Vascular Access Site and Outcomes in 58,870 Patients Undergoing Percutaneous Coronary Intervention With a Previous History of Coronary Bypass Surgery: Results From the British Cardiovascular Interventions Society National Database

Complex high-risk percutaneous coronary intervention types, trends, and outcomes according to vascular access site

BACKGROUND

Radial access is associated with improved outcomes following percutaneous coronary intervention (PCI); however, its role in complex, high-risk percutaneous coronary intervention (CHiP) remains poorly studied.

METHODS

We studied retrospectively all registered patients's records from the British Cardiovascular Intervention Society dataset and compared the baseline characteristics, trends and outcomes of CHiP procedures performed electively between January 2006 and December 2017 according to the access site.

RESULTS

Out of 137,785 CHiP procedures, 61,825 (44.9%) were undertaken via transradial access (TRA). TRA use increased over time (14.6% in 2006 to 67% in 2017). The TRA patients were older, with a greater prevalence of previous stroke, hypertension, peripheral vascular disease, and smokers. TRA was used more frequently in most CHiP procedures (elderly (51.6%), chronic renal failure (52.6%), poor left ventricular (LV) function (47.6%), left main PCI (48.0%), treatment for severe vascular calcification (50.3%); although transfemoral access (TFA) was used more commonly in those with prior history of coronary artery bypass graft surgery, and PCI to a chronic total occlusion and LV support patients. Following adjustment for differences in clinical and procedural characteristics, TFA was independently associated with higher odds for mortality [adjusted odds ratio (aOR): 1.3 (1.1-1.7)], major bleeding [aOR: 2.9 (2.3-3.4)], and MACCE (following propensity score matching) [aOR: 1.2 (1.1-1.4)]. The same was found with multiple accesses: mortality [aOR: 2.1 (1.5-2.8)], major bleeding [aOR: 5.5 (4.3-6.9)], and MACCE [aOR: 1.4 (1.2-1.7)].

CONCLUSION

TRA has become the predominant access site for CHiP procedures and is associated with significantly lower mortality, major bleeding and MACCE odds than TFA.

Single Primary Retrograde Access to Treat Femoro-Popliteal Occlusive Lesions

INTRODUCTION

The retrograde puncture of a distal artery is considered a bailout procedure in case of anterograde approach failure for peripheral artery disease (PAD) treatment. A single primary retrograde access has been suggested as an efficient and safe option. As scant data are available, we present our results using this approach.

MATERIAL AND METHODS

Between August 2019 and October 2022, we performed this technique in selected patients with femoro-popliteal PAD. Chronic total occlusions (CTOs) were selected on the basis of the CTOP classification. An ultrasound-guided retrograde puncture of a tibial artery at the ankle level was performed, followed by the preferential use of 4F materials. Hemostasis of the puncture site was obtained using manual compression. Postoperative duplex scan examination systematically included an evaluation of the punctured artery. Demographics, intraoperative, and follow-up data were collected retrospectively. The results are expressed as means with standard deviations and numbers with percentages when appropriate.

RESULTS

In total, 55 procedures were performed in 46 patients (9 bilateral). Of these, 57% (N=26) were considered at risk for femoral puncture (obesity, history of groin surgery, challenging crossover approach) and 54% (N=25) presented with critical limb-threatening ischemia (CLTI). The TASC-II femoro-popliteal classification was generally B (60%) and also C (33%) or D (7%). Mean lesion length was 105.6±49.4 mm and 65% were CTOs. Most patients were operated in an outpatient setting (N=25; 54%) under potentialized local anesthesia (N=41, 89%). The punctured site was the posterior tibial artery in 73% (N=40). The procedure time was 65.1±25.7 minutes, and the fluoroscopy time was 10.7±8.5 minutes. The technical success rate was 100%. There were no intraoperative complications. All patients could walk the same day. One CLTI patient presented an erysipelas related to the puncture in postoperative period. At 30 days, the primary patency of the treated and the punctured arteries were 98% and 100%, respectively.

CONCLUSION

A single primary retrograde access can be used safely to treat femoro-popliteal PAD. It represents a valuable alternative to the femoral puncture and allows fast ambulation. Prospective and long-term studies on larger populations are necessary to confirm our results.

