Ultrasound imaging of the arm arteries prior to cardiac catheterization can help anticipate procedural failure and enhance success. In a study of over 2,000 patients, pre-procedure ultrasound identified anatomical anomalies in 9.8% of patients and helped select the largest accessible artery. This led to a procedural success rate of 98.7% and a low 1.3% crossover rate. Pre-procedure ultrasound takes on average 6 minutes and can help reduce radiation time and procedural complications by avoiding difficult arterial access.
The document discusses optimizing transradial interventions and managing complications. It begins by emphasizing the importance of patient selection based on anatomy, using proper techniques to avoid failure, and anticipating common and rare complications. Several key points are covered, including assessing hand collateral arteries using tests like the modified Allen's test before proceeding. Anatomical variations that could impact access are reviewed. Causes of access failure like radial artery loops and spasm are described. Technical tips for successful cannulation include using a small needle and guidewire, followed by a vasodilator "cocktail" to prevent spasm. Severe spasm is identified as a rare but preventable complication.
This document discusses slender techniques for percutaneous coronary intervention (PCI) that aim to minimize trauma to arterial access sites. It describes techniques used in Europe, including the use of 5F guiding catheters and sheathless guiding catheters. A new slender approach is presented involving direct stenting via 4F diagnostic catheters using stents with integrated delivery systems. Initial experience in 22 patients found this technique was safe and feasible with short procedure and compression times and no complications at 30 days. The document concludes slender TRI techniques can reduce radial injury and complications but potential benefits require further validation.
This document summarizes the diagnosis and management of local complications associated with transradial access for coronary procedures. It discusses radial artery occlusion, hand ischemia, radial artery spasm, forearm hematoma, compartment syndrome, catheter entrapment, pseudoaneurysm, and arteriovenous fistula. Predictors and treatments for various complications are provided. The incidence of radial artery occlusion can range from 0.8-30% depending on the time and method of assessment. Hand ischemia due to radial artery occlusion is rare but can occur in systemically unwell patients with prolonged radial cannulation. Radial artery spasm is common and treatments include antispasmodic medications and adequate analgesia/sedation.
1) Percutaneous angioplasty is a feasible treatment for critical hand ischemia, with a technical success rate of 88-96% and clinical success rate of 85-100% based on a study of 75 patients.
2) Complications occurred in 6-16% of patients and included perforation, distal embolization, dissection, and access site issues.
3) Long term follow up showed a high rate of major adverse events (22.6% at 1 year) and target lesion revascularization (16%).
The document discusses the use of additional morphological and functional techniques with transradial approaches, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to assess coronary artery lesions. Functionally, fractional flow reserve (FFR) can be measured using a pressure wire. The document argues that combining anatomical data from IVUS/OCT with functional data from FFR provides more accurate diagnosis and guidance for percutaneous coronary intervention compared to angiography alone. Studies demonstrate the benefits of IVUS-guided stenting over angiography for long term mortality outcomes.
This document discusses the use of transradial approach for carotid artery stenting (CAS) in Japan. It presents two case studies where transradial IVUS-guided CAS was performed successfully despite complex aortic arch anatomy. The document also provides data on 15 patients who underwent transradial CAS. It finds that aortic arch type does not significantly impact the technical difficulty of transradial CAS. It concludes that transradial CAS is safe, feasible, and well-tolerated by patients due to reduced bleeding risks and lumbar pain compared to transfemoral CAS.
The document discusses optimizing transradial interventions and managing complications. It begins by emphasizing the importance of patient selection based on anatomy, using proper techniques to avoid failure, and anticipating common and rare complications. Several key points are covered, including assessing hand collateral arteries using tests like the modified Allen's test before proceeding. Anatomical variations that could impact access are reviewed. Causes of access failure like radial artery loops and spasm are described. Technical tips for successful cannulation include using a small needle and guidewire, followed by a vasodilator "cocktail" to prevent spasm. Severe spasm is identified as a rare but preventable complication.
This document discusses slender techniques for percutaneous coronary intervention (PCI) that aim to minimize trauma to arterial access sites. It describes techniques used in Europe, including the use of 5F guiding catheters and sheathless guiding catheters. A new slender approach is presented involving direct stenting via 4F diagnostic catheters using stents with integrated delivery systems. Initial experience in 22 patients found this technique was safe and feasible with short procedure and compression times and no complications at 30 days. The document concludes slender TRI techniques can reduce radial injury and complications but potential benefits require further validation.
This document summarizes the diagnosis and management of local complications associated with transradial access for coronary procedures. It discusses radial artery occlusion, hand ischemia, radial artery spasm, forearm hematoma, compartment syndrome, catheter entrapment, pseudoaneurysm, and arteriovenous fistula. Predictors and treatments for various complications are provided. The incidence of radial artery occlusion can range from 0.8-30% depending on the time and method of assessment. Hand ischemia due to radial artery occlusion is rare but can occur in systemically unwell patients with prolonged radial cannulation. Radial artery spasm is common and treatments include antispasmodic medications and adequate analgesia/sedation.
1) Percutaneous angioplasty is a feasible treatment for critical hand ischemia, with a technical success rate of 88-96% and clinical success rate of 85-100% based on a study of 75 patients.
2) Complications occurred in 6-16% of patients and included perforation, distal embolization, dissection, and access site issues.
3) Long term follow up showed a high rate of major adverse events (22.6% at 1 year) and target lesion revascularization (16%).
The document discusses the use of additional morphological and functional techniques with transradial approaches, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to assess coronary artery lesions. Functionally, fractional flow reserve (FFR) can be measured using a pressure wire. The document argues that combining anatomical data from IVUS/OCT with functional data from FFR provides more accurate diagnosis and guidance for percutaneous coronary intervention compared to angiography alone. Studies demonstrate the benefits of IVUS-guided stenting over angiography for long term mortality outcomes.
