This document provides information on the efficacy and safety of pre-treatment with antiplatelet drugs prior to percutaneous coronary intervention (PCI) based on multiple clinical trials and studies. The key findings are:
1) The ACCOAST trial of over 4,000 patients found no difference in the primary efficacy endpoint of cardiovascular death, myocardial infarction, stroke, urgent revascularization or bailout GP IIb/IIIa inhibitor use at 7 and 30 days between patients pre-treated with prasugrel versus no pre-treatment.
2) For the subgroup of patients undergoing PCI, there was also no difference in the primary endpoint between pre-treatment and no pre-treatment.
3) Analysis of over 15
Rotational atherectomy can be performed via the radial or femoral artery approaches with similar success rates. A study compared outcomes of 67 patients who underwent rotational atherectomy via the femoral approach to 52 patients who underwent it via the radial approach and found no significant differences in procedural characteristics, success rates, or in-hospital complications between the two groups except that pacing wires were inserted less often in the radial group. Overall, rotational atherectomy performed via the radial approach was found to be a feasible alternative to the femoral approach.
This document summarizes the results of the ARISE trial, which compared the Angio-Seal vascular closure device to manual compression using a radial artery approach in 240 patients undergoing coronary procedures for acute coronary syndrome. The trial found no significant differences in vascular complications, major bleeding, transfusion needs, or other safety outcomes between the two approaches at 30 days. Specifically, the risk difference for the primary endpoint of vascular complications was -0.83% (95% CI, -9.31-7.65) in favor of Angio-Seal, meeting the prespecified non-inferiority criterion. The results demonstrate that Angio-Seal is not inferior to manual compression in terms of safety and effectiveness when
This document discusses the use of bivalirudin as an anticoagulant for PCI procedures. It summarizes data from several clinical trials showing that bivalirudin reduces bleeding risks compared to unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, without increasing ischemic risks. The presentation argues that since bleeding is a common complication of PCI and is associated with worse outcomes, and bivalirudin reduces bleeding while maintaining efficacy, it should be the preferred anticoagulant for PCI procedures for all patients. It acknowledges that while risk models can identify patients at higher risk of bleeding, it is difficult to separate bleeding risk from ischemic risk.
Radial access for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients reduces bleeding complications compared to femoral access. Several randomized controlled trials showed lower all-cause mortality with radial versus femoral access when performed by experienced radial operators. However, the studies only included radial operators, so it is unclear if the benefits seen with radial access would apply if femoral operators performed radial procedures or vice versa. Additionally, radial access requires experienced operators at high-volume centers, and the definition of an experienced radial operator remains uncertain due to the steep learning curve for radial procedures. The primary goal of primary PCI in STEMI is restoring blood flow to the heart, not avoiding access site complications.
This document provides information on the efficacy and safety of pre-treatment with antiplatelet drugs prior to percutaneous coronary intervention (PCI) based on multiple clinical trials and studies. The key findings are:
1) The ACCOAST trial of over 4,000 patients found no difference in the primary efficacy endpoint of cardiovascular death, myocardial infarction, stroke, urgent revascularization or bailout GP IIb/IIIa inhibitor use at 7 and 30 days between patients pre-treated with prasugrel versus no pre-treatment.
2) For the subgroup of patients undergoing PCI, there was also no difference in the primary endpoint between pre-treatment and no pre-treatment.
3) Analysis of over 15
Rotational atherectomy can be performed via the radial or femoral artery approaches with similar success rates. A study compared outcomes of 67 patients who underwent rotational atherectomy via the femoral approach to 52 patients who underwent it via the radial approach and found no significant differences in procedural characteristics, success rates, or in-hospital complications between the two groups except that pacing wires were inserted less often in the radial group. Overall, rotational atherectomy performed via the radial approach was found to be a feasible alternative to the femoral approach.
