Surgery Grand Rounds - Downstate 2018
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Robotic heart surgery is associated with fewer complications compared to traditional open heart surgery. The rate of stroke after robotic CABG is 0.5%, much lower than the 1.8% rate after open CABG. Patients also recover faster after robotic surgery - they can walk further, have better treadmill endurance, and return to daily activities sooner than after open surgery. The minimally invasive nature of robotic surgery may lead to shorter hospital stays, lower costs, and allow patients to return to work more quickly. As a result, robotic CABG can provide benefits to hospitals, patients, and the healthcare system overall.
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Rao SV 201110
This document discusses best practices for transradial interventions including performing Allen's test, minimizing radial artery occlusion, and reducing radiation exposure. It summarizes evidence that testing for collateral circulation is controversial, radial artery occlusion can be reduced through minimizing trauma, adequate anticoagulation, and patent hemostasis. Radial access is associated with higher radiation exposure but exposure can be decreased through experience, limiting fluoroscopy use, and left radial access.
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The document summarizes the proposed SAFE-PCI for Women study, which aims to determine the efficacy and feasibility of the transradial approach to PCI in women compared to the transfemoral approach. The randomized controlled trial plans to enroll 1,800 female patients undergoing elective or urgent PCI at 30 sites. The primary endpoint is a composite of major bleeding or major vascular complications within 72 hours or discharge. Secondary endpoints include procedure time and radiation/contrast use. Funding support is provided through the American Recovery and Reinvestment Act.
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This document discusses the learning curve for radial angiography and coronary interventions. It summarizes a study that found procedural success rates increase as operators gain more experience, with odds of failure decreasing by 8% for every 10 additional cases and 32% for 50 cases. The document recommends novice operators complete a minimum of 50 radial cases to achieve success rates similar to experienced operators. It also provides tips for the learning phase, such as using technology like hydrophilic sheaths, selecting less complex patients, and performing radial angiography before radial PCI.
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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.Cohen MG 2016 Transradial primary PCI in shock
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This document discusses best practices for transradial interventions including performing Allen's test, minimizing radial artery occlusion, and reducing radiation exposure. It summarizes evidence that testing for collateral circulation is controversial, radial artery occlusion can be reduced through minimizing trauma, adequate anticoagulation, and patent hemostasis. Radial access is associated with higher radiation exposure but exposure can be decreased through experience, limiting fluoroscopy use, and left radial access.
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The document summarizes the proposed SAFE-PCI for Women study, which aims to determine the efficacy and feasibility of the transradial approach to PCI in women compared to the transfemoral approach. The randomized controlled trial plans to enroll 1,800 female patients undergoing elective or urgent PCI at 30 sites. The primary endpoint is a composite of major bleeding or major vascular complications within 72 hours or discharge. Secondary endpoints include procedure time and radiation/contrast use. Funding support is provided through the American Recovery and Reinvestment Act.
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This study assessed the feasibility of reducing radiation exposure during coronary CT angiography (CCTA) using only modified acquisition parameters on a 64-slice CT scanner. Over 85% of patients were able to undergo prospective CCTA, which significantly reduced radiation dose compared to historical levels and conventional angiography. Image quality remained high, with over 97% of coronary segments evaluated as having either excellent, good, or fair quality. The study demonstrated that very low dose CCTA is possible using standard equipment by optimizing acquisition settings.
Delewi R - AIMRADIAL 2015 - Radial artery occlusion
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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.Cohen MG 2016 Transradial primary PCI in shock
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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.AHA: Endurant veith 2010
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Gilchrist IC - AIMRADIAL 2015 - Still need Allen test?
Gilchrist IC - AIMRADIAL 2015 - Still need Allen test?International Chair on Interventional Cardiology and Transradial Approach
1) Prior studies have found no class I evidence or randomized data to support performing Allen's test or oximetry prior to radial artery catheterization.
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3) A recent study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's test results, suggesting there is no risk from an abnormal test.
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2) Recent data shows the radial learning curve may not be as steep as once believed, with initial competence reached after 25-40 cases, though improvement continues with greater experience and volume.
3) Procedural metrics like fluoroscopy time improve with experience but are influenced by many factors, making direct links to patient outcomes difficult to establish. Nonetheless, radial procedures in the US are being adopted quickly and appear to achieve better safety outcomes than femoral procedures.Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?International Chair on Interventional Cardiology and Transradial Approach
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Sciahbasi A - AIMRADIAL 2013 - Radiation exposureInternational Chair on Interventional Cardiology and Transradial Approach
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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.Tessitore E - AIMRADIAL 2014 - Sheathless
Tessitore E - AIMRADIAL 2014 - SheathlessInternational 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.Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approachInternational Chair on Interventional Cardiology and Transradial Approach
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.Abdelaal E - AIMRADIAL 2014 Technical - Local complications
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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.An Update on Carotid Artery PTAS:Contemporary Results, Trends, and Challenges...