This document discusses the use of transradial approach for carotid artery stenting (CAS) in Japan. It presents two case studies where transradial IVUS-guided CAS was performed successfully despite complex aortic arch anatomy. The document also provides data on 15 patients who underwent transradial CAS. It finds that aortic arch type does not significantly impact the technical difficulty of transradial CAS. It concludes that transradial CAS is safe, feasible, and well-tolerated by patients due to reduced bleeding risks and lumbar pain compared to transfemoral CAS.
This document discusses the learning curve associated with trans-radial procedures. It notes that the trans-radial approach is more challenging due to the small artery size, risk of spasm, and anatomical variation. Several studies characterized the learning curve, finding that operators improved with experience. The right radial approach has a steeper learning curve than the left. Operators were more successful with trans-radial PCI after 50-100 cases. Proper patient selection, technique, and experience were noted to help overcome challenges associated with the trans-radial learning curve.
Radialists perform better femoral PCI according to a study. While radial access has benefits, not all hospitals and operators have adopted it due to challenges like a learning curve. Studies show that default radial operators in a radial center who occasionally need to use femoral access have lower rates of access site complications and mortality compared to femoral operators. Analysis of large datasets from the UK also indicate reduced access site complications and mortality with radial access compared to femoral for PCI.
This document discusses techniques for transradial access and intervention. It begins by outlining three levels of competency for operators and discusses when radial access may not be appropriate. It then provides a step-by-step guide for radial access procedures, covering patient positioning, arterial puncture, navigating vascular anatomy, catheter selection, and hemostasis. Predictors of procedural failure are presented. The document concludes by providing tips for implementing a successful radial program.
This document discusses considerations for treating bifurcation lesions in the radial artery. It covers classifying the type of lesion, the importance of operator experience, and choosing an appropriate guide catheter and guide wires. The document recommends letting the operator do what they are comfortable with and planning treatment for the main vessel and side branch at the beginning. It describes the British Bifurcation Study approach of pretreating vessels and stenting the main vessel with or without protecting the side branch. The document shows examples of complex bifurcation cases and techniques for treatment including stenting the side branch and main vessel, using kissing balloons, and potential long-term outcomes.
This document discusses navigating complex anatomies during transradial procedures. It notes that radial artery loops, tortuosity, and anomalies can cause procedural failures. Predictors of failure include high bifurcation, tortuosity, and subclavian anomalies. Wire choice is important, with baby J wires being ideal for transradial procedures. Operators must be aware of anatomical variations and challenges. Retrograde angiography can help plan strategies to avoid complications. Finesse is more important than force when encountering resistance.
Impact of access site on bleeding and ischemic events in patients with non-ST-segment elevation myocardial infarction treated with prasugrel at the time of percutaneous coronary intervention or as pretreatment at the time of diagnosis: the ACCOAST access substudy
The document discusses the use of a 6.5F sheathless guiding catheter for transradial percutaneous coronary interventions (PCI) in patients with small radial arteries. The sheathless guiding catheter has an external diameter smaller than a 5F sheath but an internal diameter larger than a standard 6F guiding catheter. Several studies found that using the 6.5F sheathless guiding catheter for transradial PCI was feasible, effective, and safe for treating all lesion types and with various interventional techniques. The sheathless guiding catheter was particularly useful in cases where there was friction during intervention with smaller 4F-5F diagnostic catheters and sheaths or when a vessel was very small after use of a 6
The document provides guidance on patient setup and arterial access for right and left radial cardiac catheterization. It recommends using a board to position the patient comfortably, accessing from the right or left radial artery, using hydrophilic sheaths to prevent spasm, anticoagulating patients, and administering a spasmolytic cocktail. It emphasizes that training staff is important for successful radial procedures.
This document summarizes key points from a presentation on performing CT0 PCI (percutaneous coronary intervention for chronic total occlusions) via the radial approach. It discusses the radial artery diameter being on average 2.6 mm, allowing the use of 7 or 8 French guides. Bilateral radial access was used in 90% of cases in one study of 31 CT0 PCIs. The presentation provides an algorithm for radial CT0 PCI and discusses tools and techniques that can be used, noting some limitations of smaller sheath sizes. Overall success rates from one study are reported as 82.8% for the radial approach. Considerations for when femoral access may still be preferred are also outlined.
1) The study used OCT to assess remodeling of the radial artery in 30 patients who underwent primary PCI via the transradial approach.
2) OCT imaging found a significant thickening of the intimal layer 9 months after the procedure, though mean lumen area was not significantly affected.
3) While transradial PCI was found to change the radial artery structure, there was no significant effect on vessel lumen area observed with this sample size. Larger studies are needed to confirm the results.
This document discusses the benefits of using a radial artery approach for carotid artery stenting (CAS) compared to the traditional femoral artery approach. Some key benefits of the radial approach include avoiding complications associated with femoral access in patients with aorto-iliac disease, allowing for early patient mobilization to reduce bleeding risks, and eliminating vascular access site complications which are a major cause of morbidity and mortality after CAS. The document also presents several case examples demonstrating successful CAS procedures performed via the radial approach. However, it notes there is a significant learning curve for new operators and that the radial approach may not be suitable for all anatomies or allow the use of all devices.
1. The author advocates for using the left radial approach for coronary angiography and intervention in over 90% of patients.
2. Some advantages of the left approach include easier learning curve, better cannulation of the left internal mammary artery, and less limitation of daily activities for right-handed patients.
3. While both right and left approaches are equivalent alternatives to femoral access, the author finds the left approach offers slight technical advantages and higher patient satisfaction due to minimized limitations after the procedure.
