Rao SV - AIMRADIAL 2014 - Patent hemostasis
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Patent hemostasis is the standard of care for radial artery access closure. It is efficacious in preventing radial artery occlusion, as shown in randomized trials. Applying patent hemostasis takes only 10-20 seconds and does not increase bleeding risks or require additional resources compared to conventional closure. Preserving radial artery patency has no downsides, so patent hemostasis should be the standard practice for radial procedures.
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2. The PARTNER Trial Cohort B was the first randomized controlled trial of TAVI versus standard therapy and showed TAVI to be superior to standard therapy in reducing 1-year mortality for inoperable patients.
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1. The RAUST study compared ultrasound versus palpation guidance for transradial artery access and found that ultrasound guidance significantly improved first-pass success rates and reduced the number of access attempts and time to successful sheath insertion.
2. Ultrasound guidance also decreased the incidence of difficult access procedures defined as requiring 5 or more minutes or attempts. Ultrasound was an effective rescue technique for difficult palpation-guided access.
3. Clinical outcomes like radial artery spasm, vascular complications, and patient pain were similar between the ultrasound and palpation groups.08 aimradial2016 fri2 S Kedev
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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.
TAVI between dreams and reality
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2. There are several vascular access approaches for TAVI, including transfemoral, transapical, transaortic, and subclavian approaches.
3. A 2013 feasibility study of a new device for TAVI in patients with aortic insufficiency reported successful deployment in all four patients with no deaths at 30 days and improved aortic insufficiency in all patients.
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1) The study compares the transulnar approach (TUA) to coronary angiography and angioplasty with the traditional transradial approach (TRA) in Bangladeshi patients, with the goal of assessing safety, efficacy, and procedural factors of both approaches.
2) Over 12 months, 225 patients underwent TUA while 229 underwent TRA. Successful cannulation was higher with TRA (92.14% vs 81.72% for TUA), but complications were lower for TUA.
3) Procedural times, radiation exposure, and findings during coronary angiography were generally similar between the two groups. Loss of arterial pulse was lower for TUA both during hospitalization and follow-up.
Aminian A 2016 Glidesheath Slender for transradial
Aminian A 2016 Glidesheath Slender for transradialInternational 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.02 Ziakas aimradial20170922 MEMORY study
02 Ziakas aimradial20170922 MEMORY studyInternational Chair on Interventional Cardiology and Transradial Approach
This study compared manual versus mechanical compression of the radial artery after transradial coronary angiography. 589 patients from 5 centers in Greece were randomly assigned to either manual compression (n=296) or use of a compression device (n=293). The primary endpoint was early (within 24 hours) radial artery occlusion, which occurred in 11.8% with manual and 8.4% with device, a non-significant difference. Secondary endpoints like hematomas, bleeding, and success of hemostasis were also similar between groups. However, hemostasis duration was significantly shorter with manual compression, taking on average 21.6 minutes compared to 118.5 minutes for the device. The conclusions were that manual and mechanical compression resultedHemostatic effect of tranexamic acid in elective nasal
This study examined the hemostatic effect of tranexamic acid in elective nasal surgery. The study involved 400 patients, with the first 200 receiving a placebo and the remaining 200 receiving oral tranexamic acid preoperatively. The results showed that oral tranexamic acid significantly reduced intraoperative and postoperative bleeding compared to the placebo, allowing surgeons to better visualize the surgical field and complete procedures without needing packing. Previous smaller studies also suggested tranexamic acid reduces bleeding when administered topically or intravenously for nasal surgeries.
final presentation of anticoagulants.pptx
1) Managing patients on anticoagulants who require regional anesthesia or peripheral nerve blocks is challenging due to the risk of bleeding complications like epidural hematomas.
2) Guidelines provide recommendations on interrupting anticoagulants prior to a procedure and resuming them postoperatively based on the drug's half-life, bleeding risk level, and type of block performed.
3) Vigilant monitoring for neurological symptoms is important to allow early diagnosis and treatment of hematomas, which have the best outcome if evacuated within 8-12 hours of onset.
Graft thrombosis
Graft thrombosis is a major cause of failed arterial bypass surgery. Several techniques can be used to assess grafts intraoperatively, including inspection, palpation, arteriography, ultrasonography, angioscopy, and intravascular ultrasonography. Early graft failure within 30 days is often due to technical errors, while late failure over 30 days is usually caused by atherosclerosis or intimal hyperplasia. Treatment depends on the timing and cause of failure. Early failures may be treated with thrombectomy or thrombolysis, while late failures respond better to thrombolysis or open revision. The optimal conduit depends on patient and graft factors. Close surveillance after treatment is important to monitor for recurrent stenosis.