This document summarizes an update on carotid artery stenting (CAS). It discusses the rationale for CAS, guidelines for patient selection, results from clinical trials comparing CAS to carotid endarterectomy (CEA). Contemporary data shows similar perioperative risks for CAS and CEA. Embolic protection devices are recommended for CAS to prevent stroke from debris. Proper credentialing and facility requirements are important for CAS programs.
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunctionInternational Chair on Interventional Cardiology and Transradial Approach
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.Gilchrist IC - AIMRADIAL 2014 - Allen's test
Gilchrist IC - AIMRADIAL 2014 - Allen's testInternational Chair on Interventional Cardiology and Transradial Approach
This document discusses the practice of performing Allen's test or oximetry prior to radial artery catheterization. It summarizes that:
1) There is no Class I evidence or randomized data showing the predictive value of Allen's test, and the significance of an abnormal test is unclear.
2) A study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's tests, suggesting no risk from an abnormal test.
3) Recommendations are that there is no evidence to support performing Allen's test or testing for dual circulation to prevent ischemic complications of transradial catheterization. Attention should instead focus on techniques to guide hemostasis after the procedure.Gilchrist IC 201305
Ultrasound can help with planning and obtaining radial artery access for cardiovascular procedures. Planning ultrasound examines artery size and anatomy to select the optimal access site and sheath size, reducing fluoroscopy time. Ultrasound guided access improves first stick success rates and reduces average access time compared to palpation or blind access techniques. Meta-analyses show ultrasound guidance significantly increases the chance of successful first attempt radial artery access. While radial angiography provides information if access fails, ultrasound is preferable for access planning and guidance due to reduced pain, contrast, and radiation compared to angiography.
Pima society
The document summarizes new cardiac surgery programs at the University of Arizona Medical Center (UAMC) including minimally invasive and robotic techniques. It discusses implementation frameworks focusing on team development and metrics of success. Outcomes data shows the new programs achieved lower mortality and morbidity rates compared to national benchmarks. The programs increased hospital volume and referrals while improving patient satisfaction. The summary focuses on the high level information around new programs, implementation strategies, outcomes data, and business impacts.
Kandzari DE 201305
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.
Speiser B - AIMRADIAL 2014 - Nursing workload
Speiser B - AIMRADIAL 2014 - Nursing workloadInternational Chair on Interventional Cardiology and Transradial Approach
This document discusses how transradial coronary procedures can save nursing workload compared to transfemoral procedures. It provides data showing that radial access reduces nursing time spent on manual sheath removal, handling patients in the cath lab, and time spent with patients. Studies show radial procedures reduce nursing workload by 12-34 minutes on average per case. With 1000 cases per year, this can save over 1000 nursing hours or 36 nursing weeks. Radial access also improves patient quality of life scores and reduces costs due to shorter recovery times. Hospitals can further reduce nursing workload through standardized education, accelerated hemostasis removal, same day PCI procedures, and dedicated radial lounges.03 aimradial2016 fri2 A Patel
03 aimradial2016 fri2 A PatelInternational Chair on Interventional Cardiology and Transradial Approach
This study evaluated the safety and feasibility of using a combined dual access radial and pedal approach for treating chronic total occlusions of the superficial femoral arteries. 86 patients underwent endovascular intervention using a primary pedal access and dual access if the pedal approach failed. For 49 lesions where the pedal approach failed, dual transpedal and transradial access was used. The technical success rate was 98% and procedural success rate was 96%, with no peri-procedural complications. The study demonstrated the dual access approach is a safe and feasible alternative to treat complex superficial femoral artery chronic total occlusions.11 aimradial2016 fri2 T Kwan
11 aimradial2016 fri2 T KwanInternational Chair on Interventional Cardiology and Transradial Approach
This document discusses the transpedal approach for peripheral interventions. The transpedal approach involves accessing the pedal or tibial arteries in the foot retrogradely to perform endovascular interventions for conditions like chronic total occlusions in the leg arteries. Some key advantages of the transpedal approach are that it allows dual access for complex interventions, avoids complications associated with femoral access, and can be used when recanalizing total occlusions from above has failed. The document reviews various studies demonstrating the safety, feasibility and clinical outcomes of the transpedal approach.1350 1400 Systematic Approach to Cardiogenic Shock Khawaja FINAL.pptx
1) Cardiogenic shock has a high mortality rate and its incidence is increasing. Early revascularization through PCI improves survival outcomes.
2) Mechanical circulatory support devices like Impella provide better hemodynamic support compared to intra-aortic balloon pumps and are associated with reduced mortality in cardiogenic shock.
3) Protocol-driven approaches to early identification and treatment of cardiogenic shock with early hemodynamic support and revascularization have led to improved survival rates in community hospital settings.
