with severely reduced LVEF, despite being older with more comorbidities and complex coronary disease. 2. Protected PCI with Impella led to improved LVEF and quality of life in multiple studies. The Protect II trial showed Impella reduced MACCE by 29% compared to IABP at 30 days. 3. Guidelines recommend protected PCI for patients with severe/moderate/mild reduced LVE

PCI & AimRadial 2018 | Treating Cardiogenic Shock with Impella with Escalatio...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | LEFT MAIN PCILessons from the BCIS registry - Jim Nolan

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes the findings of a study analyzing 19,482 left main stem percutaneous coronary intervention (LMS-PCI) procedures from the British Cardiovascular Intervention Society National Database between 2007-2014: 1) Use of radial artery access for LMS-PCI increased significantly over time and radial access was associated with reduced vascular complications, major bleeding, and shorter hospital stays. 2) Radial access was independently associated with lower in-hospital mortality and major adverse cardiac and cerebrovascular events (MACE) compared to femoral access. 3) Independent predictors of 12-month mortality following LMS-PCI included acute kidney injury, older age, chronic renal failure, acute coronary syndrome presentation, and

PCI & AimRadial 2018 | Left Ventricular Endomyocardial Biopsy by Transradial...

International Chair on Interventional Cardiology and Transradial Approach

PCI & AimRadial 2018 | Right Heart Access by Radial - Ian C Gilchrist

International Chair on Interventional Cardiology and Transradial Approach

This document discusses accessing the right heart and central venous system through the radial vein as a safer alternative to traditional femoral access. It provides tips for establishing venous access through the forearm, including using ultrasound or no-touch technology to locate veins and heparin locks to improve efficiency. Challenges like low venous pressure, valves, and junctions are addressed. Images demonstrate techniques for navigating the radial artery into the right atrium, including using flushes of saline. Potential contraindications like arm trauma or breast cancer are noted. The document argues learning both arterial and venous radial techniques will improve cardiologist skills and safety.

PCI & AimRadial 2018 | Radial Artery Puncture - Ian C Gilchrist

International Chair on Interventional Cardiology and Transradial Approach

This document discusses techniques for radial artery puncture for cardiovascular procedures. It notes that the radial artery is smaller in diameter than the femoral artery. Successful radial access requires correctly positioning and securing the wrist. Ultrasound guidance can help find and access the radial artery, especially for trainees. The initial puncture approach can be anterior wall only or use a counterpuncture technique. Sheath size, length, and coating impact radial artery spasm and occlusion. Cocktails including nitroglycerine and calcium channel blockers are commonly used but acid in the cocktail may damage the artery if felt by the patient.

PCI & AimRadial 2018 | Post-PCI FFR: Time is coming - Olivier F. Bertrand

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes a presentation given by Dr. Olivier Bertrand on post-PCI FFR measurement. It discusses studies showing that a post-PCI FFR of 0.90 or higher is associated with lower rates of re-PCI and major adverse cardiac events. It then outlines the proposed PREDICT randomized study to evaluate whether routine post-PCI FFR measurement can guide PCI strategy and completion. The study would measure FFR after successful PCI in all-comers and randomize patients to clinical follow-up alone or with guidance from the post-PCI FFR results. The goal is to establish if physiology-guided PCI optimization can improve outcomes and reduce costs.

PCI & AimRadial 2018 | Lessons from iFR-SWEDEHEART and DEFINE-FLAIR - Hitoshi...

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes lessons learned from the DEFINE-FLAIR and iFR-SWEDEHEART clinical trials. The trials found: 1) Decision-making based on instantaneous wave-free ratio (iFR) was non-inferior to fractional flow reserve (FFR) for guiding revascularization and reducing major adverse cardiac events over 1-2 years. 2) iFR-guided decisions resulted in significantly less revascularization procedures compared to FFR. 3) Subgroup analysis found increased event rates among diabetic patients evaluated with FFR compared to iFR. 4) iFR has been upgraded to a Class IA recommendation in European Society of Cardiology guidelines based on these trials

PCI & AimRadial 2018 | Use of physiology in ACS - Colin Berry

International Chair on Interventional Cardiology and Transradial Approach

1. The document discusses the use of physiology in acute coronary syndrome (ACS) patients, including trials evaluating fractional flow reserve (FFR) and index myocardial resistance (IMR) measurements. 2. Several trials showed that FFR-guided revascularization in multivessel disease STEMI patients reduced major cardiac events compared to culprit-only PCI or medical therapy. Ongoing trials are further evaluating FFR in ACS. 3. IMR predicts mortality and heart failure in STEMI patients and adversely remodeling post-STEMI. 4. Incomplete revascularization is common in ACS and associated with worse outcomes; FFR may help guide more complete revascularization. The clinical utility of physiology in ACS

PCI & AimRadial 2018 | FFR using 4Fr catheters: Can Slender Technique Work He...

International Chair on Interventional Cardiology and Transradial Approach

This document discusses the potential use of 4 French (4F) catheters for fractional flow reserve (FFR) measurements as a less invasive alternative to larger catheters. It notes that 4F catheters have a smaller profile but can lack the ability to directly perform percutaneous coronary intervention if needed. The document outlines key considerations for using 4F catheters, including ensuring the catheter lumen is well flushed and the pressure transducer is not damped. It concludes that improvements are still needed, such as reducing friction between the pressure wire and catheter, in order to maximize the benefits of using the smallest catheter size possible.

PCI & AimRadial 2018 | FFR in Left Main Disease - William F. Fearon

International Chair on Interventional Cardiology and Transradial Approach

This document discusses using fractional flow reserve (FFR) to evaluate ambiguous left main coronary artery disease. It presents a case of an 82-year-old woman with chest pain and a recent stent in the circumflex artery. FFR measurements of the left main and left anterior descending artery were 0.64, indicating significance. Intravascular ultrasound also suggested significance. The left main and proximal left anterior descending artery were stented, and post-procedure FFR measurements improved. The document reviews evidence that FFR can safely guide decisions about revascularization of ambiguous left main lesions.

PCI & AimRadial 2018 | FFR-CT - Colin Berry

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes a presentation on CT-derived fractional flow reserve (FFR-CT). It discusses how FFR-CT increases the positive predictive value of coronary CT angiography (CTCA). Several landmark studies are summarized that evaluated the diagnostic accuracy of FFR-CT compared to CTCA. The PACIFIC trial findings showing high diagnostic accuracy of FFR-CT are described. Ongoing and upcoming clinical trials using FFR-CT like PRECISION and DECISION are mentioned. Novel applications of FFR-CT for biomechanics analysis and PCI planning are presented. Finally, new methods like user-generated CT-FFR that may reduce processing time are introduced, though accuracy needs further evaluation.

PCI & AimRadial 2018 | Image based FFR during coronary angiography - Hitoshi...

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes the results of a study evaluating the diagnostic accuracy of quantitative flow ratio (QFR) compared to fractional flow reserve (FFR) as the reference standard. The study included 317 lesions in 273 patients. Key results included: - QFR showed superior sensitivity and specificity for detecting functionally significant lesions compared to 2D quantitative coronary angiography. - QFR values correlated well with invasive FFR measurements. - QFR could be computed within a similar time frame as FFR measurements. - A hybrid approach using QFR and FFR may allow pressure wire-free assessment in 68% of lesions while maintaining high diagnostic accuracy.

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