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Anaesthesia for patient with anticoagulant
This document discusses guidelines for managing patients on anticoagulant therapy who require surgery. It is important to balance the risk of thromboembolic events from stopping anticoagulants against the risk of bleeding from continued anticoagulation. Factors like the urgency and type of surgery, the indication for anticoagulation and the patient's risk profile are considered. Bridging with low molecular weight heparin may be used when anticoagulants need to be stopped temporarily to reduce thromboembolic risk. Regional anesthesia can be used cautiously in anticoagulated patients when benefits outweigh bleeding risks.
Manan Thesis presentation-3.pptx
This study aims to compare perioperative blood loss and transfusion requirements in patients undergoing primary knee arthroplasty who receive intravenous and topical tranexamic acid versus those who do not. It will be a retrospective-prospective observational study of 50 patients over 2 years. Tranexamic acid works by competitively inhibiting plasminogen activation and fibrinolysis. The study hopes to provide more information on the effects of topical and intravenous tranexamic acid in reducing blood loss during total knee replacement surgery. Patients will be assessed based on pre-op hemoglobin, intraoperative blood loss, post-op hemoglobin, drain output, and transfusion requirements to compare outcomes between those who receive tranexamic acid and those who do not.
BloodConservation_sigit.pptx
This document discusses blood conservation techniques used in cardiac surgery to minimize blood transfusions. It begins with a brief history of blood transfusions in surgery and the efforts to reduce them due to risks. The scope of blood conservation is outlined as using techniques to minimize blood needed for treatment. It emphasizes a multidisciplinary team approach including various medical professionals and the patient/family. Phases of the surgery where conservation is used are described from pre-op patient screening to intra-op techniques like acute normovolemic hemodilution and post-op restrictive transfusion thresholds. Specific intra-op techniques are then detailed for each phase before, during, and after use of the cardiopulmonary bypass machine.
Management of patients with bleeding disorders.pptx
The document provides an overview of managing patients with bleeding disorders. It discusses hemostasis, common lab tests used to evaluate clotting mechanisms, and causes of bleeding disorders including platelet disorders and factor deficiencies. Guidelines are presented for identifying patients with bleeding disorders based on their history. Techniques to maintain hemostasis during surgery include using a harmonic scalpel. The document also reviews recommendations for treating patients taking antiplatelet drugs, anticoagulants, or fibrinolytic drugs and discusses hemophilia and conclusions.
Coronary angioplasty : simplified
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Pre op-assessment-of-the-surgical-patientsdfg
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Shroff A - AIMRADIAL 2014 - Same-day discharge
Shroff A - AIMRADIAL 2014 - Same-day dischargeInternational 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.04 Shah aimradial20170921 Acute kidney failure
04 Shah aimradial20170921 Acute kidney failureInternational Chair on Interventional Cardiology and Transradial Approach
1) Bleeding is a major complication of percutaneous coronary intervention (PCI) that is associated with increased mortality.
2) Studies show transradial access (TRA) reduces bleeding compared to transfemoral access, especially in high risk patients such as those with chronic kidney disease (CKD).
3) Some concerns with TRA in CKD patients include using too much contrast and difficulty accessing the arteries due to tortuosity and calcification. However, contemporary equipment and techniques can help overcome access challenges, and studies show TRA may reduce contrast use and risk of acute kidney injury in CKD patients undergoing PCI.Journal Club Thrombolysis.pptx
This document summarizes various thrombolytic agents and treatment strategies for acute ischemic stroke. It discusses that alteplase is currently the only approved thrombolytic, but tenecteplase is being studied as a potential alternative due to easier administration. Ongoing trials are comparing tenecteplase to alteplase. Other emerging strategies discussed include intra-arterial thrombolysis, mechanical thrombectomy, and the use of mobile stroke units.
ALTERNATIVES TO BLOOD TRANSFUSION.pptx
There are several alternatives to blood transfusion that can help reduce its use and risks. These include treating pre-existing anemia, using medications to stimulate red blood cell production or stop bleeding, employing blood-saving surgical techniques and technologies like cell salvage machines. While blood substitutes have been studied, none have gained approval due to safety issues. Implementing strategies of patient blood management can help minimize allogenic blood transfusions.
Terapi Endovaskuler, Standar Baru Manajemen Stroke Iskemik Akut?