1) The document discusses carotid artery stenting (CAS) and carotid endarterectomy (CEA) for treating carotid artery disease. It reviews data from clinical trials comparing the two procedures.
2) Operator experience is an important factor for CAS outcomes, with over 100 cases associated with lower risk. New technologies like mesh-covered stents may further reduce risks of CAS.
3) Future studies like CREST-2 aim to provide more data on CAS and CEA in asymptomatic patients to help guide treatment decisions. Both procedures can effectively treat carotid artery disease when performed by experienced operators.
This document compares the risk of microembolization during diagnostic coronary angiography between single catheter and double catheter strategies. In the first study, a left radial approach was found to have a lower rate of microembolization than a right radial approach, likely due to less catheter manipulation and exchanges. Independent predictors of high microembolization included a greater number of catheters used. A second study found that using a single "Tiger" catheter halved the rate of microembolization compared to using a double catheter "Judkins" strategy, mainly by reducing catheter exchanges. Minimizing catheter exchanges may help reduce the risk of air embolism and microembolization during coronary angiography procedures.
Safety and efficacy of using a single transradial MAC guiding catheter for coronary angiography and intervention in patients with ST-elevation myocardial infarction (RAPID)
This study evaluated the safety and efficacy of the novel Svelte Acrobat Integrated Delivery System (IDS) for percutaneous coronary interventions (PCI) via a radial approach using 5-French catheters. The study enrolled 55 patients and found a primary endpoint success rate of 91%, defined as direct stent implantation without need for post-dilation. Secondary endpoints including procedural success rates were also high. The study concluded the IDS system allows for safe and effective PCI via the radial approach in select patient populations and can reduce costs compared to traditional systems by an estimated $300 per procedure.
The document summarizes the NAUSICA trial which compared outcomes of percutaneous coronary interventions (PCI) using 4 French versus 6 French guide catheters. The trial found that 4 French PCI resulted in significantly lower access site complications and hemostasis times compared to 6 French PCI, with comparable procedural success. 4 French PCI also showed a numerically lower risk of radial artery occlusion. The 4 French coronary accessor was also found to be useful for the mother-child guiding catheter technique, providing backup support comparable to larger catheters.
The document summarizes information about the Terumo Glidesheath Slender, a new thinner-walled sheath for transradial procedures. It discusses studies showing the Glidesheath Slender reduces sheath size while maintaining lumen size. This decreases vascular complications and radial artery occlusion rates compared to standard sheaths. The document outlines several prospective studies and a large randomized trial that aim to further evaluate the Glidesheath Slender's safety, efficacy and ability to facilitate more complex transradial procedures.
Transradial access is a safe and effective alternative to femoral access for subclavian artery interventions, with comparable outcomes. A prospective study of 41 patients found a 100% technical success rate for subclavian angioplasty and stenting via transradial access. Major adverse event rates within 1 year were low at 4.9%. Access site complications were also low and less severe than typically seen with femoral access. Transradial access is a viable option for subclavian interventions with acceptable safety and morbidity.
Challenges of Radial Access-Anatomy, Tools and SuccessMir Ahmed
The document discusses some of the challenges of the transradial approach for coronary procedures. It notes that anatomical variations can occur in around 23% of cases, including radial artery tortuosity, stenosis, hypoplasia, and abnormal origins. Success rates for transradial procedures range from 83-96.7%, but can be lower for certain variations like arteria lusoria. It also discusses techniques for overcoming challenges like vascular loops and spasm, and notes there is a learning curve associated with the transradial approach.
This document discusses the learning curve associated with trans-radial procedures. It notes that the trans-radial approach is more challenging due to the small artery size, risk of spasm, and anatomical variation. Several studies characterized the learning curve, finding that operators improved with experience. The right radial approach has a steeper learning curve than the left. Operators were more successful with trans-radial PCI after 50-100 cases. Proper patient selection, technique, and experience were noted to help overcome challenges associated with the trans-radial learning curve.
Radialists perform better femoral PCI according to a study. While radial access has benefits, not all hospitals and operators have adopted it due to challenges like a learning curve. Studies show that default radial operators in a radial center who occasionally need to use femoral access have lower rates of access site complications and mortality compared to femoral operators. Analysis of large datasets from the UK also indicate reduced access site complications and mortality with radial access compared to femoral for PCI.
This document discusses techniques for transradial access and intervention. It begins by outlining three levels of competency for operators and discusses when radial access may not be appropriate. It then provides a step-by-step guide for radial access procedures, covering patient positioning, arterial puncture, navigating vascular anatomy, catheter selection, and hemostasis. Predictors of procedural failure are presented. The document concludes by providing tips for implementing a successful radial program.
This document discusses considerations for treating bifurcation lesions in the radial artery. It covers classifying the type of lesion, the importance of operator experience, and choosing an appropriate guide catheter and guide wires. The document recommends letting the operator do what they are comfortable with and planning treatment for the main vessel and side branch at the beginning. It describes the British Bifurcation Study approach of pretreating vessels and stenting the main vessel with or without protecting the side branch. The document shows examples of complex bifurcation cases and techniques for treatment including stenting the side branch and main vessel, using kissing balloons, and potential long-term outcomes.
This document discusses navigating complex anatomies during transradial procedures. It notes that radial artery loops, tortuosity, and anomalies can cause procedural failures. Predictors of failure include high bifurcation, tortuosity, and subclavian anomalies. Wire choice is important, with baby J wires being ideal for transradial procedures. Operators must be aware of anatomical variations and challenges. Retrograde angiography can help plan strategies to avoid complications. Finesse is more important than force when encountering resistance.
