Meerkin D - AIMRADIAL 2014 - Structural disease

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International Chair on Interventional Cardiology and Transradial Approach

This document discusses the use of transradial artery (TRA) access for structural heart interventions. It provides reasons for and against TRA, as well as specific examples where TRA is beneficial. Some key benefits of TRA include avoiding bleeding complications, keeping large venous and arterial sheaths separate, and providing hemodynamic monitoring and support during complex procedures. Specific cases where TRA is useful include left atrial appendage occlusion, MitraClip procedures, coronary arteriovenous fistula closure, coarctation of the aorta repair, and post-myocardial infarction ventricular septal defect closure. TRA can improve visualization, device positioning and manipulation, and allow for pressure monitoring during challenging structural heart interventions.

Health & Medicine

David Meerkin
Structural and Congenital
Heart Disease Unit
Shaare Zedek Medical Center
Jerusalem, Israel
3rd Advanced International Masterclass
AIM-RADIAL 2014
Chicago-October 24, 2014

Relevant Conflict of
Interest
Proctor/Consultant St Jude Medical
There is no “evidence based medicine” on this topic

Why NOT TRA for
Structural Interventions
 Most procedures are transvenous
 Use the groin anyway
 Complex procedures need maximum access
possibilities

Why YES TRA for
Structural Interventions
 Same as for any other intervention
 Bleeding complications
 Anticoagulated patients
 Keep the arterial sheath away from the large
venous sheath
 Avoid fistulae
 Leave the groin for other device (e.g. IABP)
 Avoid “crosstalk” of catheters

Role of TRA in
Structural Interventions
 Primary Intervention route
 Procedure performed through TRA catheter
 Secondary Intervention route
 TRA catheter assists in advancing or positioning
primary catheter
 Supportive
 Positioning (Marker)
 Monitoring

MitraClip
Why TRA?
 If you want arterial access, keep away from the 24F
venous access
 Easier transeptal postioning
 Online arterial pressures
 Assess afterload for MR assessment
 Aware of hemodynamic embarresment in case of
complications
 If the anesthesiologist wants the pressure monitoring you
can benefit with a 4F approach

Coronary-Cameral Fistula
Why TRA?
 Provides for arterial access
 Particularly when large devices are not
necessary
 Can provide the strength and support needed
for the devices traversing the AV loop

Add TRA
 Improved visibility and passage

Coarcation of Aorta
Why TRA?
 Pressure gradients
 Less trouble navigating the lesion
 Easy navigation to the Innominate for system
stabilization
 Improved imaging of the proximal stent edge (left
subclavian ostium)

Post MI VSD
 What happens
when you don’t
use TRA

Post MI VSD
Why TRA?
 Don’t need a second femoral puncture (additional to
IABP)
 Keep the vein from the artery (if femoral vein
approach)
 Don’t interfere with IABP position (height)

Additional and Future
Indications
 Paravalvular leaks
 Aortic
 Retrograde approach
 Mitral
 requiring AV loops
 Parachute
 For LV aneursyms

This document discusses transradial access for treating erectile dysfunction. It provides background on the definition and causes of ED, and the relationship between ED and coronary artery disease. Treatment options for ED are discussed including oral medications, injections, devices, and angioplasty of the internal iliac arteries, pudendal arteries, and penile arteries performed through radial artery access. The results of one physician's experience with this technique are presented, showing high success rates and low complications. Ultrasound is also summarized as a diagnostic tool for evaluating penile blood flow velocities and identifying venous leakage.

Kwan TW - AIMRADIAL 2014 Technical - Selection of catheters

International Chair on Interventional Cardiology and Transradial Approach

The document discusses selection of diagnostic catheters for transradial cardiac catheterization. It describes different catheter options for cannulating the left and right coronary arteries from the radial approach. The Judkins catheters and Tiger/Jacky catheters are commonly used and each has advantages and disadvantages. Factors such as access site, vascular anatomy, and operator experience influence catheter selection. Tips are provided for navigating tortuous anatomy and engaging coronary arteries from the radial approach.

Abdelaal E - AIMRADIAL 2014 Technical - Local complications

International Chair on Interventional Cardiology and Transradial Approach

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.

