Risk of local adverse events by gender following cardiac catheterization

Acute Coronary Syndromes in Women: A Narrative Review of Sex-Specific Characteristics

Acute coronary syndromes (ACSs) encompass a spectrum of life-threatening cardiovascular conditions, including unstable angina (UA) and myocardial infarction. While significant progress has been made in the understanding and management of ACS over the years, it has become increasingly evident that sex-based differences play a pivotal role in the pathophysiology, presentation, and outcomes of these conditions. Despite this recognition, the majority of clinical research in the field has historically focused on male populations, leading to a significant knowledge gap in understanding the unique aspects of ACS in women. This review article aims to comprehensively explore and synthesize the current body of literature concerning the sex-specific characteristics of ACS, shedding light on the epidemiology, risk factors, clinical presentation, diagnostic challenges, treatment strategies, and prognosis in women. By elucidating the distinct aspects of ACS in women, this review intends to foster greater awareness and improved clinical management, ultimately contributing to enhanced cardiovascular care for female patients.

Complications and related risk factors of transradial access cannulation for hemodynamic monitoring in general surgery: a prospective observational study

PURPOSE

To examine the short-term complications of arterial cannulation for intraoperative monitoring and their related risk factors.

METHODS

We included adult inpatients (≥ 18 years old) who underwent an initial transradial access (TRA) cannulation and were scheduled for general surgery between April 8 and November 30, 2020. We used 20G arterial puncture needles for puncturing and manual compression for hemostasis. Demographic, clinical, surgical, anesthetic, and laboratory data were extracted from electronic medical records. Vascular, neurologic, and infectious complications of TRA cannulation were recorded and analyzed. Logistic regression analyses were used to identify risk factors related to TRA cannulation for intraoperative monitoring.

RESULTS

Among 509 included patients, 174 developed TRA cannulation-related complications. Puncture site bleeding/hematoma and median nerve injury were observed in 158 (31.0%) and 16 (3.1%) patients, respectively. No patient developed cannula-related infections. Logistic regression analysis revealed increased odds of puncture site bleeding/hematoma in women (odds ratio 4.49, 95% CI 2.73-7.36; P < 0.001) and patients who received intraoperative red blood cell (RBC) suspension transfusion ≥ 4U (odds ratio 5.26, 95% CI 1.41-19.57; P = 0.01). No risk factors for nerve injury were identified.

CONCLUSION

Bleeding/hematoma were a common complication of TRA cannulation for intraoperative hemodynamic monitoring during general surgery. Median nerve injury may be an under recognized complication. Female sex and extensive intraoperative RBC transfusion are associated with an increased risk of bleeding/hematoma; however, the risk factors for nerve injury remain unclear.

TRIAL REGISTRATION

The study protocol was registered at https://www.chictr.org.cn (ChiCTR1900025140).

Percutaneous Ultrasound-Guided Carotid Access and Puncture Closure with Angio-Seal in Horses

Simple Summary

Endovascular surgery is a type of image-guided minimally invasive surgery that aims to solve different types of pathologies from inside the blood vessel. This technique requires access to a peripheral vessel (vein or artery) and the navigation through the vascular system to reach the operating site, using different catheters. In horses, the main indication for endovascular therapy involves access to the common carotid artery for different purposes. Traditionally, this was performed by open dissection of the neck to reach and incise the common carotid artery, followed by vascular suture of the vessel and skin closure when the procedure was over. However, this can also be performed by percutaneous puncture of the artery, using ultrasound to guide the needle to its adequate position in the artery, as has been reported in experimental horses. Along with that, in human medicine, commercial closure systems are used to seal these arterial punctures and avoid some complications (mainly haematomas and haemorrhages). We describe our experience in a series of 11 clinical cases in which this minimally invasive way of access was used, and the puncture site was sealed with one of these devices (AngioSeal arterial closure system), reporting its first use in horses. In all cases, the artery was effectively accessed, and the planned procedure could be performed. Our haematoma/bleeding rate (16.66%) was lower than in other studies using the same type of access, even considering two failures due to incorrect use of the device. However, further studies comparing AngioSeal use to simple manual compression would be necessary to be able to recommend their routine use in horses.