This document summarizes the results of the ARISE trial, which compared the Angio-Seal vascular closure device to manual compression using a radial artery approach in 240 patients undergoing coronary procedures for acute coronary syndrome. The trial found no significant differences in vascular complications, major bleeding, transfusion needs, or other safety outcomes between the two approaches at 30 days. Specifically, the risk difference for the primary endpoint of vascular complications was -0.83% (95% CI, -9.31-7.65) in favor of Angio-Seal, meeting the prespecified non-inferiority criterion. The results demonstrate that Angio-Seal is not inferior to manual compression in terms of safety and effectiveness when
This document discusses the use of bivalirudin as an anticoagulant for PCI procedures. It summarizes data from several clinical trials showing that bivalirudin reduces bleeding risks compared to unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor, without increasing ischemic risks. The presentation argues that since bleeding is a common complication of PCI and is associated with worse outcomes, and bivalirudin reduces bleeding while maintaining efficacy, it should be the preferred anticoagulant for PCI procedures for all patients. It acknowledges that while risk models can identify patients at higher risk of bleeding, it is difficult to separate bleeding risk from ischemic risk.
Radial access for primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) patients reduces bleeding complications compared to femoral access. Several randomized controlled trials showed lower all-cause mortality with radial versus femoral access when performed by experienced radial operators. However, the studies only included radial operators, so it is unclear if the benefits seen with radial access would apply if femoral operators performed radial procedures or vice versa. Additionally, radial access requires experienced operators at high-volume centers, and the definition of an experienced radial operator remains uncertain due to the steep learning curve for radial procedures. The primary goal of primary PCI in STEMI is restoring blood flow to the heart, not avoiding access site complications.
1) The study compared transradial access (TRA) to transfemoral access (TFA) for coronary angiography in orthotopic heart transplant patients.
2) It found that while procedural time was similar, TRA was associated with higher contrast use, longer fluoroscopy time, and more catheters used for left coronary ostium cannulation compared to TFA.
3) However, no differences in adverse cardiac events or vascular complications between the two access routes were observed. The results suggest TRA may require a specific learning curve for operators, even for those experienced with radial procedures.
This document discusses the benefits and risks of transradial intervention (TRI) compared to transfemoral approach (TFA) for primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients.
The main benefits of TRI are reduced access site bleeding, earlier ambulation for patients, and the ability to use more aggressive anticoagulation. However, TRI may be associated with longer procedures, more contrast use, longer fluoroscopy times, and longer door-to-balloon times. Several randomized controlled trials have shown lower rates of major bleeding but similar mortality with TRI compared to TFA. Registry data also suggests lower mortality and bleeding with TRI. Alternative bleeding avoidance strategies like vascular closure devices
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 use of a slender 6Fr intra-aortic balloon pump (IABP) system compared to the standard 8Fr system. A study of 42 patients undergoing elective percutaneous coronary intervention with prophylactic IABP support found no complications with the 6Fr system, while the 8Fr system had re-bleeding and hematoma in some patients. The 6Fr system also allowed for shorter bed rest time. Trans-brachial insertion of the 6Fr IABP had even shorter bed rest and hospital stay times than transfemoral insertion. However, the 6Fr system has limitations such as a small balloon volume and inability to monitor pressure or use radial approaches.
This document summarizes the results of several clinical trials evaluating renal denervation for the treatment of hypertension. The SYMPLICITY HTN-3 trial, the largest study to date, found no significant difference in blood pressure reduction between the renal denervation and sham procedure groups. Subgroup analyses found some predictors of greater blood pressure response, such as use of alpha-1 blockers or baseline blood pressure over 180 mmHg. Overall, the data from clinical trials on renal denervation is mixed, with early studies showing promising results but larger trials like SYMPLICITY HTN-3 finding no clear benefit over sham procedures.
This study compared ambulation times to discharge for 367 patients who received radial or femoral access for cardiac catheterization. It found that patients with radial access were discharged 41-122 minutes sooner than those with femoral access, depending on the specific procedure. Radial access was associated with shorter discharge times even after controlling for various patient characteristics and procedural factors. The study concluded that radial access results in shorter hospital stays compared to femoral access for cardiac catheterization.
This study evaluated muscle force of the hand, thumb, and forefinger in patients who experienced prolonged radial artery occlusion after transradial percutaneous coronary procedures. The study found that radial artery occlusion was not associated with a reduction in hand and finger strength, regardless of Allen test results. However, the study had limitations including a small sample size and being conducted at a single center. The conclusions were that while radial artery occlusion may not impair hand function, interventional cardiologists should still aim to prevent radial artery occlusion after such procedures.
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.
This document summarizes a systematic review and meta-analysis comparing radiation exposure between transradial and transfemoral access for cardiac catheterization. The analysis included 68 studies with over 666,000 patients. It found that while transradial access was initially associated with slightly higher fluoroscopy times and dose-area products, the difference has decreased over time as operator experience has increased, and recent studies show less than a 1 minute difference between approaches. Transradial access may also reduce operator radiation exposure.