Yeh RW 2016 Transradial access and intervention

International Chair on Interventional Cardiology and Transradial Approach

This document provides guidance on performing percutaneous coronary interventions (PCIs) using the transradial approach. It discusses: 1) Evidence from clinical trials showing lower mortality, lower bleeding rates, and shorter hospital stays with transradial compared to transfemoral access. 2) Tips for patient selection, accessing the radial artery, engaging coronary arteries, and successfully completing interventions. 3) How to manage complications like bleeding and spasm. The overall recommendation is that transradial should become the default access approach, especially for higher risk cases, if the operator takes time to learn the technique.

Delewi R - AIMRADIAL 2015 - Radial artery occlusion

International Chair on Interventional Cardiology and Transradial Approach

This study evaluated the incidence of radial artery occlusion (RAO) in 339 patients who underwent a second cardiac catheterization or percutaneous coronary intervention (PCI) using the radial artery approach within 1 year of a previous radial procedure. The incidence of RAO was low at 1.5%, occurring in 5 patients. Risk factors for the cases of RAO included the use of a 6 French catheter and having undergone multiple prior radial procedures. The study concludes that contemporary techniques including slender catheters, manual bandages, and new P2Y12 inhibitors result in low rates of RAO.

Tessitore E - AIMRADIAL 2014 - Sheathless

International Chair on Interventional Cardiology and Transradial Approach

This study compared the use of Sheathless Eaucath guiding catheters to standard guiding catheters for transradial percutaneous coronary interventions (TR PCI) in 233 patients. The Sheathless catheter reduced equipment size in the radial artery and was as safe and effective as standard catheters, with comparable complication rates. Crossing over to the Sheathless catheter after standard catheter failure allowed successful PCI in most cases. Patients reported less pain and operators found it easier to cross the arm with the Sheathless catheter.

Kandzari DE 201305

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes research on transradial intervention and guiding catheter selection from 38 randomized controlled trials including over 18,000 patients. It finds that guiding catheter selection impacts procedural outcomes for transradial PCI. Appropriate catheters for transradial PCI include standard catheters for left coronary access and Amplatz or Ikari catheters for right coronary access. Limitations of existing transradial guiding catheters include inadequate backup support, but complex PCI can be performed with 6 French guiding catheters using techniques to enhance support. Practical suggestions are provided to optimize guiding catheter selection and support for transradial PCI.

Bernat I - AIMRADIAL 2014 Technical - Right and left

International Chair on Interventional Cardiology and Transradial Approach

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.

This document discusses the current state of interventional radiology and needs for further advancement. It outlines catheters, guidewires, and devices currently used, including the longest lengths available. The summary identifies key needs such as longer catheters and balloons to access more distal vasculature like the lower extremities, as well as covered stents for complex cases. Improved techniques are also needed to navigate difficult anatomy like iliac tortuosity.

Bernat I - AIMRADIAL 2014 - Slender techniques in Europe

International Chair on Interventional Cardiology and Transradial Approach

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.

Ikari Y - AIMRADIAL 2015 - Carotid artery stenting

International Chair on Interventional Cardiology and Transradial Approach

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.

Van Leeuwen M - AIMRADIAL 2015 - Upper limb function

International Chair on Interventional Cardiology and Transradial Approach

1) The ACRA study evaluated the effects of transradial access (TRA) on upper limb function and found that upper limb function, as measured by the QuickDASH score, was unaffected after TRA. A clinical relevant decrease in upper limb function occurred in only 6.3% of patients. 2) Rates of persisting extremity problems were equally reported in patients who received TRA or transfemoral access. 3) Cold intolerance, as measured by the CISS questionnaire, was also unaffected after TRA procedures. 4) While the study found no effects of TRA on upper limb function or cold intolerance, limitations included a potential for response bias and lack of power to detect effects in specific patient groups.

Speiser B - AIMRADIAL 2014 Technical - Patient preparation

International Chair on Interventional Cardiology and Transradial Approach

This document provides information on transradial catheterization procedures. It defines ideal candidates for transradial catheterization and lists contraindications. It describes the pre-procedure assessment including checking for dual circulation in the hand. The patient setup is also outlined, including positioning the arm and wrist, applying pulse oximetry, and preparing equipment like sheaths and catheters. Post-procedure care instructions including use of a TR band, monitoring the access site, and discharge instructions are provided.