Impact of access site on bleeding and ischemic events in patients with non-ST-segment elevation myocardial infarction treated with prasugrel at the time of percutaneous coronary intervention or as pretreatment at the time of diagnosis: the ACCOAST access substudy
The document discusses the use of a 6.5F sheathless guiding catheter for transradial percutaneous coronary interventions (PCI) in patients with small radial arteries. The sheathless guiding catheter has an external diameter smaller than a 5F sheath but an internal diameter larger than a standard 6F guiding catheter. Several studies found that using the 6.5F sheathless guiding catheter for transradial PCI was feasible, effective, and safe for treating all lesion types and with various interventional techniques. The sheathless guiding catheter was particularly useful in cases where there was friction during intervention with smaller 4F-5F diagnostic catheters and sheaths or when a vessel was very small after use of a 6
The document provides guidance on patient setup and arterial access for right and left radial cardiac catheterization. It recommends using a board to position the patient comfortably, accessing from the right or left radial artery, using hydrophilic sheaths to prevent spasm, anticoagulating patients, and administering a spasmolytic cocktail. It emphasizes that training staff is important for successful radial procedures.
This document summarizes key points from a presentation on performing CT0 PCI (percutaneous coronary intervention for chronic total occlusions) via the radial approach. It discusses the radial artery diameter being on average 2.6 mm, allowing the use of 7 or 8 French guides. Bilateral radial access was used in 90% of cases in one study of 31 CT0 PCIs. The presentation provides an algorithm for radial CT0 PCI and discusses tools and techniques that can be used, noting some limitations of smaller sheath sizes. Overall success rates from one study are reported as 82.8% for the radial approach. Considerations for when femoral access may still be preferred are also outlined.
1) The study used OCT to assess remodeling of the radial artery in 30 patients who underwent primary PCI via the transradial approach.
2) OCT imaging found a significant thickening of the intimal layer 9 months after the procedure, though mean lumen area was not significantly affected.
3) While transradial PCI was found to change the radial artery structure, there was no significant effect on vessel lumen area observed with this sample size. Larger studies are needed to confirm the results.
This document discusses the benefits of using a radial artery approach for carotid artery stenting (CAS) compared to the traditional femoral artery approach. Some key benefits of the radial approach include avoiding complications associated with femoral access in patients with aorto-iliac disease, allowing for early patient mobilization to reduce bleeding risks, and eliminating vascular access site complications which are a major cause of morbidity and mortality after CAS. The document also presents several case examples demonstrating successful CAS procedures performed via the radial approach. However, it notes there is a significant learning curve for new operators and that the radial approach may not be suitable for all anatomies or allow the use of all devices.
1. The author advocates for using the left radial approach for coronary angiography and intervention in over 90% of patients.
2. Some advantages of the left approach include easier learning curve, better cannulation of the left internal mammary artery, and less limitation of daily activities for right-handed patients.
3. While both right and left approaches are equivalent alternatives to femoral access, the author finds the left approach offers slight technical advantages and higher patient satisfaction due to minimized limitations after the procedure.
1) The document discusses carotid artery stenting (CAS) and carotid endarterectomy (CEA) for treating carotid artery disease. It reviews data from clinical trials comparing the two procedures.
2) Operator experience is an important factor for CAS outcomes, with over 100 cases associated with lower risk. New technologies like mesh-covered stents may further reduce risks of CAS.
3) Future studies like CREST-2 aim to provide more data on CAS and CEA in asymptomatic patients to help guide treatment decisions. Both procedures can effectively treat carotid artery disease when performed by experienced operators.
This document compares the risk of microembolization during diagnostic coronary angiography between single catheter and double catheter strategies. In the first study, a left radial approach was found to have a lower rate of microembolization than a right radial approach, likely due to less catheter manipulation and exchanges. Independent predictors of high microembolization included a greater number of catheters used. A second study found that using a single "Tiger" catheter halved the rate of microembolization compared to using a double catheter "Judkins" strategy, mainly by reducing catheter exchanges. Minimizing catheter exchanges may help reduce the risk of air embolism and microembolization during coronary angiography procedures.
Safety and efficacy of using a single transradial MAC guiding catheter for coronary angiography and intervention in patients with ST-elevation myocardial infarction (RAPID)
This study evaluated the safety and efficacy of the novel Svelte Acrobat Integrated Delivery System (IDS) for percutaneous coronary interventions (PCI) via a radial approach using 5-French catheters. The study enrolled 55 patients and found a primary endpoint success rate of 91%, defined as direct stent implantation without need for post-dilation. Secondary endpoints including procedural success rates were also high. The study concluded the IDS system allows for safe and effective PCI via the radial approach in select patient populations and can reduce costs compared to traditional systems by an estimated $300 per procedure.
The document summarizes the NAUSICA trial which compared outcomes of percutaneous coronary interventions (PCI) using 4 French versus 6 French guide catheters. The trial found that 4 French PCI resulted in significantly lower access site complications and hemostasis times compared to 6 French PCI, with comparable procedural success. 4 French PCI also showed a numerically lower risk of radial artery occlusion. The 4 French coronary accessor was also found to be useful for the mother-child guiding catheter technique, providing backup support comparable to larger catheters.
The document summarizes information about the Terumo Glidesheath Slender, a new thinner-walled sheath for transradial procedures. It discusses studies showing the Glidesheath Slender reduces sheath size while maintaining lumen size. This decreases vascular complications and radial artery occlusion rates compared to standard sheaths. The document outlines several prospective studies and a large randomized trial that aim to further evaluate the Glidesheath Slender's safety, efficacy and ability to facilitate more complex transradial procedures.
Transradial access is a safe and effective alternative to femoral access for subclavian artery interventions, with comparable outcomes. A prospective study of 41 patients found a 100% technical success rate for subclavian angioplasty and stenting via transradial access. Major adverse event rates within 1 year were low at 4.9%. Access site complications were also low and less severe than typically seen with femoral access. Transradial access is a viable option for subclavian interventions with acceptable safety and morbidity.