This document summarizes the results of the DRAGON trial which compared the radial versus femoral approach for percutaneous coronary intervention (PCI) in over 1,700 patients. The trial found that the radial approach (TRI) was non-inferior to the femoral approach (TFI) for the primary endpoint of major adverse cardiac events at 12 months. TRI also had significantly less major bleeding complications at 7 days compared to TFI, meeting the secondary endpoint for superiority. Propensity score matching was used to adjust for baseline differences between the groups. The trial demonstrated that an ad-hoc radial approach strategy can provide similar clinical outcomes to femoral approach with less bleeding risks.
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 several studies on vascular complications in overweight patients undergoing percutaneous coronary interventions (PCI) and coronary angiography. The TROP study analyzed outcomes in 346 overweight patients undergoing PCI or angiography. It found the radial approach reduced complications compared to femoral. Other studies also found lower risks with radial access, especially in obese patients. Overall, obesity is a risk factor for cardiovascular disease and complications, and the radial approach may help reduce risks in overweight and obese patients undergoing coronary procedures.
This document discusses tips and tricks for successful transradial primary PCI. It begins with an introduction and disclosure from the author. It then reviews several studies that found high rates of success (90-100%) and normalization of coronary blood flow with transradial PCI for AMI. No major vascular complications occurred in these studies. Additional studies showed similar success rates and procedural times for transradial PCI compared to transfemoral, with lower rates of major vascular complications. Bleeding complications were associated with increased mortality. The experience of over 880 AMIs at one center using a transradial approach found no major vascular complications. While transradial PCI can present challenges in complex cases, it allows intervention even if thrombolysis was used
This document discusses anticoagulation options for coronary procedures. Unfractionated heparin (UFH) is the most cost-effective option. The goals of anticoagulation are to prevent radial artery occlusion after angiography, avoid complications like stent thrombosis during percutaneous coronary intervention (PCI), and reduce bleeding. UFH 5000 IU is effective for preventing radial occlusion after angiography. For planned PCI, STEMI, or NSTEMI, UFH or low molecular weight heparin are first-line options, though bivalirudin reduces bleeding. The benefit of bivalirudin may be mitigated for radial procedures and its high cost is a limitation. More data is needed on anticoagulant
1) The AURA OF ARTEMIS study was a randomized trial comparing transulnar versus transradial arterial access as the default strategy for coronary procedures.
2) In the interim analysis, the composite primary endpoint was significantly higher in the ulnar arm compared to the radial arm, with a 24.3% difference between arms. The study was terminated early due to the inferiority of the transulnar approach.
3) Complications associated with the transulnar approach included pseudoaneurysms, perforations, occlusions and arteriovenous fistulas. Crossover from ulnar to other access sites was also more common.
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16Euro CTO Club
This document summarizes recent publications and research on chronic total occlusions (CTOs) from 2015-2016. It finds that the number of published manuscripts on CTOs has significantly increased in recent years. Several studies examined outcomes of patients undergoing percutaneous coronary intervention (PCI) on CTOs versus medical therapy or bypass surgery, finding lower mortality and adverse event rates with PCI. Other publications identified predictors of successful CTO recanalization and evaluated new techniques and scoring systems. Additional research investigated the physiological and anatomical changes in CTO arteries pre- and post-PCI using imaging modalities like intravascular ultrasound (IVUS) and computed tomography angiography (CTA).
1) The study compared transradial access (TRA) to transfemoral access (TFA) for coronary angiography in orthotopic heart transplant patients.
2) It found that while procedural time was similar, TRA was associated with higher contrast use, longer fluoroscopy time, and more catheters used for left coronary ostium cannulation compared to TFA.
3) However, no differences in adverse cardiac events or vascular complications between the two access routes were observed. The results suggest TRA may require a specific learning curve for operators, even for those experienced with radial procedures.
This document discusses the benefits and risks of transradial intervention (TRI) compared to transfemoral approach (TFA) for primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients.