POLAR ACS: plataforma bio absorbible en síndromes coronarios agudos
POLAR ACS: plataforma bio absorbible en síndromes coronarios agudosSociedad Latinoamericana de Cardiología Intervencionista
Dr. Dariusz Dudek. Congreso euroPCR 2013. Encuentre más presentaciones de este congreso en la página web oficial de SOLACI: www.solaci.org/
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Bernat I - AIMRADIAL 2014 Technical - Right and leftInternational 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.AHA: Endurant veith 2010
This document summarizes early outcomes from the US IDE trial and global ENGAGE registry of the Endurant AAA endograft. In the US trial (n=150), the 30-day major adverse event rate was 4.0% and there was no mortality. At 1 year, the aneurysm sac size decreased or remained stable in most patients and the reintervention rate was low. The ENGAGE registry includes over 800 patients so far who mirror "real-world" cases. Procedural success was high at 99.6% with a median implant time of 90 minutes. Early outcomes suggest the Endurant endograft is a safe and effective option for treating abdominal aortic aneurysms.
Gilchrist IC - AIMRADIAL 2015 - Still need Allen test?
Gilchrist IC - AIMRADIAL 2015 - Still need Allen test?International Chair on Interventional Cardiology and Transradial Approach
1) Prior studies have found no class I evidence or randomized data to support performing Allen's test or oximetry prior to radial artery catheterization.
2) Performing Allen's test has been considered a ritual or standard practice without clear data on its predictive value or significance.
3) A recent study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's test results, suggesting there is no risk from an abnormal test.
4) The focus should be on oximetry-plethysmography and techniques to guide hemostasis after radial procedures to minimize radial artery occlusion, not on pre-procedural testing for dual circulation.Applegate RJ - AIMRADIAL 2013 - Learning curve
Applegate RJ - AIMRADIAL 2013 - Learning curveInternational Chair on Interventional Cardiology and Transradial Approach
1) The document discusses the learning curve for radial artery procedures in the US based on multiple data sources.
2) Recent data shows the radial learning curve may not be as steep as once believed, with initial competence reached after 25-40 cases, though improvement continues with greater experience and volume.
3) Procedural metrics like fluoroscopy time improve with experience but are influenced by many factors, making direct links to patient outcomes difficult to establish. Nonetheless, radial procedures in the US are being adopted quickly and appear to achieve better safety outcomes than femoral procedures.Bertrand OF - AIMRADIAL 2013 - Radial in 100%?
Bertrand OF - AIMRADIAL 2013 - Radial in 100%?International Chair on Interventional Cardiology and Transradial Approach
This document discusses rates of transradial access failure in percutaneous coronary intervention (PCI) cases. In a high-volume radial center, transradial access failed in 2.7% of all PCI cases and 1.8% required crossover to transfemoral access during the procedure. Among STEMI patients, 5% had primary transradial failure and 2.2% had crossover failure. Risk scores were developed to predict failure - for all comers it was based on female gender, prior CABG, and cardiogenic shock; for STEMI it considered 9 factors including age, weight, creatinine, the operator's radial experience, and intubation status. These scores had good predictive ability to identify patients at higherSciahbasi A - AIMRADIAL 2013 - Radiation exposure
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Bernat I - AIMRADIAL 2014 - Slender techniques in EuropeInternational 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.Tessitore E - AIMRADIAL 2014 - Sheathless
Tessitore E - AIMRADIAL 2014 - SheathlessInternational 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.Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approachInternational Chair on Interventional Cardiology and Transradial Approach
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.Abdelaal E - AIMRADIAL 2014 Technical - Local complications
Abdelaal E - AIMRADIAL 2014 Technical - Local complicationsInternational 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.An Update on Carotid Artery PTAS:Contemporary Results, Trends, and Challenges...
This document summarizes an update on carotid artery stenting (CAS). It discusses the rationale for CAS, guidelines for patient selection, results from clinical trials comparing CAS to carotid endarterectomy (CEA). Contemporary data shows similar perioperative risks for CAS and CEA. Embolic protection devices are recommended for CAS to prevent stroke from debris. Proper credentialing and facility requirements are important for CAS programs.
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunctionInternational Chair on Interventional Cardiology and Transradial Approach
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.Gilchrist IC - AIMRADIAL 2014 - Allen's test
Gilchrist IC - AIMRADIAL 2014 - Allen's testInternational Chair on Interventional Cardiology and Transradial Approach
This document discusses the practice of performing Allen's test or oximetry prior to radial artery catheterization. It summarizes that:
1) There is no Class I evidence or randomized data showing the predictive value of Allen's test, and the significance of an abnormal test is unclear.
2) A study found no differences in outcomes between patients with normal, intermediate, or abnormal Allen's tests, suggesting no risk from an abnormal test.
3) Recommendations are that there is no evidence to support performing Allen's test or testing for dual circulation to prevent ischemic complications of transradial catheterization. Attention should instead focus on techniques to guide hemostasis after the procedure.Gilchrist IC 201305
Ultrasound can help with planning and obtaining radial artery access for cardiovascular procedures. Planning ultrasound examines artery size and anatomy to select the optimal access site and sheath size, reducing fluoroscopy time. Ultrasound guided access improves first stick success rates and reduces average access time compared to palpation or blind access techniques. Meta-analyses show ultrasound guidance significantly increases the chance of successful first attempt radial artery access. While radial angiography provides information if access fails, ultrasound is preferable for access planning and guidance due to reduced pain, contrast, and radiation compared to angiography.