Abstract

Background: There are different indications for endovascular surgery in horses, mainly the treatment of guttural pouch mycosis. Traditionally, these procedures are carried out by open arteriotomy of the common carotid artery (CCA), although less invasive percutaneous ultrasound-guided carotid access (PUGCA) has been described in experimental horses. In human medicine, commercial closure systems are used to seal these arterial puncture sites and reduce complications. The aims of this study are to retrospectively describe our experience with PUGCA in clinical cases and to report, for the first time, the use of the commercial vascular closure device Angio-Seal after PUGCA in horses. Methods: Retrospective study of clinical case records. Collected parameters, including the feasibility of the PUGCA and variables related to the safety and efficacy of the use of the Angio-Seal. Results: Twelve PUGCA procedures in 11 horses were included. In all cases, the artery was effectively accessed, and the planned procedure could be performed. In two cases, haematoma/bleeding due to incorrect use of the Angio-Seal was recorded. This complication rate (16.66%) was lower than that obtained in other studies using PUGCA in horses, but where the puncture was sealed by manual compression only. Main limitations: A control group of clinical cases with PUGCA but without using Angio-Seal is not available. Conclusions: Clinical data confirm previous experimental results, which showed that PUGCA is safe and effective in horses. The Angio-Seal system, regardless of possible complications due to incorrect use, can be used safely and effectively in horses. Further studies comparing arterial access site management using manual compression or Angio-Seal would be necessary to state if its routine use in horses is advisable.

ST-Segment Elevation Myocardial Infarction: Sex Differences in Incidence, Etiology, Treatment, and Outcomes

PURPOSE

Although there have been marked improvements in the standard of care for treatment of ST-elevation myocardial infarction, women, especially younger women, continue to have significantly worse outcomes than men.

RECENT FINDINGS

This review highlights the current sex differences in presentation, etiology, treatment, and outcomes among these patients in order to make providers aware of the heterogeneous entities that cause ST-elevation myocardial infarction particularly in women and of disparities in treatment that lead to poorer outcomes in women. Furthermore, it emphasizes evidence-based strategies including standardized protocols for early revascularization, mechanical circulatory support, and access methodology that can reduce sex-based disparities in treatments and outcomes.

Comparison of Vascular Closure Devices Versus Manual Compression After Femoral Artery Puncture in Women

BACKGROUND

The value of vascular closure devices (VCD) in women undergoing transfemoral catheterization has not been sufficiently investigated.

METHODS AND RESULTS

This is a sex-specific analysis of 1395 women enrolled in a large-scale, randomized, multicenter trial, in which patients undergoing transfemoral diagnostic coronary angiography were randomly assigned in a 1:1:1 ratio to arteriotomy closure with an intravascular VCD, extravascular VCD, or manual compression (MC). Primary objective was to assess the safety and efficacy of 2 different VCD compared with MC regarding vascular access-site complications at 30 days. A secondary comparison was between 2 different types of contemporary VCD. Overall, women were at higher risk for vascular access-site complications compared with men (9.0% versus 6.4%; P=0.002). Vascular access-site complications were comparable in women assigned to VCD and MC (8.6% versus 9.8%; P=0.451). There was no interaction of treatment effect and sex ( P_interaction=0.970). Time to hemostasis was significantly shortened with VCD compared with MC (1 [interquartile range, 0.5-2.0] minutes) versus 11 [interquartile range, 10-15] minutes; P<0.001); however, more women with VCD required repeat MC (2.4% versus 0.6%; P=0.018). The use of the intravascular compared with the extravascular VCD was associated with a numerical reduction in vascular access-site complications (6.6% versus 10.7%; P=0.027) and significant reductions in time to hemostasis and VCD failure.

CONCLUSIONS

In women undergoing diagnostic coronary angiography via the common femoral artery, VCD and MC provided comparable safety, while time to hemostasis was reduced with VCD.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01389375.