Fischman AM - AIMRADIAL 2013 - Peripheral interventions

International Chair on Interventional Cardiology and Transradial Approach

Helfrich CD - AIMRADIAL 2014 - Advantages and barriers to radial access

International Chair on Interventional Cardiology and Transradial Approach

1) The study surveyed interventional cardiologists in VA hospitals about their perceptions of radial access versus femoral access for percutaneous coronary intervention (PCI). 2) While radial access was seen as superior for patient comfort and safety, many cardiologists viewed it as inferior for procedure time and success, especially at hospitals performing fewer radial procedures. 3) The main barriers to radial access identified were the long learning curve and concerns about equivalent outcomes once proficient, while increased radiation exposure was only a key concern for hospitals performing fewer radial procedures.

Bertrand OF - AIMRADIAL 2014 - Patent hemostasis

International Chair on Interventional Cardiology and Transradial Approach

This document discusses issues with patent hemostasis as the standard of care for transradial procedures. It notes that while patent hemostasis aims to prevent radial artery occlusion (RAO), the definition of RAO is unclear and methods to assess hemostasis and RAO vary. Studies have found patent hemostasis fails in about 25% of cases and may not impact hematoma or pseudoaneurysm rates. The document examines different hemostasis protocols and their impacts on RAO in various studies and practices. It concludes that while RAO prevention should be a quality goal, standardization is needed on definitions, assessment methods, and optimal hemostasis protocols given variability in results.

Aminian A 2016 Glidesheath Slender for transradial

International Chair on Interventional Cardiology and Transradial Approach

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.

Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention

International Chair on Interventional Cardiology and Transradial Approach

This multicenter study evaluated the feasibility and safety of using a transradial approach for iliac angioplasty. The study included 149 patients from 5 centers in Italy undergoing iliac interventions via the radial artery. Procedural success was achieved in 98% of patients. At 1 month, 97.3% of patients were free from symptoms and the target vessel revascularization rate was 2.7%. Technical data showed average fluoroscopy and procedural times comparable to femoral access. The study demonstrated that a transradial approach is a feasible and safe option for treating iliac disease in experienced hands.

Bagur R - AIMRADIAL 2014 Technical - Cannulate the LIMA

International Chair on Interventional Cardiology and Transradial Approach

This document outlines the steps to cannulate the left internal mammary artery (LIMA) graft from a right radial approach. It begins with performing angiography of the left and right coronary arteries. A catheter is advanced to the descending aorta and pulled back to locate the left subclavian artery. A wire is placed in the left subclavian artery and advanced into the brachial artery for support. External compression on the left arm can aid wire and catheter advancement. The catheter is gently advanced over the wire into the distal subclavian artery. When the catheter reaches the LIMA ostium, an angiogram is performed to access the graft. Percutaneous coronary intervention of the LIMA is then carried out.

Saito S - AIMRADIAL 2013 - NAUSICA trial

International Chair on Interventional Cardiology and Transradial Approach

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.

Jaffe R

International Chair on Interventional Cardiology and 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.

Biederman DM - AIMRADIAL 2014 Endovascular - Surefire catheter

International Chair on Interventional Cardiology and Transradial Approach

This document discusses a study evaluating the feasibility and technical outcomes of using the Surefire Infusion System to deliver chemotherapy or radiation via a transradial (wrist) approach. The study found that the Surefire Catheter can be safely deployed through the wrist to treat liver tumors in 15 patients. Using a transradial approach with the Surefire System offers advantages over traditional techniques like fewer vascular complications and immediate patient ambulation. Pre-procedural imaging can help guide whether this approach is suitable.

Cohen MG 201111

International Chair on Interventional Cardiology and Transradial Approach

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.

Edwards M - AIMRADIAL 2014 Endovascular - Amplatzer in visceral arteries

International Chair on Interventional Cardiology and Transradial Approach

The document summarizes a study examining the use of the Amplatzer Vascular Plug 4 (AVP4) for embolization of visceral arteries via a transradial approach. In the study, AVP4 placement was attempted in 20 patients in 21 vessels and was technically successful in all cases. Complete vessel occlusion was achieved in 15 of 18 vessels at deployment and follow-up. There were no procedural complications. The study concludes that AVP4 placement in visceral arteries from a transradial approach is technically feasible, safe and effective.