The main benefits of TRI are reduced access site bleeding, earlier ambulation for patients, and the ability to use more aggressive anticoagulation. However, TRI may be associated with longer procedures, more contrast use, longer fluoroscopy times, and longer door-to-balloon times. Several randomized controlled trials have shown lower rates of major bleeding but similar mortality with TRI compared to TFA. Registry data also suggests lower mortality and bleeding with TRI. Alternative bleeding avoidance strategies like vascular closure devices
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 use of a slender 6Fr intra-aortic balloon pump (IABP) system compared to the standard 8Fr system. A study of 42 patients undergoing elective percutaneous coronary intervention with prophylactic IABP support found no complications with the 6Fr system, while the 8Fr system had re-bleeding and hematoma in some patients. The 6Fr system also allowed for shorter bed rest time. Trans-brachial insertion of the 6Fr IABP had even shorter bed rest and hospital stay times than transfemoral insertion. However, the 6Fr system has limitations such as a small balloon volume and inability to monitor pressure or use radial approaches.
This document summarizes the results of several clinical trials evaluating renal denervation for the treatment of hypertension. The SYMPLICITY HTN-3 trial, the largest study to date, found no significant difference in blood pressure reduction between the renal denervation and sham procedure groups. Subgroup analyses found some predictors of greater blood pressure response, such as use of alpha-1 blockers or baseline blood pressure over 180 mmHg. Overall, the data from clinical trials on renal denervation is mixed, with early studies showing promising results but larger trials like SYMPLICITY HTN-3 finding no clear benefit over sham procedures.
This study compared ambulation times to discharge for 367 patients who received radial or femoral access for cardiac catheterization. It found that patients with radial access were discharged 41-122 minutes sooner than those with femoral access, depending on the specific procedure. Radial access was associated with shorter discharge times even after controlling for various patient characteristics and procedural factors. The study concluded that radial access results in shorter hospital stays compared to femoral access for cardiac catheterization.
This study evaluated muscle force of the hand, thumb, and forefinger in patients who experienced prolonged radial artery occlusion after transradial percutaneous coronary procedures. The study found that radial artery occlusion was not associated with a reduction in hand and finger strength, regardless of Allen test results. However, the study had limitations including a small sample size and being conducted at a single center. The conclusions were that while radial artery occlusion may not impair hand function, interventional cardiologists should still aim to prevent radial artery occlusion after such procedures.
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.
This document summarizes a systematic review and meta-analysis comparing radiation exposure between transradial and transfemoral access for cardiac catheterization. The analysis included 68 studies with over 666,000 patients. It found that while transradial access was initially associated with slightly higher fluoroscopy times and dose-area products, the difference has decreased over time as operator experience has increased, and recent studies show less than a 1 minute difference between approaches. Transradial access may also reduce operator radiation exposure.
This document summarizes the results of the DRAGON trial which compared the radial versus femoral approach for percutaneous coronary intervention (PCI) in over 1,700 patients. The trial found that the radial approach (TRI) was non-inferior to the femoral approach (TFI) for the primary endpoint of major adverse cardiac events at 12 months. TRI also had significantly less major bleeding complications at 7 days compared to TFI, meeting the secondary endpoint for superiority. Propensity score matching was used to adjust for baseline differences between the groups. The trial demonstrated that an ad-hoc radial approach strategy can provide similar clinical outcomes to femoral approach with less bleeding risks.
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 several studies on vascular complications in overweight patients undergoing percutaneous coronary interventions (PCI) and coronary angiography. The TROP study analyzed outcomes in 346 overweight patients undergoing PCI or angiography. It found the radial approach reduced complications compared to femoral. Other studies also found lower risks with radial access, especially in obese patients. Overall, obesity is a risk factor for cardiovascular disease and complications, and the radial approach may help reduce risks in overweight and obese patients undergoing coronary procedures.
This document discusses tips and tricks for successful transradial primary PCI. It begins with an introduction and disclosure from the author. It then reviews several studies that found high rates of success (90-100%) and normalization of coronary blood flow with transradial PCI for AMI. No major vascular complications occurred in these studies. Additional studies showed similar success rates and procedural times for transradial PCI compared to transfemoral, with lower rates of major vascular complications. Bleeding complications were associated with increased mortality. The experience of over 880 AMIs at one center using a transradial approach found no major vascular complications. While transradial PCI can present challenges in complex cases, it allows intervention even if thrombolysis was used
This document discusses anticoagulation options for coronary procedures. Unfractionated heparin (UFH) is the most cost-effective option. The goals of anticoagulation are to prevent radial artery occlusion after angiography, avoid complications like stent thrombosis during percutaneous coronary intervention (PCI), and reduce bleeding. UFH 5000 IU is effective for preventing radial occlusion after angiography. For planned PCI, STEMI, or NSTEMI, UFH or low molecular weight heparin are first-line options, though bivalirudin reduces bleeding. The benefit of bivalirudin may be mitigated for radial procedures and its high cost is a limitation. More data is needed on anticoagulant
1) The AURA OF ARTEMIS study was a randomized trial comparing transulnar versus transradial arterial access as the default strategy for coronary procedures.