Challenges of Radial Access-Anatomy, Tools and SuccessMir Ahmed
The document discusses some of the challenges of the transradial approach for coronary procedures. It notes that anatomical variations can occur in around 23% of cases, including radial artery tortuosity, stenosis, hypoplasia, and abnormal origins. Success rates for transradial procedures range from 83-96.7%, but can be lower for certain variations like arteria lusoria. It also discusses techniques for overcoming challenges like vascular loops and spasm, and notes there is a learning curve associated with the transradial approach.
1) The study evaluated 565 patients undergoing cardiac catheterization or percutaneous coronary intervention to compare the diameters of the radial and ulnar arteries using intraprocedural ultrasound.
2) The radial artery was found to be larger in 37.1% of patients, while the ulnar artery was larger in 6.5% of patients. A dual radial artery was present in 4.4% of patients.
3) In some cases where the radial artery diameter was very small (<2mm), the ulnar artery was significantly larger and may be a better access site. Evaluating both arteries ultrasonographically can help determine the best access site.
1. Ultrasound guidance for transradial artery access significantly improves accuracy and reduces time to access compared to palpation alone.
2. Ultrasound guidance decreases difficult access procedures and reduces the need to crossover to a different technique or vascular access site.
3. A study of 1000 consecutive transradial procedures using ultrasound guidance found a crossover rate of less than 1%, demonstrating that low and predictable crossover rates are attainable with ultrasound.
This study evaluated whether administering nitroglycerin through the sheath at the end of a transradial catheterization procedure reduces radial artery occlusion. Over 1700 patients were randomly assigned to receive either 500 μg of nitroglycerin or a placebo saline solution intra-sheath after transradial catheterization. Radial artery patency was assessed by ultrasound the next day. The incidence of radial artery occlusion was lower in the nitroglycerin group compared to placebo at 8.3% vs 11.7%. Administration of nitroglycerin through the sheath may reduce radial artery occlusion by its vasodilatory effects.
Coronary Ostial stenting techniques:Current statusPawan Ola
Ostial lesions, located within 3 mm of a vessel origin, pose unique challenges for percutaneous coronary intervention (PCI). Precise stent placement is required to avoid geographic miss and ensure optimal coverage of the lesion. Several techniques have been developed to aid accurate stent placement for ostial lesions, including aorto-free floating wire, stent pull-back, and Szabo/anchor wire methods. The use of these targeted approaches can reduce the risk of additional stenting and reintervention compared to conventional PCI for ostial lesions.
Alfredo R. Galassi - How to deal with very LVEF: the last remaining option to...Euro CTO Club
This document summarizes a presentation on CTO PCI in patients with multiple vessel disease and low left ventricular ejection fraction (LVEF). The presentation discusses:
1. The importance of assessing viability and ischemia before revascularization.
2. The need for hemodynamic support, particularly when using retrograde approaches.
3. Tips for procedural success including using the easiest CTO first and considering staged procedures.
4. The debate around complete vs. incomplete revascularization and factors to consider.
5. The importance of clinical and angiographic follow-up given the risk of restenosis in this complex patient group.
This document discusses vascular access for cardiac catheterization procedures. It covers the pros and cons of radial versus femoral artery access. For femoral access, it describes anatomical landmarks, fluoroscopic guidance, and ultrasound guidance techniques. Risk factors for bleeding complications are outlined. Various hemostasis devices are also discussed. For radial access, the radial artery anatomy and modified Allen's test are explained. Access techniques including counterpuncture versus anterior approaches are compared. Complications like radial occlusion and methods for prevention are summarized.
[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.
Zoltan Ruzsa presents results from a pilot study evaluating transradial access for femoral artery interventions. The study included 141 patients with symptomatic femoral artery stenosis treated via transradial access using 6F sheathless guiding catheters between 2014-2016. Angiographic and technical success rates were high at 87.2% and 75.9% respectively, with minor access site complications in only 3 patients (2.1%). While long term follow up showed revascularization was needed in 23.4% of patients at 12 months, the results demonstrate transradial access for femoral interventions can be performed safely with acceptable morbidity. Larger comparative studies are still needed to determine long term outcomes compared to traditional femoral access.
Transradial balloon aortic valvuloplasty (BAV) is a feasible and safe procedure for selected high-risk patients as a bridge to surgical aortic valve replacement or transcatheter aortic valve implantation. A study of 17 patients undergoing transradial BAV found it can be performed safely with proper patient selection using ultrasound to access the radial artery. The procedure resulted in significant reductions in aortic valve gradients and increases in aortic valve area with no major vascular complications within 30 days. Transradial BAV is a viable option for bridging high-risk patients with aortic stenosis to other interventions when transfemoral access is not possible or preferred.
The document discusses anatomical variations of the radial artery that can cause failures in transradial interventions, techniques to manage arterial spasm and loops during the procedure, and evidence that the radial approach has better outcomes than femoral especially in STEMI patients while emphasizing the need for dedicated equipment and techniques to minimize complications.
This document discusses guide catheter selection for transradial coronary procedures. It provides guidance on the most commonly used guide catheters for accessing the left and right coronary arteries from the radial approach. Specific catheter shapes like the Judkins left and extra backup are recommended for the left coronary while the Judkins right is suitable for the right coronary. Newer catheter technologies including hydrophilic sheathless catheters are also reviewed. The conclusion emphasizes that knowledge of guide catheter selection and engagement technique enables successful transradial PCI.