Shroff A - AIMRADIAL 2014 - Same-day discharge

International Chair on Interventional Cardiology and Transradial Approach

This document discusses same day discharge after elective percutaneous coronary intervention (PCI). It reviews the literature on criteria for selecting low-risk patients suitable for same day discharge. Studies show same day discharge is safe and feasible in properly selected patients and can provide significant cost savings compared to overnight admission. The document outlines one institution's protocol for same day discharge following radial PCI, including clinical, procedural, and socio-demographic criteria for patient selection. It emphasizes focusing on low risk patients, procedures, and clinical scenarios to safely implement a same day discharge program.

Aminian A - AIMRADIAL 2013 - Glidesheath slender

International Chair on Interventional Cardiology and Transradial Approach

Louvard Y - AIMRADIAL 2014 - Sheathless

International Chair on Interventional Cardiology and Transradial Approach

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

Cohen MG - Transradial access - 201507

International Chair on Interventional Cardiology and Transradial Approach

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.

Kedev S - AIMRADIAL 2014 Endovascular - Carotid stenting

International Chair on Interventional Cardiology and Transradial Approach

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.

Mamas M - AIMRADIAL 2014 - Cardiogenic shock

International Chair on Interventional Cardiology and Transradial Approach

Cardiogenic shock is a leading cause of death in AMI patients, with mortality rates between 30-60%. While radial access has been shown to reduce bleeding complications, patients presenting with cardiogenic shock are often treated via transfemoral access. Recent studies have demonstrated that radial access PCI is feasible in cardiogenic shock patients, with one study showing a reduction in in-hospital mortality for radial versus transfemoral access. However, experienced radial centers only use the radial approach in around 50% of cardiogenic shock cases, indicating radial access is still underutilized despite potential benefits in this high-risk group.

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Fischman AM - AIMRADIAL 2014 Endovascular - Interventional radiology

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Ikari Y - AIMRADIAL 2015 - Carotid artery stenting

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Van Leeuwen M - AIMRADIAL 2015 - Upper limb function

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Bertrand OF - AIMRADIAL 2014 - Patent hemostasis

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Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention

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Shroff A - AIMRADIAL 2014 - Same-day discharge

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Aminian A - AIMRADIAL 2013 - Glidesheath slender

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Speiser B - AIMRADIAL 2014 Technical - Patient preparation

Fischman AM - AIMRADIAL 2013 - Peripheral interventions

Helfrich CD - AIMRADIAL 2014 - Advantages and barriers to radial access

Bertrand OF - AIMRADIAL 2014 - Patent hemostasis

Aminian A 2016 Glidesheath Slender for transradial

Cortese B - AIMRADIAL 2014 Endovascular - Iliac intervention

Bagur R - AIMRADIAL 2014 Technical - Cannulate the LIMA

Saito S - AIMRADIAL 2013 - NAUSICA trial

Jaffe R

Biederman DM - AIMRADIAL 2014 Endovascular - Surefire catheter

Cohen MG 201111

Edwards M - AIMRADIAL 2014 Endovascular - Amplatzer in visceral arteries

Shroff A - AIMRADIAL 2014 - Same-day discharge

Aminian A - AIMRADIAL 2013 - Glidesheath slender

Louvard Y - AIMRADIAL 2014 - Sheathless

Cohen MG - Transradial access - 201507

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Kedev S - AIMRADIAL 2014 Endovascular - Carotid stenting

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Dangoisse V - AIMRADIAL 2014 - Distal buddy in jail

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This document describes a technique called the "Distal Buddy-in-Jail technique" for treating difficult coronary anatomies requiring multiple stents. The technique involves trapping a wire distally during initial stent placement to provide support, allowing subsequent proximal stenting over the trapped "buddy wire" or the free wire. The technique was used in 29 patients with difficult anatomies. It allowed successful placement of multiple stents using 5 or 6F guiding catheters. Outcomes were good with one minor complication, demonstrating this technique can help treat complex cases using conventional guiding catheters.