The Food and Drug Administration Office of Women's Health: Impact of Science on Regulatory Policy: An Update

The U.S. Food and Drug Administration Office of Women's Health (FDA OWH) has supported women's health research for ∼20 years, funding more than 300 studies on women's health issues, including research on diseases/conditions that disproportionately affect women in addition to the evaluation of sex differences in the performance of and response to medical products. These important women's health issues are studied from a regulatory perspective, with a focus on improving and optimizing medical product development and the evaluation of product safety and efficacy in women. These findings have influenced industry direction, labeling, product discontinuation, safety notices, and clinical practice. In addition, OWH-funded research has addressed gaps in the knowledge about diseases and medical conditions that impact women across the life span such as cardiovascular disease, pregnancy, menopause, osteoporosis, and the safe use of numerous medical products.

Enrollment and monitoring of women in post-approval studies for medical devices mandated by the Food and Drug Administration

BACKGROUND

Disease presentation, prevalence, and treatment effects vary by sex, thus it is important to ensure adequate participation of both sexes in medical device post-approval studies (PAS).

METHODS

The goals of this study were to determine the participation rate of women in PAS mandated by the Food and Drug Administration (FDA) and if participation varied by clinical area. The study also evaluated the frequency in which enrollment by sex is reported by applicant reports and FDA reviews, as well as the frequency in which final study reports analyze whether outcomes differ by sex.

RESULTS

Of 89 studies with enrollment completed, data on sex of participants were available in 93% of submitted reports, while data on enrollment by sex was evaluated and noted in 43% of FDA review memos. Study participation varied by clinical area, with female participation ranging from 32% in cardiovascular PAS to 90% in PAS for reconstructive devices. Of 53 completed studies, data on enrollment by sex was provided in 49 of the final reports. Of these 14% included a multivariate analysis that included sex as a covariate and 4% included a subgroup analysis for female participants.

CONCLUSIONS

Data on sex was not routinely assessed in FDA reviews. Based on these findings, FDA implemented new procedures to ensure participation by sex is evaluated in PAS reviews. FDA will continue working with applicants to develop PAS that enroll and retain proportions of women consistent with the sex-specific prevalence for the disease or condition the device is used to treat.

Patterns of use and comparative effectiveness of bleeding avoidance strategies in men and women following percutaneous coronary interventions: an observational study from the National Cardiovascular Data Registry

OBJECTIVES

This study sought to compared the use and effectiveness of bleeding avoidance strategies (BAS) by sex.

BACKGROUND

Women have higher rates of bleeding following percutaneous coronary intervention (PCI).

METHODS

Among 570,777 men (67.5%) and women (32.5%) who underwent PCI in the National Cardiovascular Data Registry's CathPCI Registry between July 1, 2009 and March 31, 2011, in-hospital bleeding rates and the use of BAS (vascular closure devices, bivalirudin, radial approach, and their combinations) were assessed. The relative risk of bleeding for each BAS compared with no BAS was determined in women and men using multivariable logistic regressions adjusted for clinical characteristics and the propensity for receiving BAS. Finally, the absolute risk differences in bleeding associated with BAS were compared.

RESULTS

Overall, the use of any BAS differed slightly between women and men (75.4% vs. 75.7%, p = 0.01). When BAS was not used, women had significantly higher rates of bleeding than men (12.5% vs. 6.2%, p < 0.01). Both sexes had similar adjusted risk reductions of bleeding when any BAS was used (women, odds ratio: 0.60, 95% confidence interval [CI]: 0.57 to 0.63; men, odds ratio: 0.62, 95% CI: 0.59 to 0.65). Women and men had lower absolute bleeding risks with BAS; however, these absolute risk differences were greater in women (6.3% vs. 3.2%, p < 0.01).

CONCLUSIONS

Women continue to have almost twice the rate of bleeding following PCI. The use of any BAS was associated with a similarly lower risk of bleeding for men and women; however, the absolute risk differences were substantially higher in women. These data underscore the importance of applying effective strategies to limit post-PCI bleeding, especially in women.

Prospective comparison of angio-seal versus manual compression for hemostasis after neurointerventional procedures under systemic heparinization

BACKGROUND AND PURPOSE

The use of arterial closure device in patients with prolonged high ACT values has not been extensively studied. The aim of this study was to compare the safety and efficacy of an arterial closure device, Angio-Seal, with manual compression in patients on anticoagulation following neurointerventional procedures.