Pima society
The document summarizes new cardiac surgery programs at the University of Arizona Medical Center (UAMC) including minimally invasive and robotic techniques. It discusses implementation frameworks focusing on team development and metrics of success. Outcomes data shows the new programs achieved lower mortality and morbidity rates compared to national benchmarks. The programs increased hospital volume and referrals while improving patient satisfaction. The summary focuses on the high level information around new programs, implementation strategies, outcomes data, and business impacts.
Kandzari DE 201305
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.
Speiser B - AIMRADIAL 2014 - Nursing workload
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This document discusses how transradial coronary procedures can save nursing workload compared to transfemoral procedures. It provides data showing that radial access reduces nursing time spent on manual sheath removal, handling patients in the cath lab, and time spent with patients. Studies show radial procedures reduce nursing workload by 12-34 minutes on average per case. With 1000 cases per year, this can save over 1000 nursing hours or 36 nursing weeks. Radial access also improves patient quality of life scores and reduces costs due to shorter recovery times. Hospitals can further reduce nursing workload through standardized education, accelerated hemostasis removal, same day PCI procedures, and dedicated radial lounges.03 aimradial2016 fri2 A Patel
03 aimradial2016 fri2 A PatelInternational Chair on Interventional Cardiology and Transradial Approach
This study evaluated the safety and feasibility of using a combined dual access radial and pedal approach for treating chronic total occlusions of the superficial femoral arteries. 86 patients underwent endovascular intervention using a primary pedal access and dual access if the pedal approach failed. For 49 lesions where the pedal approach failed, dual transpedal and transradial access was used. The technical success rate was 98% and procedural success rate was 96%, with no peri-procedural complications. The study demonstrated the dual access approach is a safe and feasible alternative to treat complex superficial femoral artery chronic total occlusions.11 aimradial2016 fri2 T Kwan
11 aimradial2016 fri2 T KwanInternational Chair on Interventional Cardiology and Transradial Approach
This document discusses the transpedal approach for peripheral interventions. The transpedal approach involves accessing the pedal or tibial arteries in the foot retrogradely to perform endovascular interventions for conditions like chronic total occlusions in the leg arteries. Some key advantages of the transpedal approach are that it allows dual access for complex interventions, avoids complications associated with femoral access, and can be used when recanalizing total occlusions from above has failed. The document reviews various studies demonstrating the safety, feasibility and clinical outcomes of the transpedal approach.What's hot (20)
Gilchrist IC - AIMRADIAL 2015 - Transradial in breast cancer
Gilchrist IC - AIMRADIAL 2015 - Transradial in breast cancer
Bernat I - AIMRADIAL 2014 Technical - Right and left
Bernat I - AIMRADIAL 2014 Technical - Right and left
Gilchrist IC - AIMRADIAL 2015 - Still need Allen test?
Gilchrist IC - AIMRADIAL 2015 - Still need Allen test?
Bernat I - AIMRADIAL 2014 - Slender techniques in Europe
Bernat I - AIMRADIAL 2014 - Slender techniques in Europe
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Sciahbasi A - AIMRADIAL 2015 - Hand grip test and transradial approach
Abdelaal E - AIMRADIAL 2014 Technical - Local complications
Abdelaal E - AIMRADIAL 2014 Technical - Local complications
An Update on Carotid Artery PTAS:Contemporary Results, Trends, and Challenges...
An Update on Carotid Artery PTAS:Contemporary Results, Trends, and Challenges...
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
Biederman D - AIMRADIAL 2015 - Radial access in hepatic dysfunction
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1350 1400 Systematic Approach to Cardiogenic Shock Khawaja FINAL.pptx
1) Cardiogenic shock has a high mortality rate and its incidence is increasing. Early revascularization through PCI improves survival outcomes.
2) Mechanical circulatory support devices like Impella provide better hemodynamic support compared to intra-aortic balloon pumps and are associated with reduced mortality in cardiogenic shock.
3) Protocol-driven approaches to early identification and treatment of cardiogenic shock with early hemodynamic support and revascularization have led to improved survival rates in community hospital settings.
POLAR ACS: plataforma bio absorbible en síndromes coronarios agudos
POLAR ACS: plataforma bio absorbible en síndromes coronarios agudosSociedad Latinoamericana de Cardiología Intervencionista
Dr. Dariusz Dudek. Congreso euroPCR 2013. Encuentre más presentaciones de este congreso en la página web oficial de SOLACI: www.solaci.org/
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16
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).