Sheets JD 2016 Transradial robotic PCI

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Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction

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This document summarizes a study examining the use of transradial access (TRA) for non-coronary interventions in patients with severe hepatic dysfunction (MELD score ≥ 20). The study found TRA to be feasible in this high-risk population with a 100% technical success rate and very low rates of bleeding (0%) and access site (1 minor hematoma) complications. TRA in patients with liver dysfunction was shown to be safe and effective for renal/visceral interventions like embolization and stenting as well as radioembolization procedures, with few coagulation blood products required.

Ruzsa Z - AIMRADIAL 2015 - Carotid stenting learning curve

International Chair on Interventional Cardiology and Transradial Approach

Cohen MG - AIMRADIAL 2014 Technical - Tortuosity

International Chair on Interventional Cardiology and Transradial Approach

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.

Kalpak O - AIMRADIAL 2014 - Total wrist access for STEMI

International Chair on Interventional Cardiology and Transradial Approach

Cohen MG 2016 Transradial primary PCI in shock

International Chair on Interventional Cardiology and Transradial Approach

This document discusses the use of transradial access for primary PCI and in patients with cardiogenic shock. It summarizes data showing that transradial access is associated with lower mortality, MACCE, and bleeding rates compared to transfemoral access in these high-risk settings. However, transradial primary PCI requires an experienced team. The document provides tips for a successful transradial program and overcoming challenges in shock patients, such as using left radial access, ultrasound guidance, and single catheter techniques.

Devito FS - AIMRADIAL 2014 - Svelte Acrobat & 5Fr

International Chair on Interventional Cardiology and Transradial Approach

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.

Cohen MG - AIMRADIAL 2014 - Radial and TAVI

International Chair on Interventional Cardiology and Transradial Approach

Louvard Y

International Chair on Interventional Cardiology and Transradial Approach

The document discusses the transradial approach for treating chronic total occlusions (CTOs). It notes that specific techniques are needed when using the transradial approach due to limitations in support and catheter size. These techniques include anchoring balloon techniques for wire handling, the "mother and child" technique using a 5Fr catheter, homolateral microinjection, and parallel wiring. The transradial approach also enables double radial approaches to overcome limitations. While the transradial approach reduces vascular complications, simply using it does not make one an expert CTO operator - experience remains important. The transradial approach can allow good operators to treat CTOs without reducing chances of success for patients.

Pacchioni A - AIMRADIAL 2014 - Cerebral microembolism

International Chair on Interventional Cardiology and Transradial Approach

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.

Porto I - AIMRADIAL 2014 - Bleeding and events

International Chair on Interventional Cardiology and Transradial Approach

Saito S DRAGON trial

International Chair on Interventional Cardiology and Transradial Approach

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.

Mars C - AIMRADIAL 2015 - Allergic reactions SACRED study

International Chair on Interventional Cardiology and Transradial Approach

Stables R - AIMRADIAL 2015 - Bivalirudin and radial approach

International Chair on Interventional Cardiology and Transradial Approach

This single-center randomized controlled trial compared outcomes of STEMI patients treated with bivalirudin (n=907) versus unfractionated heparin (n=905) during primary percutaneous coronary intervention (PPCI). At 28 days, the primary efficacy outcome (composite of death, stroke, reinfarction, unplanned revascularization) occurred more frequently in the bivalirudin group (8.7% vs 5.7%, p=0.01). The increased risk was driven by a higher rate of stent thrombosis with bivalirudin (3.4% vs 0.9%, p=0.001). Major bleeding rates were similar between groups (3.5% vs

Pancholy SB - AIMRADIAL 2014 Endovascular - Renal denervation

International Chair on Interventional Cardiology and Transradial Approach

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.

Rinfret S - Case of bleeding, compartment syndrome

International Chair on Interventional Cardiology and Transradial Approach

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This document provides an overview of trans-catheter aortic valve implantation (TAVI). It discusses the indications for TAVI including symptomatic severe aortic stenosis in high-risk surgical patients. The pre-procedural workup involves imaging to assess anatomy and risk. The procedure involves accessing the femoral or other arteries and deploying a balloon-expandable or self-expanding bioprosthetic valve. Complications include conduction abnormalities, paravalvular regurgitation, and hypotension. Two clinical cases are presented of high-risk patients undergoing TAVI.