MATERIALS AND METHODS

This was a 2-center prospective study approved by our institutional review boards. In total, 153 consecutive patients with 174 arteriotomies (86 men, 67 women; mean age, 56.1 ± 16.2 years) following femoral arterial puncture for neurointerventional procedures were enrolled in convenience sampling. All of the patients were systemically heparinized with an ACT between 250 and 500 seconds before removal of the sheath after the procedure. Group 1 consisted of 104 arteriotomies that were closed with an arterial closure device (Angio-Seal), and group 2 consisted of 70 arteriotomies treated with manual compression. The ACT before sheath removal, time to hemostasis, and complications immediately and 24 hours after the procedure were recorded.

RESULTS

The mean ACT before sheath removal was 284.8 ± 37.6 seconds (range, 250-414 seconds). The mean hemostasis time was significantly shorter in group 1 (2.4 ± 11.7 minutes) compared with group 2 (44.7 ± 27.4 minutes) (95% CI, 38.16-51.24 minutes; P < .001). Hematoma occurred in 9 patients in group 1 (8.6%) and 18 in group 2 (25.7%). One patient developed an arterial occlusion after hemostasis with the closure device, but this was successfully revascularized.

CONCLUSIONS

Angio-Seal was found to safely and effectively achieve rapid closure of the femoral access site in patients undergoing neuroendovascular procedures under systemic heparinization with an ACT in the range of 250-500 seconds.

[Percutaneous coronary angioplasty in women: clinical, procedural and prognostic features]

AbstractX Les résultats de l′angioplastie transluminale (ATL) des coronaires chez la femme ont été pendant de nombreuses années controversés et longtemps considérés comme moins favorable que chez l′homme. Le but de notre travail était d’évaluer les caractéristiques de l'angioplastie coronaire chez la femme, ainsi que les résultats immédiats et à moyen terme et de les comparer à ceux chez l'homme.

Nous avons comparé 200 patients dont 100 femmes, ayant bénéficié d'une angioplastie coronaire, colligés au service de cardiologie de l'hôpital Hédi Chaker de Sfax entre 2002 et 2007.

Les femmes étaient significativement plus âgées que les hommes. La comparaison de la fréquence des facteurs de risque d'athérosclérose chez les deux sexes, a permis de noter une co-morbidité franchement plus importante chez la femme, avec une différence statiquement significative. L'ATL a été plus motivée chez la femme devant un angor stable sévère (p<0,05) et un SCA ST- (p=NS). Les femmes avaient plus d'atteinte polytronculaire (p<0,05), d'atteintes des segments moyens et distaux (p<0,05) et plus des lésions serrées (p=NS), longues et calcifiées (p<0,05). 259 stents ont été déployés, un stenting direct était plus fréquent dans la population féminine (p<0,05). Le diamètre des artères féminines, assimilé à celui du stent et/ou ballon utilisé, a été significativement moins important que celui des hommes. La longueur des stents et/ou ballon utilisés, ainsi que les pressions de larguage des stents ont été plus importantes chez la population féminine (p<0,05). Le succès angiographique global a été obtenu chez 94% de la population générale, sans différence significative entre les deux sexes. Les évènements cardiaques majeurs (MACE) hospitaliers ont été plus fréquents chez la femme (p=0,05). Après un suivi moyen de 31 mois, le taux de MACE global a été significativement plus important chez la femme (39% vs. 28%, p<0,05), portant surtout sur la mortalité globale (13% vs. 3%, p<0,05). Le taux de resténose a été comparable chez les deux sexes.

L'angioplastie coronaire constitue actuellement un moyen thérapeutique efficace et sur chez la femme, au prix de complications plus fréquentes.

Significantly Improved Vascular Complications Among Women Undergoing Percutaneous Coronary Intervention

Background— Women are at a higher risk for bleeding/vascular complications (VC) related to cardiovascular procedures. Although the overall incidence of percutaneous coronary intervention (PCI)-related bleeding/VC has declined, the impact of this decline, specifically in women, is unknown.