09 Cohen aimradial20170922 Ventricular support
09 Cohen aimradial20170922 Ventricular supportInternational Chair on Interventional Cardiology and Transradial Approach
This document discusses the use of left ventricular support devices for complex percutaneous coronary interventions (PCI). It begins by outlining the types of patients that typically require high-risk PCI, including those with severe diffuse coronary artery disease, significant three-vessel disease, or left main disease. It then reviews various left ventricular support devices like intra-aortic balloon pumps (IABP), Impella, TandemHeart, and extracorporeal membrane oxygenation and the evidence for their use. Finally, it emphasizes that while transradial access is associated with lower bleeding risks, operators must maintain skills in large bore femoral access and closure for cases requiring left ventricular support devices.Pancholy SB 2014
Position statement: radial intervention will become the first choice for all coronary interventions, including STEMI and cardiogenic shock
09 Pancholy aimradial20170921 Reduce RAO
09 Pancholy aimradial20170921 Reduce RAOInternational Chair on Interventional Cardiology and Transradial Approach
This document summarizes the key points from a presentation on acute radial artery occlusion (RAO). It discusses the incidence of RAO, which varies between studies but averages around 9.4%. The main mechanism of RAO is thrombosis or rapid fibrotic lumen obliteration. Several studies are referenced that examine the impact of heparin dosing, sheathless techniques, hemostasis methods, ulnar compression, and residual spasm on rates of RAO. The document concludes by presenting the results of the PROPHET-II randomized trial, which found that prophylactic ulnar compression during hemostasis lowers the risk of RAO compared to patent hemostasis alone.What do we need to indicate CTO PCI?
1. Successful PCI of chronic total occlusions (CTO) is associated with improved symptoms, increased exercise capacity, reduced need for CABG, and survival benefit compared to failed CTO PCI based on observational studies.
2. Randomized trials are still needed to provide high-level evidence on the benefits of CTO PCI given limitations of observational data though several large randomized trials are underway.
3. Expert operators can now achieve high success rates of over 90% for CTO PCI with low complication rates even for complex CTOs, using bilateral injections, IVUS, retrograde approaches and specialized guidewires and catheters.
Reunion Madeira 2015 Nuevos Retos en la Cardiología Intervencionista.Posición...
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Nuevos Retos en la Cardiología Intervencionista.Posición de la Sociedad Española de Cardiología Programa INCARDIOSCA non-ST+ de la personne âgée - D.U. MUPA 2018
1. The document discusses the management of elderly patients presenting with possible acute coronary syndrome (ACS). Biomarkers like high-sensitivity troponin have improved detection of myocardial infarction in this population, but interpretation can be challenging due to age-related changes.
2. Risk stratification tools like the HEART score and evaluation of troponin kinetics can help identify low-risk elderly patients for early discharge. A pathway integrating HEART score, high-sensitivity troponin levels, and clinical judgement may optimize care for these patients.
3. Guidelines recommend aspirin, a P2Y12 inhibitor like clopidogrel, and consideration of extended dual antiplatelet therapy based on risk assessment for secondary prevention
Oesophageal Doppler Stroke Volume Optimisation
Intraoperative oesophageal Doppler monitoring (ODM) guided fluid management was compared to standard central venous pressure (CVP) guided fluids in a randomized controlled trial of 128 colorectal surgery patients. ODM guided fluid optimization resulted in significantly shorter hospital length of stay, earlier return of gut function, fewer postoperative complications, and cost savings compared to CVP-guided fluids. ODM provided a more reliable assessment of intravascular volume status and cardiac preload than CVP alone.
Oesophageal Doppler Stroke Volume Optimisation
Oesophageal Doppler Monitoring (ODM) provides a non-invasive assessment of stroke volume and cardiac output during surgery. A randomized controlled trial found that using ODM to guide intraoperative fluid management in colorectal surgery patients resulted in shorter hospital length of stay, earlier return of gut function, fewer complications, better hemodynamic measurements, and cost savings compared to managing fluids to maintain CVP between 12-15 mmHg. ODM may help optimize fluid management and improve recovery in complex and orthopedic surgeries.
11 Kanovsky aimradial20170922 OCT Serial study
11 Kanovsky aimradial20170922 OCT Serial studyInternational Chair on Interventional Cardiology and Transradial Approach
This study evaluated radial artery injury after percutaneous coronary intervention (PCI) using optical coherence tomography (OCT) at baseline and 9-month follow up in 100 patients. At baseline, 11% had intimal tears and 3% had medial dissections. At follow up, 10% had intimal tears and 7% had medial dissections, with no significant differences between time points. Compared to prior studies using longer sheaths, this study found a lower number of radial artery injuries, possibly due to the use of shorter 7cm sheaths. Serial OCT analysis found no persistent changes in arteries with initial injuries. This suggests short sheath use may reduce radial artery injury risk after transradial PCI.Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...
This document summarizes the role of subcutaneous implantable cardioverter defibrillators (S-ICD) in preventing sudden cardiac death. It discusses:
- How S-ICDs detect and treat ventricular fibrillation and tachycardia without leads in the heart.
- Studies showing S-ICDs effectively detect and terminate arrhythmias while having a lower risk of complications than transvenous ICDs.
- S-ICDs should be considered for any patient with an ICD indication who does not require cardiac pacing. Ongoing randomized trials will further establish the role of S-ICDs.
Ikari Y - AIMRADIAL 2014 - Radial and IABP
Ikari Y - AIMRADIAL 2014 - Radial and IABPInternational Chair on Interventional Cardiology and Transradial Approach
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.Recherche clinique en cardiologie interventionnelle - Gilles MONTALESCOT - Re...