TAVI

Praveen Nagula

15635053447d429f01cd46bf1b42b9b4301eaa6fd8.pptx

FrankyQ2

The document discusses dissection complications during transcarotid artery revascularization (TCAR). It reports dissection rates from clinical trials ranging from 4.2-7.3%. Optimizing TCAR results relies on obtaining stable access to the common carotid artery through careful anatomical evaluation and technical execution. Additional tips are provided to minimize dissections, including adequate anticoagulation and vascular control during access. The key is being prepared to manage any dissections by potentially stenting across the site or converting to open surgery if needed.

02 pacemakers and ic ds an overview-samir rafla

Alexandria University, Egypt

This document provides an overview of pacemakers and implantable cardioverter defibrillators (ICDs). It discusses the different types of pacemakers including single-chamber pacemakers (VVI), dual-chamber pacemakers (DDD), and biventricular pacemakers (CRT). It outlines the indications for pacemaker and ICD implantation and reviews potential complications of the procedures such as infection, lead issues, and pacemaker syndrome. Guidelines for device implantation and management are summarized including recommendations on timing after heart events, upgrades, and device selection. Risks associated with dual chamber devices are also mentioned.

Vascular access surgery by Dr. Ali Mujtaba

Dr Ali MUJTABA

This document provides an introduction to vascular access surgery. It discusses the history and development of vascular access methods beginning in the late 19th century. The three primary methods used today are native arteriovenous fistulas, prosthetic arteriovenous grafts, and intravenous catheters. Arteriovenous fistulas are preferred when possible due to their longer lifespan and lower risk of complications compared to grafts and catheters. The document outlines considerations for patient evaluation, access selection, creation of arteriovenous anastomoses, maturation of fistulas, post-dialysis hemostasis, and frequent complications.

Vascular access in hemodialysis chaken 2018

CHAKEN MANIYAN

This document provides guidelines and information about vascular access for hemodialysis. It discusses: - Types of vascular access including arteriovenous fistulas, grafts, and catheters. Fistulas have the lowest risk of complications but the highest risk of early failure. - Evaluations for permanent access including history, physical exam, ultrasound of arteries and veins, and central vein evaluation. - Placement of fistulas at least 6 months before starting dialysis to allow for maturation. Grafts can be placed 3-6 weeks before starting. - Goals for types of access used - 50% of patients should have fistulas, 40% grafts, and no more than 10%

Tamer elsaid mansouraoct2019

FAARRAG

CTO-- TEN COMMANDMENTS

Nilesh Tawade

09 technical Zafirovska aimradial20170922 Ulnar anomalies

International Chair on Interventional Cardiology and Transradial Approach

This document summarizes the results of a 6-year study examining radial and ulnar artery anomalies in STEMI patients who underwent routine wrist artery angiography prior to procedures. The study found that radial artery anomalies were significantly more common than ulnar anomalies. Routine wrist angiography allowed procedures to be successfully planned and helped identify anomalies like tortuosity to prevent complications. It also facilitated ulnar access as an alternative when radial access was not feasible. In over 30,000 cases, wrist angiography improved outcomes for STEMI patients by enabling optimal arterial access planning.

EVAR - Nicola Tanner

welshbarbers

This document discusses abdominal aortic aneurysms (AAAs) and their endovascular repair (EVAR). It defines AAAs as a dilatation of the abdominal aorta over 3cm in diameter. EVAR involves inserting a folded graft through the femoral artery which expands to exclude the aneurysm sac from blood flow and pressure. The benefits of EVAR over open repair include lower peri-operative mortality and complications. Proper patient assessment including vascular anatomy and medical comorbidities is important for determining candidacy for EVAR. The procedure involves deploying graft components in the aorta and iliac arteries under imaging guidance. Post-operative surveillance with imaging is needed to monitor for complications like endoleaks.

Dialysis basics

Dr Ashutosh Ojha

Dialysis is used to treat kidney failure and manage its complications. There are different modalities including peritoneal dialysis, hemodialysis, and continuous renal replacement therapy. Hemodialysis uses a dialyzer, tubing, and machine to remove waste and fluid by diffusion and ultrafiltration as blood and dialysate flow countercurrently. Vascular access includes catheters, arteriovenous grafts, and arteriovenous fistulas. Complications can include infections, thrombosis, and fluid overload.