Methods and Results— We studied 13 653 female and 32 334 male consecutive cases, from 2002 to 2007, in the Northern New England PCI Registry. We sought to (1) compare absolute rates of bleeding/VC in women and men over time, (2) define predictors of bleeding/VC in women and men undergoing PCI, and (3) trend the impact of female gender in predicting bleeding/VC over time. Bleeding/VC was defined as any access-site vessel injury requiring surgical intervention or bleeding requiring transfusion. The overall risk of bleeding/VC was significantly higher in women versus men (4.5�1.3% versus 1.6�0.5%; P <0.004). Over time, there was a significant ( P <0.001) 50% decrease in absolute bleeding/VC rates in both women and men. After adjustment for baseline differences, female gender remained a significant predictor of increased risk in 2007 (odds ratio, 2.6; 95% CI, 1.74 to 3.91). Independent predictors of increased risk of bleeding/VC in women included older age, shock, renal failure, presentation with non-ST-elevation myocardial infraction and larger sheath sizes, whereas the use of fluoroscopy-guided access, closure devices, history of dyslipidemia or prior PCI, and use of bivalirudin were protective.

Conclusion— Women undergoing PCI have had a significant decline in bleeding/VC rates during the last 6 years. Despite the improvement in procedural safety, female gender continues to be associated with a >2-fold risk of bleeding/VC compared with men.

Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR)

BACKGROUND

Although prior studies have demonstrated disparities in the management and outcomes of women with acute coronary syndrome (ACS), there are limited large-scale contemporary data on gender differences in post-intervention outcomes in this population.

METHODS

We analyzed patients according to 2 ACS categories, unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and ST-elevation myocardial infarction (STEMI) who had a percutaneous coronary intervention in the ACC-NCDR from January 1, 2004, to March 30, 2006. Of 199,690 patients, 55,691 women presented with UA/NSTEMI, and 12,335 women presented with STEMI. Clinical and angiographic characteristics, procedural and treatment patterns, and in-hospital outcomes were examined.

RESULTS

Women presented more often with UA/NSTEMI than men (82% of women vs 77% of men, P < .0001). Despite having greater comorbidities, women in both ACS categories had fewer high risk angiographic features than men. Women were less likely to receive aspirin or glycoprotein IIb/IIIa inhibitors, and were less often discharged on aspirin or statin. For in-hospital mortality, the adjusted odds ratio for men compared to women was similar (odds ratio 0.97, P = .5). Women had higher rates of cardiogenic shock, congestive heart failure, any bleeding, and any vascular complications. Importantly, rates of subacute stent thrombosis were less in women compared to men (0.43% vs 0.57%, P = .0003).

CONCLUSIONS

Although women had fewer high-risk angiographic features than men, they continue to have higher rates of in-hospital complications. This suggests the need for gender-tailored techniques to minimize post-intervention complications and maximize application of evidence-based antiplatelet therapies.

Ischemic complications of percutaneous femoral artery catheterization

Ischemic injuries following percutaneous femoral artery catheterization are uncommon but have been associated with vascular closure devices (VCDs). The purpose of this study was to retrospectively compare ischemic and hemorrhagic complications of femoral artery catheterization and to identify factors associated with ischemic injuries. The operative registries of the attending vascular surgeons at one academic and two community hospitals were retrospectively reviewed to identify all complications of femoral artery catheterization requiring operative intervention. Demographic, clinical, procedural, operative, and outcome data were compared between patients who sustained ischemic and hemorrhagic complications. From January 2001 to December 2006, 95 patients required operative management of complications related to femoral artery catheterization including 40 patients who experienced ischemic (group 1) and 55 patients who experienced hemorrhagic (group 2) complications. Compared to those sustaining hemorrhagic complications, ischemic complications were more frequently associated with younger age, smoking, VCD deployment, and, when controlling for VCD use, female gender. Time to presentation was also significantly longer in patients experiencing ischemic complications. Ischemic complications are increasingly recognized following femoral artery catheterization. Vascular surgeons should anticipate a new pattern of injury following femoral artery catheterization, one that often requires complex arterial reconstruction.