This document discusses clinical research in interventional cardiology conducted by the ACTION network in France. It summarizes several studies, including the ATOLL trial which compared enoxaparin to unfractionated heparin in STEMI patients undergoing primary PCI, finding a reduction in bleeding with enoxaparin. It also discusses the ARCTIC trial which evaluated platelet function monitoring after PCI and found no benefit to adjustment of antiplatelet therapy based on monitoring. The network aims to conduct large, high quality clinical trials to advance interventional cardiology treatments and addresses challenges in patient recruitment.
PCI & AimRadial 2018 | Coronary Physiology To Guide Interventions - K. Lance ...
PCI & AimRadial 2018 | Coronary Physiology To Guide Interventions - K. Lance ...International Chair on Interventional Cardiology and Transradial Approach
- Coronary physiology guided interventions like fractional flow reserve (FFR) have the potential to provide benefit by reducing myocardial infarction and death compared to angiogram-guided revascularization alone.
- Tests like FFR measure the pressure difference across a stenosis to determine the functional significance and guide whether intervention is needed. Studies show FFR can identify patients unlikely to benefit from intervention who can avoid unnecessary procedures.
- Coronary flow reserve (CFR) measured by positron emission tomography (PET) provides a continuous measure of coronary physiology severity associated with risk of future adverse events like death or MI. Patients with severely reduced CFR may benefit from revascularization while mild/moderate reductions can be managed medically.14 FFR Johnson N aimradial2016 - contrast vasodilatory agent
14 FFR Johnson N aimradial2016 - contrast vasodilatory agentInternational Chair on Interventional Cardiology and Transradial Approach
The CONTRAST study evaluated the diagnostic accuracy of contrast FFR (cFFR) compared to resting indices and FFR. It found that cFFR had superior accuracy (85.8%) compared to resting Pd/Pa (78.5%) and iFR (79.9%) for detecting lesions with FFR ≤0.8. cFFR also showed good test-retest repeatability. The study demonstrated that cFFR provides a viable alternative to adenosine for assessing lesion-specific ischemia when FFR is not feasible or contraindicated.STEMI – My Approach 2010
- Primary PCI is the preferred reperfusion strategy for STEMI when it can be performed at an experienced center within 120 minutes of first medical contact. Fibrinolysis is an alternative if PCI cannot be performed within this time window.
- Clopidogrel in combination with aspirin results in significant improvements in outcomes for STEMI patients over aspirin alone based on the CLARITY-TIMI 28 and COMMIT trials.
- Enoxaparin is superior to unfractionated heparin as an anticoagulant to support reperfusion therapy for STEMI based on the ExTRACT-TIMI 25 trial.
Fda Iri Dgf Workshop 09 Sep2011 W Irish
This document discusses cold machine perfusion versus static cold storage for preserving kidneys from standard criteria, extended criteria, and donation after cardiac death donors for transplantation. It summarizes the incidence and impact of delayed graft function, outlines kidney preservation methods and clinical trials comparing outcomes between cold storage and machine perfusion. It identifies unanswered questions around how preservation method may differentially impact outcomes based on donor and recipient risk factors.
Anemo 2014 - Rossini - Protocollo GISE-ANMCO-SIAARTI: risultati positivi?
This document contains guidelines and proposals for operational models from GISE-ANMCO-SIAARTI on the topic of coronary stents and surgery. It includes a protocol, results from position papers, consensus documents, studies on risk stratification and perioperative management of antiplatelet therapy, as well as proposals for apps and regional guidelines. The key points are to maintain aspirin in most patients, postpone high risk surgery if possible, discontinue P2Y12 inhibitors after 6 months only for low risk PCI, and use bridging LMWH in selected high risk cases.
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More from Robert Poston
SUNY-Downstate CT Surgery Results
Outcomes of patients undergoing cardiac surgery at SUNY-Downstate between Aug '18 and Aug '19. Includes 148 patients that underwent cases that are risk adjustable according to STS definitions.
Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
The classic focus of cardiac surgeons attempting to implement robotics programs is on the technical tasks. This presentation focuses on the managerial and political challenges that can strongly influence the chances of success with these high profile programs.
Outcomes for cardiac surgery at Mt. View 2017
Dr. Poston arrived at Mt View in 2017 as their director of cardiothoracic surgery. The most comprehensive way to understand the performance of his program is to review the quarterly report from STS national cardiac surgery database. This provides risk adjusted outcomes. It shows that compared to the year prior to his arrival, both outcomes and total surgical volume increased.
Team training for robotic heart surgery at Downstate
Downstate University had not done robotic heart surgery in the past. In order to train the surgical team, we performed a series of "dry runs". This involved setting up the OR as close as possible to a live case and then rehearsing the normal course of events as well as emergency scenarios.
Dr. Poston's surgical laser training
This certificate certifies that Robert S. Poston, M.D. successfully completed training in Transmyocardial Revascularization (TMR) using a Holmium:YAG laser system on May 13, 2013. The training covered the history and clinical applications of TMR, patient selection criteria, intra-operative and post-operative management, the mechanism of action and clinical benefits of TMR, and laser safety and operation. The certificate was awarded by William F. Northrup III, MD, Vice President of Physician Relations and Education at CryoLife.