This document describes a novel "snuff-box technique" for transradial catheterization using a distal puncture of the radial artery. The author hypothesizes that distal puncture may reduce rates of radial artery occlusion (RAO) and bleeding complications compared to traditional puncture sites. Data from 637 patients found lower RAO rates and complication risks with distal versus traditional access. A future randomized trial is proposed to further evaluate distal access versus traditional sites.
1. The history of cerebral revascularization began in 1942 with various techniques being developed through the 1970s including EDAMS, CCA-ICA bypass, and STA-MCA bypass.
2. Revascularization can be direct, using vessel to vessel anastomoses, or indirect, promoting new capillary formation. Direct techniques provide immediate flow but require a recipient vessel over 1mm, while indirect revascularization relies on collateral formation.
3. Common indications for revascularization include moyamoya disease, complex aneurysms, skull base tumors, and cerebral ischemia. However, recent studies found no benefit for revascularization over medical management for treating ischemia.
This document discusses complications that can occur from radial artery access during cardiac catheterization procedures. It identifies several major complications including radial artery occlusion, compartment syndrome, hematoma, spasm, hand ischemia, and perforation. For each complication, it provides information on incidence, risk factors, etiology where relevant, and approaches to prevention and treatment. The overall goal is to educate practitioners on identifying and managing risks associated with radial artery access.
This document provides an overview of percutaneous prosthetic valve leakage (PVL) closure, including indications, approaches, techniques, and closure devices. It discusses that over 210,000 prosthetic valve surgeries are performed each year, with PVL occurring in some cases. While surgical closure has a high mortality rate, percutaneous closure has a procedural success rate of 86% and less complications. Indications for closure include symptomatic heart failure, hemolysis, rocking prosthesis, or leaks over 30% of the sewing ring. Techniques discussed include retrograde and transapical approaches using devices like the Amplatzer and Occlutech plugs. A team approach and techniques like sequential deployment are emphasized for
Trans-radial access (TRad) is commonly used for coronary interventions due to lower complication rates compared to femoral access. This study evaluated the safety and feasibility of TRad for non-coronary and peripheral vascular interventions in 24 cases over 3 years. TRad was successful in all cases with no access complications. Indications included absent femoral pulses, morbid obesity, femoral bypass, and groin infections. Procedures included diagnostic angiograms and interventions like iliac angioplasty/stenting and femoral anastomosis angioplasty. 31% had asymptomatic radial artery occlusion. Larger sheath sizes were associated with higher occlusion rates. TRad is a safe alternative to femoral access for select peripheral cases
TRICUSPID VALVE ANATOMY PATHOPHYSIOLOGY INDICATIONS AND INTERVENTIONS.pptxJaydeep Malakar
The document discusses tricuspid valve intervention techniques. It describes Tricuspid Annular Plane Systolic Excursion (TAPSE) which measures tricuspid annular motion and is used to estimate right ventricular function. It discusses approaches to tricuspid valve repair including annuloplasty techniques using rings. It also discusses transcatheter therapies being developed for tricuspid regurgitation including annuloplasty devices and coaptation devices.
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.
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.
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.
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- 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.
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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.
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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
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.
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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.
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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
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.
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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:
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Chugh S 201111
1. Anticipating Failure:
ROLE OF ARM IMAGING PRIOR TO
ARTERIAL ACCESS
Sanjay Chugh
MD(Cal.),DM (AIIMS), MRCP(I), FACC, FSCAI(USA)
Principal Consultant, Interventional Cardiology,
Fortis Escorts Heart Institute, New Delhi, India
2. Conflict of Interest Statement
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation
with the organization(s) listed below.
Physician Name Company/Relationship
NONE NONE
3. There`s been a paradigm shift in
interventional Cardiology to
transradial access
because of….
↓ VASCULAR COMPLICATIONS
↑PATIENT COMFORT
4. BUT IF PATIENT INTEREST IS SUPREME
THEN……
• IS A TRIAL & ERROR APPROACH by operators
on their Radial Learning Curve justified even
at the expense of ↑ procedure failure,
complications and patient inconvenience?
5. A SCIENTIFIC APPROACH TO
↓TRIAL & ERROR
in
THE LEARNING CURVE
& HENCE CROSS-OVER, RADIATION
TIME, PATIENT DISCOMFORT
&
PROCEDURE FAILURE
Is therefore needed
6. So What`s the trial & error about ?
In the `Learning Curve`
which may lead to
TR Procedure failure (~5%)
• ACCESS RELATED 52.6%(Guedes et al, J INVASIVE CARDIOL 2010;22:391–7)
• Inability to advance guide catheter to ascending aorta
51% ( Dehghani P et al(JACC Cardiovasc Interv. 2009 ;2(11):1057-64.)
• RADIAL ARTERY SPASM 38% (Circ Cardiovasc Interv. Ball WT, et
al2011e pub)
7. SIZE MATTERS……
•PUNCTURING SMALL ARTERIES IS MORE
DIFFICULT!
•SPASM IS MORE IN SMALLER ARTERIES
“ predictors of failure=
"small radial artery" size
(OR 2.6, 95% CI 1.4 to 5.0;
p = 0.003) or a "difficult
access" (OR 2.5, 95% CI
1.3-4.9; p = 0.006)”.
Guedes et al,
1.7 mm Radial artery RA spasm
J INVASIVE CARDIOL
2010;22:391–397
8. SHORT STATURE (OR:0.97; 95% CI: 0.95 to 0.99, p = 0.02) & AGE>75 (odds ratio [OR]: 3.86; 95%
confidence interval [CI]: 2.33 to 6.40, p = 0.0006) =
INDEPENDENT PREDICTORS OF FAILURE
142 cm
36 kg
1 mm; R
Ao root
1.2 mm U
2.4cm
1.4 mm R;
1.5 mm U
SCAI 2011 Dr Sanjay Chugh. Guide Cath
selection for Transradial PCI
10. Is it okay to shove any size Guiding
Catheter into any Radial artery ?
eg A 7F GUIDE INTO A 1.7 mm ARTERY ?