Konon, plenary pertama International Stroke Conference (ISC) 2015 yang digelar di Nashville, Tennessee bulan Februari lalu merupakan sesi ISC terseru selama beberapa tahun terakhir. Sebagaimana diberitakan dalam Medscape (Hughes, 2015), para presenter terpaksa memberi jeda beberapa saat untuk menyambut applause dari audiens. Suatu kejadian langka dalam partemuan saintifik. Adalah MR CLEAN, ESCAPE, EXTEND-IA, dan SWIFT PRIME yang menjadi topik hangat lantaran keempat studi ini dirilis dengan hasil yang positif dramatis hingga diprediksi bakal menjadikan terapi endovascular sebagai standar baru dalam manajemen stroke iskemik akut. Sehebat apakah 4 studi yang “menyejarah” dalam tatalaksana stroke iskemik akut ini? Bagaimana bila studi-studi ini diadopsi dan diaplikasikan dalam praktik sehari-hari di sentra kita?
Note: Esai ini ditulis saat SWIFT PRIME fulltext belum published (akhir Maret-awal April 2015). Update & beberapa revisi dibuat menjelang presentasi tanggal 18 Mei 2015.
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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
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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...
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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
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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:
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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 ...
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This document discusses expanding the FDA indication for protected PCI procedures using the Impella heart pump. Key points include:
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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:
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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
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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
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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...
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This document summarizes lessons learned from the DEFINE-FLAIR and iFR-SWEDEHEART clinical trials. The trials found:
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4) iFR has been upgraded to a Class IA recommendation in European Society of Cardiology guidelines based on these trialsPCI & AimRadial 2018 | Use of physiology in ACS - Colin Berry
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.
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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
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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
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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...
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Rao SV - AIMRADIAL 2014 - Patent hemostasis
- 1. Patent Hemostasis is the Standard of Care Sunil V. Rao The Duke Clinical Research Institute Duke University Medical Center The Durham VA Medical Center
- 2. Disclosures ■ Consultant ● Terumo Medical, The Medicines Company ■ Research funding ● Bellerophon ■ Off-label uses may be discussed
- 3. Radial Hemostasis Why not? ■ Fundamental law of cardiovascular medicine: AN OPEN ARTERY IS BETTER THAN A CLOSED ONE ■ Why would we adopt a strategy into clinical practice? ● It is efficacious ● It is effective (not cumbersome to implement) ● It is safe ● It doesn’t cost too much ■ Does patent hemostasis fit this paradigm?
- 4. Radial Artery Occlusion – who cares? ■ “I don’t care about radial artery occlusion” ■ “Radial artery occlusion is asymptomatic so who cares?” ■ “Trying to preserve the radial artery is too complicated.”
- 5. Why not do patent hemostasis? ■ “I don’t care about radial artery occlusion” ● I can guarantee that your patients do. If you are not doing patent hemostasis, do you explain the risk of RAO during the consent process? ■ “Radial artery occlusion is asymptomatic so who cares?” ● Not all RAO is asymptomatic. Your patient will care the next time they need a cath and they ask why you are accessing their femoral artery. ■ “Trying to preserve the radial artery is too complicated.” ● If patent hemostasis is too complicated, then maybe you shouldn’t be doing radial procedures.
- 6. Goals of hemostasis ■ Minimize access site bleeding ■ Minimize forearm hematomas ■ Minimize long-term consequences of radial artery access Yonetsu T, et. al. EHJ 2010
- 7. Patent hemostasis is efficacious at preventing radial artery occlusion Diagnostic catheterization N=480 Patent hold Conventional hold Hemoband 24 –hour and 30-day Radial artery patency Assessed with Reverse Barbeau test Pancholy S, et. al. CCI 2008
- 8. Titration to pressure below MAP – The RACOMAP Study (N=351) ■ Randomized to MAP guided pressure vs. 15 cc of air ■ TR-Band left on for 3 hours in both groups ■ Significant differences in amount of air (8.8 cc vs. 15 cc, p=0.0001) ■ Enrollment stopped after 50% of planned sample size ■ Radial occlusion significantly lower with MAP-guided compression ● 1.1% vs. 12%, p=0.0001 ■ No major bleeds, no differences in minor bleeds or re-bleeds
- 9. Patent hemostasis is effective and safe ■ Applying patent hemostasis takes 10-20 seconds ■ No increase in bleeding in either of the randomized trials ● PROPHET Trial – no patients developed a bleeding complication ● RACOMAP – No major bleeding No difference in minor bleeding compared with conventional hemostasis
- 10. Patent hemostasis does not require additional resources ■ Original trial (PROPHET) was done using the Hemoband ■ The additional nursing care is not onerous ● Original protocol was to achieve patent hemostasis in the cath lab ● Leave the hemostasis device in place for 2 hours then remove ● EASY!
- 11. Radial hemostasis - Summary ■ Radial hemostasis is easy – one reason to adopt radial ■ Preserving the radial artery has no down side ■ Patent hemostasis is a best practice ■ Patent hemostasis is efficacious, effective, safe, and requires few resources ■ Why not patent hemostasis?