2) In the interim analysis, the composite primary endpoint was significantly higher in the ulnar arm compared to the radial arm, with a 24.3% difference between arms. The study was terminated early due to the inferiority of the transulnar approach.
3) Complications associated with the transulnar approach included pseudoaneurysms, perforations, occlusions and arteriovenous fistulas. Crossover from ulnar to other access sites was also more common.
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16Euro CTO Club
This document summarizes recent publications and research on chronic total occlusions (CTOs) from 2015-2016. It finds that the number of published manuscripts on CTOs has significantly increased in recent years. Several studies examined outcomes of patients undergoing percutaneous coronary intervention (PCI) on CTOs versus medical therapy or bypass surgery, finding lower mortality and adverse event rates with PCI. Other publications identified predictors of successful CTO recanalization and evaluated new techniques and scoring systems. Additional research investigated the physiological and anatomical changes in CTO arteries pre- and post-PCI using imaging modalities like intravascular ultrasound (IVUS) and computed tomography angiography (CTA).
This study aimed to investigate compliance with and staff perceptions of the WHO surgical safety checklist (SSC) at a multi-specialty hospital in India. Observational data found highest compliance rates during sign-in and lowest during time-out. Staff generally expressed satisfaction with SSC introduction and perceived improved teamwork, safety and reduced errors, though some felt it increased workload. The study concluded SSC compliance was variable and proposed continued monitoring and training to optimize implementation and outcomes.
1) The study assessed the impact of a digital reporting terminal called Aspect Reporter on reducing the time to deliver HIV viral load and early infant diagnostic results from centralized laboratories to remote clinics in Malawi.
2) Results showed that with digital reporting, 100% of results were delivered to clinics compared to 5% missing with paper reporting, and the average time to deliver results reduced from 22 days to just 1 day.
3) Across clinics, the time to deliver results using the digital reporter continued to improve over the 4 months of the study, going from an average of 8.1 days initially to just 0.6 days, representing a 95% reduction in turnaround time compared to the paper-based system.
Published data on CTO complications
Nikolaos Konstantinidis, Thessaloniki, Greece
11th Experts Live CTO
The annual Euro CTO meeting
September 13th –14th, 2019 - Berlin, Germany
- The study compared safety and technical outcomes of radial versus femoral artery access for endovascular interventions of peripheral arterial lesions.
- 184 patients underwent interventions via radial (65 patients) or femoral (123 patients) access. Radial access failed in 16.9% of cases due to tortuosity or complex lesions.
- There were no differences in major complications between the two groups. Radial access was associated with higher contrast use but no difference in radiation exposure or length of stay.
- Left radial access was associated with less radiation than right radial access. No single predictor of radial access failure was identified.
- The study concluded that radial access for peripheral interventions is safe and feasible for treating a range of lesion
This document summarizes the results of a study analyzing the angiographic and clinical outcomes of patients who underwent successful percutaneous coronary intervention (PCI) to treat a chronic total occlusion (CTO). The study found that the use of everolimus-eluting stents was associated with significantly lower rates of CTO vessel reocclusion compared to first-generation drug-eluting stents. Additionally, the use of the STAR technique for CTO PCI was associated with a very high rate of vessel reocclusion despite initial success. Patients treated with everolimus-eluting stents or conventional antegrade/retrograde approaches had much higher sustained vessel patency linked to improved one-year clinical outcomes.
Glaucoma poses significant challenges for care in the Himalayan regions of Tibet and Nepal. It is a leading cause of irreversible blindness. Hospital data from Nepal shows primary angle-closure glaucoma is more common and causes greater visual impairment than primary open-angle glaucoma. Population studies estimate glaucoma accounts for 5% of blindness, higher than previously thought. Most cases are asymptomatic and diagnosed late with severe vision loss. Strategies to address challenges include training programs to expand the eye care workforce and opportunistic screening to enhance case detection.