11. Of course not! (SHEATH / GUIDING ) > 1:1 : (RA)
initiates spasm
SPASM MAKES CATHETER
MANIPULATION DIFFICULT--->
Saito et al.CCI 46, 1999:173
LEADS TO RADIAL OCCLUSION
12. HOW DO WE DECIDE IF THE ARTERY IS
BIG ENOUGH TO SAFELY TAKE WHAT
YOU WANT TO SHOVE INTO IT ?
SIZE IT
13. RA Sizing
ASE 2007
SCAI 2011 Dr Sanjay Chugh. Guide Cath
13
selection for Transradial PCI
14. FAILURE: (1) SMALL ARTERY SIZE AND SPASM :
(2) LOOPS / ANOMALIES/ STENOSIS
•7% of procedural failure& CROSSOVER (Jolly SS, et alAm Heart J. 2009
Jan;157(1):132-40 in transradial intervention is due to radial artery
tortuosity, loops, or stenosis (Dehghani P ,et al.JACC Cardiovasc Interv. 2009
BRACHIAL Nov;2(11):1057-64.)
ULNAR
RADIAL
•Inability to advance the wire or catheter through the brachial artery accounts for
up to 73% of procedural failure (Guedes et al, JIC 2010).
15. CAN WE ANTICIPATE FAILURE
& HENCE
ENHANCE SUCCESS BY AVOIDING
THESE BY PRE-PROCEDURE
IMAGING?
16. YES, BY KNOWING THE HAND
BEFORE-HAND !
ENHANCE SUCCESS BY ANTICIPATING
FAILURE
17. Feasibility and Utility of Pre-
procedure Ultrasound Imaging of
the Arm to facilitate Trans-Radial
Coronary Diagnostic and
Interventional Procedures.
TCT 2011 (In Press)
18. • Pre-procedure ultrasound assessment of the Right and Left Radial, Ulnar, and
Brachial arteries, using a linear probe in all patients.
• Endpoints:
Incidence and Correlates of :
* Arterial anomalies
* Procedure success
* Crossover to alternate access
* Fluoroscopy time
* Ultrasound assessment time.
• Patient Demographics, Medical history, and Procedural characteristics , angiographic
assessment of arm arteries were recorded
19. • Prospective Single center Registry
• Consecutive patients undergoing diagnostic
and interventional procedures (2006 to 2011).
• Institutions: Fortis Escorts Heart Institute New
Delhi, (including Fortis Escorts Kalyani Heart
Centre, Gurgaon) India,
28. While radial artery loops and tortuosity may be
easily traversed with 0.014” guidewires, doing so
increases procedure time and radiation exposure
to the patient and operator, and also may result in
significant spasm and discomfort for the patient.
31. Stenosis in upstream RA can cause
procedural delay or failure & crossover
(CAN BE PICKED UP BY DOPPLER PRE-PROCEDURE)
PLETHYSMOGRAPHY MAY
NOT PICK THIS UP!
Stenosis in Radial
artery------------------
Why diversify ?
32. NEVER NEEDED TO LOOK FOR UPSTREAM
OBSTACLES EXCEPT ONCE
BECAUSE WE WERE IN AN ACCESSORY SMALL
RADIAL INSTEAD OF ULNAR ARTERY
33. Access Artery (Radial/Ulnar) Selection
for Angiogram or PCI
(BRACHIAL NEVER USED)
• 5F in ≥ 1.6mm for angio; 6F≥1.8 mm for PCI
Knowledge of the arm anatomy allowed us
to choose :
• The Biggest artery
• Without anomaly/abnormality
34. PREFERENCE ORDER FOR ACCESS SIDE
• RIGHT SIDE PREFERRED IN MOST
• LEFT ACCESS PREFERRED in PCI to Shepherd
crook/ tortuous/ calcific RCA
• Access opposite to arm with previous injury
scar/fracture /Venous cannula/phlebitis
35. PREFERENCE ORDER FOR CHOICE OF
ACCESS ARTERY
(RRA >LRA>RUA>LUA)
• RADIAL OVER ULNAR
• ULNAR PREFERRED only IF
*LOOP OR PARALLEL RADIAL & ULNAR
*IF BOTH RADIALS WERE SMALL
(PROVIDED ULNAR CONSIDERED EASY TO COMPRESS
MANUALLY FOR HEMOSTASIS)
• Groin was used if both arteries in both arms were
unsuitable because of small size or anomaly.
36. Aortic root 3.8 cm
LT RADIAL 1.8 Cm
ULNAR 2.1 Cm
Rt Radial 1.8 cm
Ulnar 1.7 cm
37. Spasm was recorded as per the
following grades:
• Grade-4: Severe pain and spasm disallowing any catheter movement
necessitating crossover.
• Grade-3: Moderate pain and spasm restricting catheter movement &
necessitating a pause in procedure and > 2 doses of additional intra-
arterial Diltiazem or Verapamil> 5mg and/ or > 1 mg of intravenous
Midazolam .
• Grade-2: Mild pain and spasm not restricting catheter movement ; no
pause in procedure but > 1 dose of (additional) intra-arterial Diltiazem (or
Verapamil) of 5mg and / or 0.5 mg of intravenous Midazolam .
• Grade-1: Mild pain and spasm not restricting catheter movement ; no
pause in procedure and only 1 dose of either or both intra-arterial
Diltiazem (or Verapamil) of 5mg and/or > 0.5 mg of intravenous
Midazolam.