Dr. Poston's robotic training
Dr. Poston underwent training and started his robotic practice in Aug 2006. One year later, he submitted for publication the outcomes of his first 100 robotic cardiac cases (see: Ann Surg 2008; 248(4):638-46). He has maintained a steady practice of >100 robotic cases per year since that time.
Culture of safety for Downstate ct surgery
The document summarizes the results of a survey conducted on July 5th, 2018 about the culture of safety at Downstate CT Surgery. It provides percentages of positive responses for various safety culture questions compared to national averages. Overall, Downstate's positive responses were lower than national averages for most questions, indicating opportunities to improve communication, teamwork, and handling of errors.
Cardiac Surgery at Mountain View Medical Center 2017
Summary of the processes used to improve cardiac surgery at MVRMC and the resulting outcomes for the program during 2017.
Data.sts.sfmc2016
National database analysis completed 11/16 regarding the results for cardiac surgery performed at St Francis Medical Center, Trenton, NJ. from 2015-16.
Support group at St. Francis
The cardiothoracic surgery support group meets monthly to provide a forum for past and future patients to interact with each other and their surgeons, which helps reduce anxiety and demonstrate the program's commitment to long-term outcomes. The group receives program updates and in one meeting had a live demonstration of the da vinci robot used in surgeries to help patients better explain their procedures to others.
Grand Rounds: Univ of Chicago Cardiology
This document discusses marketing strategies for less invasive cardiac surgery techniques like robotic CABG. It notes that patients generally prefer less invasive procedures due to quicker recovery times. The document outlines tactics for marketing robotic CABG such as developing websites, publications, presentations and advertising. It acknowledges both benefits like improved cosmesis but also challenges like higher costs and learning curves. Data on early ad campaigns for robotic CABG show they increased elective case volume and reduced length of stay. The document emphasizes integrating marketing messages and reassessing based on the local environment.
Invited Presentation: Hybrid coronary revascularization, ISMICS
Invited presentation at the major robotic cardiac surgery meeting at a society called ISMICS. This presentation described the use of less invasive cardiac surgery as a way to accelerate the recovery so this patient could under go chemotherapy for metastatic breast cancer.
Abstract presentation - Bleeding and patient satisfaction
Robotic CABG patients who received transfusions were more likely to have unmet expectations about recovery time and lower satisfaction scores. Using topical hemostatics during robotic CABG reduced transfusions and led to higher patient satisfaction and fewer patients with unmet expectations about recovery compared to controls. Surgeons experience high stress during robotic cardiac surgery. Managing bleeding and expectations may improve the patient experience with robotic CABG.
Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
Invited presentation at a minimally invasive surgical society to discuss the financial advantages of robotics.
Summary of UA CT Surgery 2011-14
1) The chief of cardiothoracic surgery at UAMC led an era of innovation from 2011-2014 by introducing several new less invasive programs including robotic coronary bypass, mitral valve repair, lobectomy, and esophagectomy.
2) Data shows that from 2011-2014, the percentage of less invasive cases at UAMC increased from 0.5% to 82% and the hospital saw a 48% increase in cardiac case volume during this time period.
3) Outcomes for the chief's patients were very positive, with in-hospital mortality and operative mortality rates well below national benchmarks, indicating the safety and effectiveness of the new approaches.
Invited Presentation: Ex Vivo Storage of Vein Grafts
This document discusses the link between the ex vivo storage interval of vein grafts and subsequent graft failure after coronary artery bypass grafting (CABG). It notes that veins and arteries used as grafts can be considered transplant organs that are subject to damage during harvesting and storage prior to grafting. Studies have found that buffered preservation solutions may better protect grafts during storage compared to saline or blood, with one trial finding a 70% reduced risk of graft failure when using buffered solutions. The document argues that grafts should be viewed similarly to transplanted organs in order to reduce storage-related damage that can lead to asymptomatic graft failure over time.
Sfmc.2015results
This document provides an update from the Chairman of Cardiothoracic Surgery at St. Francis Hospital on outcomes for heart bypass and other cardiac surgical cases from February 2015 to March 2016. Several graphs show mortality, complication rates, and transfusion rates for St. Francis are equal to or below national benchmarks. The chairman also discusses the typical life cycle of innovation when a new program such as robotics is introduced, with an initial learning curve followed by maintaining or improving results over time.
Ems.presentation
Invited presentation given on 5/18/16 about robotic surgery and the unusually low rate of postoperative strokes that are noted after this procedure.
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Invited Presentation at the Eastern Cardiothoracic Surgical Society 2018
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Society of Laparoscopic Surgery, Invited Presentation, Aug 2015
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我们所定的价格是非常合理的，而且我们现在做得单子大多数都是代理和回头客户介绍的所以一般现在有新的单子 我给客户的都是第一手的代理价格，因为我想坦诚对待大家 不想跟大家在价格方面浪费时间
对于老客户或者被老客户介绍过来的朋友，我们都会适当给一些优惠。
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India Medical Devices Market: Size, Share, and In-Depth Competitive Analysis ...