Safety and efficacy of using a single transradial MAC guiding catheter for coronary angiography and intervention in patients with ST-elevation myocardial infarction (RAPID)
(May 29th, 2024) Advancements in Intravital Microscopy- Insights for Preclini...Scintica Instrumentation
Intravital microscopy (IVM) is a powerful tool utilized to study cellular behavior over time and space in vivo. Much of our understanding of cell biology has been accomplished using various in vitro and ex vivo methods; however, these studies do not necessarily reflect the natural dynamics of biological processes. Unlike traditional cell culture or fixed tissue imaging, IVM allows for the ultra-fast high-resolution imaging of cellular processes over time and space and were studied in its natural environment. Real-time visualization of biological processes in the context of an intact organism helps maintain physiological relevance and provide insights into the progression of disease, response to treatments or developmental processes.
In this webinar we give an overview of advanced applications of the IVM system in preclinical research. IVIM technology is a provider of all-in-one intravital microscopy systems and solutions optimized for in vivo imaging of live animal models at sub-micron resolution. The system’s unique features and user-friendly software enables researchers to probe fast dynamic biological processes such as immune cell tracking, cell-cell interaction as well as vascularization and tumor metastasis with exceptional detail. This webinar will also give an overview of IVM being utilized in drug development, offering a view into the intricate interaction between drugs/nanoparticles and tissues in vivo and allows for the evaluation of therapeutic intervention in a variety of tissues and organs. This interdisciplinary collaboration continues to drive the advancements of novel therapeutic strategies.
The document summarizes findings from a study on the appropriateness of upper endoscopy referrals in Italy. Key findings include:
1) 22% of over 13,000 endoscopies were deemed inappropriate based on guidelines. Relevant findings were found in 51% of appropriate referrals and 32% of inappropriate ones.
2) Common relevant findings included esophagitis, gastric erosions, esophageal varices, and ulcers. New cancers were found in 1.6% of patients.
3) Guidelines had high sensitivity but low specificity for relevant findings and cancer. A simple rule using age and alarm symptoms had similar accuracy to guidelines.
4) Over 20% of endoscopy
The document summarizes a study evaluating the MO.MA device for proximal cerebral protection during carotid artery stenting. The study enrolled 225 high surgical risk patients across 25 sites in the US and Europe. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) within 30 days, which occurred in 2.7% of patients. The MO.MA device demonstrated high rates of procedural success and no device-related complications. The results support the safety and effectiveness of the MO.MA device for proximal protection during carotid stenting in high surgical risk patients.
Stephen Radley Consultant Obstetrician & Gynaecologist3GDR
This document discusses the benefits and practicalities of setting up and running virtual clinics. It provides an overview of virtual clinics and how they can utilize different communication methods like the internet to provide remote medical care. It then describes how the presenter has set up virtual urogynaecology clinics using an electronic pelvic floor questionnaire (ePAQ) to collect patient data before appointments. Patients found the virtual approach eased disclosure of sensitive issues and clinicians saw benefits like embedded outcomes tracking. The presentation concludes by discussing lessons learned and the practical steps involved in implementing a virtual clinic.
Omer Goktekin - TransradialApproach is BetterEuro CTO Club
The document discusses the advantages of the transradial approach for percutaneous coronary interventions including CTO PCI, with benefits such as reduced vascular complications, patient comfort, and early ambulation compared to the transfemoral approach. While the transradial approach is technically more challenging, studies have shown comparable success rates for CTO PCI between the two approaches. The document also reviews data demonstrating the feasibility and safety of using large bore guides and bilateral transradial access for complex CTO PCI cases.
This document summarizes information about colorectal cancer (CRC) screening in Italy and Europe. It discusses various screening tests including fecal occult blood tests (FOBTs), colonoscopy, flexible sigmoidoscopy, stool DNA tests, and virtual colonoscopy. Key findings from randomized controlled trials on CRC screening programs using FOBTs in Europe and the US show a 15-18% reduction in mortality. Colonoscopy is effective for both early detection and prevention by removal of precancerous polyps, reducing CRC incidence by up to 65-70%. However, compliance with screening tests is generally low, not exceeding 40-50% even in wealthy nations. Improving awareness and involving general practitioners are important to increase compliance with CRC screening programs
Understanding the role of telemedicine in expanding outpatientRatnakar Kamath
This study analyzed 658 patient consultations through a teledermatology program connecting Sir J. J. Hospital in Mumbai to 23 referring hospitals across distances up to 1000km. The majority (95%) used static image store-and-forward teledermatology, finding it effective for common infections and inflammatory conditions. While static images proved suitable for most cases, the study found videoconferencing may better enable counseling for conditions requiring long-term management and follow-up. Overall, teledermatology was found to improve access to dermatology expertise for remote populations while saving significant travel time compared to physical consultations.