Dialysis access interventions

Arun Jagannathan

This document discusses arteriovenous (AV) access for hemodialysis, including fistulas, grafts, and catheters. It provides guidelines on creating and maintaining different types of access based on Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations. Catheters are best for short-term use but carry higher infection risks than fistulas or grafts. Fistulas have the highest patency rates but take longer to mature than grafts. Early detection of access dysfunction through regular monitoring and treatment of stenoses is important to preserve access sites. Complications like infection, ischemia, and stenosis should be referred for imaging and intervention.

When is MR Venography Useful? What makes it so Operator Dependent?

Vein Global

PA CATHETER (1).pptx

CutiePie71

This document discusses the history and development of pulmonary artery catheters and their uses and complications. It traces the evolution of PA catheters from early experimentation in the 1920s-1930s to the introduction of flow-directed balloon tip catheters in the 1970s. The document then reviews guidelines for PA catheter insertion and uses, including hemodynamic monitoring, assessment of oxygen delivery and consumption, and temporary transvenous pacing. Potential complications of PA catheters like arrhythmias, pulmonary artery rupture, embolism, and infection are also summarized.

04 endovascular Vasilev aimradial20170921 Iliac intervention

International Chair on Interventional Cardiology and Transradial Approach

This document discusses using the transradial approach for interventions in the illiac arteries. It presents three case studies demonstrating bilateral and single transradial access. For bilateral access, short sheaths are inserted in both radial arteries and wiring and stenting of bilateral common iliac artery lesions is performed. For single access, wiring and stenting of a right common iliac artery chronic total occlusion is performed through one radial sheath. The document concludes that transradial access allows for effective and safe treatment of iliac lesions without risks of femoral access, though dedicated equipment is still limited.

Diethrich Sweden

Imran Javed

1. Endovascular techniques are increasingly being used to treat aortic pathologies like aneurysms and dissections as they can reduce mortality and morbidity compared to open surgery. 2. However, many challenging cases involve the ascending aorta and aortic arch, which are still difficult to treat using endovascular methods alone due to anatomical constraints. 3. Hybrid procedures combining endovascular and open surgical techniques show promise for expanding the applications of endovascular therapy in complex cases, with extra-anatomic bypass grafts and branches helping to create adequate landing zones for endografts.

Tavi,Transcatheter Aortic Valve Replacement, TAVI,TAVR,

Dr.Hasan Mahmud

Transcatheter aortic valve implantation (TAVI) has been developed as an alternative to surgical aortic valve replacement for high-risk patients. TAVI involves threading a collapsible valve through blood vessels and implanting it to replace the diseased valve. Over 30,000 high-risk patients with severe aortic stenosis have undergone TAVI, based on evidence from studies showing it is safer than surgery for this group. TAVI indications may expand as longer-term data on outcomes becomes available and the procedure requires a multidisciplinary team approach and dedicated training.

Body CT for Emergency Physicians

Rathachai Kaewlai

Similar to Meerkin D - AIMRADIAL 2014 - Structural disease (20)

Tavi 3

TAVI procedure review with cases

TAVI

15635053447d429f01cd46bf1b42b9b4301eaa6fd8.pptx

02 pacemakers and ic ds an overview-samir rafla

Vascular access surgery by Dr. Ali Mujtaba

Vascular access in hemodialysis chaken 2018

Tamer elsaid mansouraoct2019

CTO-- TEN COMMANDMENTS

09 technical Zafirovska aimradial20170922 Ulnar anomalies

EVAR - Nicola Tanner

Dialysis basics

Dialysis access interventions

When is MR Venography Useful? What makes it so Operator Dependent?

PA CATHETER (1).pptx

04 endovascular Vasilev aimradial20170921 Iliac intervention

Diethrich Sweden

Tavi,Transcatheter Aortic Valve Replacement, TAVI,TAVR,

Body CT for Emergency Physicians

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

PCI & AimRadial 2018 | FFR-CT - Colin Berry

International Chair on Interventional Cardiology and Transradial Approach

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

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

International Chair on Interventional Cardiology and Transradial Approach

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

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