According to TechSci Research report, “India Medical Devices Market Industry Size, Share, Trends, Competition, Opportunity and Forecast, 2019-2029,” the India Medical Devices Market was valued at USD 15.35 billion in 2023 and is anticipated to witness impressive growth in the forecast period, with a Compound Annual Growth Rate (CAGR) of 5.35% through 2029. This growth is driven by various factors, including strategic collaborations and partnerships among leading companies, a growing population, and the increasing demand for advanced healthcare solutions.
Recent Trends
Strategic Collaborations and Partnerships
One of the most significant trends driving the India Medical Devices Market is the increasing number of collaborations and partnerships among leading companies. These alliances aim to merge the expertise of individual companies to strengthen their market position and enhance their product offerings. For instance, partnerships between local manufacturers and international companies bring advanced technologies and manufacturing techniques to the Indian market, fostering innovation and improving product quality.
Browse over XX market data Figures and spread through XX Pages and an in-depth TOC on " India Medical Devices Market.” - https://www.techsciresearch.com/report/india-medical-devices-market/8161.html
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - ...rightmanforbloodline
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.
TEST BANK FOR Health Assessment in Nursing 7th Edition by Weber Chapters 1 - 34.Hypertension and it's role of physiotherapy in it.
This particular slides consist of- what is hypertension,what are it's causes and it's effect on body, risk factors, symptoms,complications, diagnosis and role of physiotherapy in it.
This slide is very helpful for physiotherapy students and also for other medical and healthcare students.
Here is summary of hypertension -
Hypertension, also known as high blood pressure, is a serious medical condition that occurs when blood pressure in the body's arteries is consistently too high. Blood pressure is the force of blood pushing against the walls of blood vessels as the heart pumps it. Hypertension can increase the risk of heart disease, brain disease, kidney disease, and premature death.
Test bank clinical nursing skills a concept based approach 4e pearson educati...
Test bank clinical nursing skills a concept based approach 4e pearson educati...rightmanforbloodline
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According to the TechSci Research report titled "India Home Healthcare Market - By Region, Competition, Forecast and Opportunities, 2029," the India home healthcare market is anticipated to grow at an impressive rate during the forecast period. This growth can be attributed to several factors, including the rising demand for managing health issues such as chronic diseases, post-operative care, elderly care, palliative care, and mental health. The growing preference for personalized healthcare among people is also a significant driver. Additionally, rapid advancements in science and technology, increasing healthcare costs, changes in food laws affecting label and product claims, a burgeoning aging population, and a rising interest in attaining wellness through diet are expected to escalate the growth of the India home healthcare market in the coming years.
Browse over XX market data Figures spread through 70 Pages and an in-depth TOC on "India Home Healthcare Market”
https://www.techsciresearch.com/report/india-home-healthcare-market/15508.html
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- 1. Robotic Heart Surgery Robert Poston, MD Chief, Division of Cardiothoracic Surgery SUNY-Downstate, Brooklyn, NY
- 7. COMMON PRACTICE COMMON COMPLICATION Ultrasound probe Ultrasound image Partial cross clamp Aorta Aorta
- 8. ON-PUMP CABG
- 10. 10% 5% 1.6% 1970 1980 1990 2000 2010 INCIDENCE OF STROKE AFTER BYPASS GRAFTING OVER TIME
- 12. ON-PUMP CABG MINIMALLY INVASIVE CABG/HYBRID
- 13. Database n Stroke ref STS National Cardiac Database 2006-12 9862 0.5% Whellan D, ATS 2016 National Inpatient Sample 2009-10 2582 0.4% P Cavallaro, JTCVS 2015 National Inpatient Sample 2008-9 132 0% Anderson, JACS 2012 Meta-analysis of clinical trials 2002-15 8034 0.7% Cao C, Ann CT Surg 2016 NIH Observational trial 2012-13 200 0% Puskas, JACC 2016 TOTAL 20,810 0.5% Open CABG 155,012 1.8% 2017 STS- NCD report STROKES AFTER ROBOTIC CABG
- 14. Recovery at 3 weeks Open CABG Robotic CABG P value Walking distance 0.5 ± 1.0 mi 1.7 ± 1.5 mi 0.04 Treadmill MVO2 (% baseline) 43% 93% NS 6 min walk test 57% 97% 0.02 Duke Activity Index 49% 98% 0.02 Faster Recovery after Robotic CABG Poston R. Wireless Technology Demonstrates that Physical Capabilities in the Early Phase of Recovery are Enhanced by Less Invasive, Robotic CABG, ISMICS oral presentation, 2015
- 15. Epstein A, et al. Impact of Minimally Invasive Surgery on Medical Spending and Employee Absenteeism JAMA Surg. 2013;148(7):641-647. Quicker Return to Work after Robotic CABG
- 16. Ann Thorac Surg 2018;106:691–5
- 17. Hallinan JT. Wall Street Journal. June 21, 2005
- 18. Impact of R-CABG on Postop Strokes • Hospital costs • Postacute care • Return to work • Malpractice premiums • Word of mouth reputation