39. Illustration-5
N=6125
Presented for
Angiogram/PCI* (2006-
2011)
2344
Complete ultrasound data
on arm arteries
12.9% (n=279) unsuitable
8.9% (n=193) unsuitable
for trans- radial / trans-
for even for an angiogram
Remaining 1872 patients
ulnar PCI*(because of small underwent a transradial /
because of small radial &
diameter of bilateral radial transulnar procedure
Ulnar arteries
and ulnar arteries)
*PCI=Percutaneous Coronary Intervention
40. PATIENT DEMOGRAPHICS
1.Sex
1179(63%) M;
693(37%) F
2.Mean age (yrs) 51.6 (±23.7)
RISK FACTORS
1.Diabetic 569(30.4%)
2.Tobacco abuse 624(33%)
3.Hypertensive 649(34.6%)
4.Dyslipidemia 702(37.5%)
•
41. CLINICAL DIAGNOSIS
Stable Angina including 711(38%)
Post MI *
& patients with positive
Stress test
Unstable Angina/ACS 1161(52%)
42. ARM IMAGING (ULTRASOUND) TIME
• The mean time (bilateral forearm )=
6.4 min ± 1.8min(95% confidence interval).
43. Our ultrasound strategy only required
a minimum of effort and time
• 62% in the inpatient setting (Coronary care
Unit and Wards);
• in 33% patients our protocol could be
implemented on the day of the procedure in
the pre-procedure area.
• 5% of the ultrasound studies were performed
in the clinic setting
44. Doppler assessment of anomaly was
accurate in all cases
on
COMPARISON WITH ANGIOGRAPHIC
ASSESSMENT
45. SIZE OF RADIAL & ULNAR
ARTERY ON THE 2 SIDES
SIZE OF RADIAL & ULNAR ARTERY MEAN
ON THE 2 SIDES Diameter (mm)
Left Radial Artery Male 1.8±0.29
Female 1.7±0.26
Left Ulnar Artery Male 1.8±0.30
Female 1.7±0.3
Right Radial Artery Male 1.9±1.12
Female 1.7±0.29
Right Ulnar Artery Male 1.8±0.30
Female 1.6±0.28
46. Table-II: +ve Correlations of Radial
artery with Ulnar artery size
Left Radial Artery Left Ulnar Artery
Left Radial Artery Pearson Correlation 1 .404(**)
Sig. (2-tailed) 0.000
Left Ulnar Artery Pearson Correlation .404(**) 1
Sig. (2-tailed) 0.000
**. Correlation is significant at
the 0.01 level (2-tailed).
Right Radial Artery Right Ulnar Artery
Right Radial Artery Pearson Correlation 1 .416(**)
Sig. (2-tailed) 0.000
Right Ulnar Artery Pearson Correlation .416(**) 1
Sig. (2-tailed) 0.000
47. Table III- 9.8 %
Incidence of Anomalies in Radial Artery in the study
population
Anomalies Radial Artery
Intimal thickness 3.6%
Parallel Radial and Ulnar suggesting 4.7%
possibility of high origin of radial
from Brachial or Radioulnar loop or
similar anomaly
Loop seen at Cubital Fossa 0.9%
Blocked artery 0.6%
53. We may have prevented failure, access site crossover,
or patient discomfort in nearly 30% of our cases with
Pre-procedure Arm Imaging
54. Success & Crossover
In our study
• Left Access
55% PCI & 38% Angiograms
• SUCCESS >97.6 %
(> Success of 95% in RIVAL)
• Crossover = 2.4%
( <7.6%in RIVAL & = crossover from Femoral to arm (2%)!)
55. RIVAL
TRI
Radial Femoral P
(n=3507) (n=3514)
PCI Success 95.4 95.2 0.83
Access site Cross-over (%) 7.6 2.0 <0.0001
PCI Procedure duration (min) 35 34 0.62
Fluoroscopy time (min) 9.3 8.0 <0.0001
Preference (%) 90 49 <0.0001
57. LIMITATION-1
• We did not randomize patients to an
ultrasound-based strategy or usual care;
therefore, our comparisons of radiation
times , procedure success and access site
crossover are with the published literature
rather than direct comparison
58. A journey of a 1000 miles begins with
the 1st step…..
• The purpose of our study was to describe our
experience, which is the first using a routine
pre-procedure ultrasound evaluation of the
arm arterial structures.
59. LIMITATION-2
• One operator performed all of the ultrasound
procedures, and
• One separate operator performed all of the
coronary procedures.
• It is difficult to generalize our results to other
operators who may have varying levels of
experience with ultrasound imaging or radial
procedures.
60. COST IMPLICATIONS
• Cost -effectiveness OF PRE-PROCEDURE ARM
IMAGING was not studied.
• THE COST OF PRE PROCEDURE ULTRASOUND
MAY BE OFFSET BY REDUCTION IN RADIATION
TIME, PROCEDURAL COMPLICATIONS &
FAILURE
61. Impact on RA /UA Occlusion
• not tested in our study,
• is being done as a part of an on going study at
our Institution.
.
63. This single center prospective registry shows
PRE-PROCEDURE ULTRASOUND IMAGING
OF ARM ARTERIAL STRUCTURES IS
*FEASIBLE,
**REQUIRES MINIMUM TIME AND EFFORT,
***PROVIDES INFORMATION ON ARTERIAL
SIZE AND ANATOMICAL VARIANTS
****THUS FACILITATING TR & TU PROCEDURES
& REDUCING
SPASM, CROSSOVER, PROCEDURE FAILURE
& PT .DISCOMFORT
64. RANDOMIZED STUDY NEEDED
BUT….
WOULD I EVER DO A TRANSRADIAL
WITHOUT PRE-PROCEDURE ARM
IMAGING;
NEVER !