Similar to Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach (20)
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.
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.
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.
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
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
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.
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.
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.
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
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
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.
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.
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.
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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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
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10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
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Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Gabric ID - AIMRADIAL 2014 - Primary PCI and left radial approach
1. Gabric ID1, Pintaric H1, Babic Z1, Trbusic M1, Krcmar T1, Stambuk
K2, Budimilic-Mikolaci J3, Benko I1, Vinter O1, Zeljkovic I1, Manola
S1, Radeljic V1, Planinc D1, Delic-Brkljacic D1
1 University Hospital Center “Sestre milosrdnice”, Zagreb,
Croatia
2 Special Hospital for Cardiovascular Surgery and Cardiology,
Krapinske Toplice, Croatia
3 Croatian National Public Health Institute, Zagreb, Croatia
2. CROSS – STEMI
CROatian Single center Study
in STEMI patients
3. Dr. Ivo Darko Gabrić has no relevant
financial interests to disclose
7. - 0,02 - 0,01 1 + 0,01
Procedural success
(%)
Total procedure time
(min)
Fluoroscopy time
(min)
„Door to balloon” time
(min)
Radiation dose
(cGy/cm2)
Contrast used (ml)
Left Radial Femoral
NS
Gabrić ID, Pintarić H, Babić Z et all: STEMI Patients Undergoing Primary PCI in a Radial Approach Skilled Center
can be Equally Treated with Either Femoral, Left, or Right Radial Access, J. Invasive Cardiol, Vol 25, Supp E, 2013
8. - 0,04 - 0,02 1 + 0,02
Procedural success
(%)
Total procedure time
(min)
Fluoroscopy time
(min)
„Door to balloon” time
(min)
Radiation dose
(cGy/cm2)
Contrast used (ml)
Left Radial Right Radial
NS
Gabrić ID, Pintarić H, Babić Z et all: STEMI Patients Undergoing Primary PCI in a Radial Approach Skilled Center
can be Equally Treated with Either Femoral, Left, or Right Radial Access, J. Invasive Cardiol, Vol 25, Supp E, 2013
9. in STEMI pts primary PCI using left
radial approach
Learning period and time of day
influence on:
Efficiency: procedure success, total
procedure and “door to balloon” time
Operator and pts safety: contrast,
fluoroscopy time and radiation dose
10. Data from registry and medical records
Two analysis
1. Learning curve pts divided into 6
month period groups (7 groups)
2. Time of day 3 groups (A: 8-16, B: 16-
24 and C: 24-8 h)
14. A
(08 -16 h)
B
(16-24 h)
C
(24-08 h)
Total P-level
% of LR
56%
(262 of 468)
62,6%
(219 of 350)
59,9%
(115 of 192)
59%
(596 of 1010)
0,435
Procedure
success (%)
91,2 89,7 88,9 90,3 0,875
Contrast used
(ml)
155
(50-614)
136,5
(54-642)
154
(54-430)
150
(50-642)
0,286
Fluoroscopy
time (min)
9,9
(2,1-49,5)
8,5
(2,2-45)
10,0
(3,12-34,2)
9,4
(2,1-49,5)
0,364
Radiation dose
(cGy/cm2)
4671
(381-56178)
4520
(420-46059)
5211
(807-52073)
4723
(381-56178)
0,785
„door to ballon”
time (min)
40
(20-113)
35
(15-85)
40
(20-110)
36
(12-113)
0,414
Total procedure
time (min)
80,5
(24-162)
71
(28-142)
72
(31-171)
73
(24-171)
0,125
15. Fluoroscopy time, amount of contrast used
and fluoroscopy dose are higher in STEMI pts
treated with primary PCI in the first year after
changing the setup of the cath lab from
femoral to left radial.
with more experience of the operators, they
can be significantly improved.
Time of day when the pPCI with left radial
approach in pts with STEMI was done did not
show any significant influence on procedure
efficiency or safety.