CLINICAL IMPACT

This study demonstrates that a single primary retrograde access can be used safely without damaging the punctured artery to treat femoro-popliteal lesions, especially in claudicant patients. Chronic total occlusions can be treated successfully using this technique. This approach represents a valuable alternative to the femoral puncture and allows fast ambulation without risk of major bleeding.

Comparing Left Internal Mammary Angiography via Right Radial or Femoral Access With a Single-Catheter Technique

BACKGROUND

We compared the safety and effectiveness of left internal mammary artery (LIMA) angiography through right radial (Rad) or femoral (Fem) artery access with a single-catheter technique.

METHODS

LIMA selective imaging was attempted through Rad access with a Bartorelli-Cozzi 5.2Fr catheter in 190 consecutive patients. They were compared with 190 consecutive patients in whom LIMA was imaged with a mammary catheter via Fem access. Successful LIMA imaging within 15 min and time needed for imaging were efficacy end-point. Safety metrics were cerebral ischemic events and access site complications.

RESULTS

Overall success rate of Rad LIMA imaging was 62 %. The success rate of Fem LIMA imaging was 97 %. In Rad group, patient age emerged as the single independent correlate of success at multivariate analysis (OR 9.938, CI 0.902-0.977 p = 0.002), with 77 % success rate in the lowest age quartile (<67 years). Median time needed to obtain selective LIMA imaging was significantly longer in Rad than in Fem (5.5 min vs. 4.0 min, p < 0.001), but right radial access was not a significant predictor of time needed to image LIMA at multivariate analysis (K 0.726, CI [-0.130-1.581], p = 0.09). Access site complications (6 vs. 0 cases, p = 0.030), and clinically significant bleeding (4 vs. 0 cases, p = 0.1) occurred in Fem group only. No peri-procedural cerebrovascular events were seen in either Group.

CONCLUSIONS

Right radial artery is a suboptimal, yet reasonable access for LIMA-graft selective imaging in younger patients. The technique is free from vascular complications and peri-procedural cerebrovascular events.

Radial versus femoral access in patients with coronary artery bypass surgery: Frequentist and Bayesian meta-analysis

BACKGROUND

The optimal access site for cardiac catheterization in patients with prior coronary artery bypass surgery (CABG) continues to be debated.

METHODS

We performed a random effects frequentist and Bayesian meta-analysis of 4 randomized trials and 18 observational studies, including 60,192 patients with prior CABG (27,236 in the radial group; 32,956 in the femoral group) that underwent cardiac catheterization. Outcomes included (1) access-site complications, (2) crossover to a different vascular access, (3) procedure time, and (4) contrast volume. Mean differences (MD) and 95% confidence interval (CI) were calculated for continuous outcomes and odds ratios (OR) and 95% CI for binary outcomes.

RESULTS

Among randomized trials, crossover (OR: 7.63; 95% CI: 2.04, 28.51; p = 0.003) was higher in the radial group, while access site complications (OR: 0.96; 95% CI: 0.34, 2.87; p = 0.94) and contrast volume (MD: 15.08; 95% CI: -10.19, 40.35; p = 0.24) were similar. Among observational studies, crossover rates were higher (OR: 5.09; 95% CI: 2.43, 10.65; p < 0.001), while access site complication rates (OR: 0.52; 95% CI: 0.30, 0.89; p = 0.02) and contrast volume (MD: -7.52; 95% CI: -13.14, -1.90 ml; p = 0.009) were lower in the radial group. Bayesian analysis suggested that the odds of a difference existing between radial and femoral are small for all endpoints except crossover to another access site.

CONCLUSION

In a frequentist and Bayesian meta-analysis of patients with prior CABG undergoing coronary catheterization, radial access was associated with lower incidence of vascular access complications and lower contrast volume but also higher crossover rate.

Access Site Related Vascular Complications following Percutaneous Cardiovascular Procedures

Vascular access site complications (ASC) are among the most frequent complications of percutaneous cardiovascular procedures (PCP) and are associated with adverse outcome and high resources utilization. In this prospective study, we investigated patients with postprocedural clinical suspicion of ASC evaluated by duplex ultrasound (DUS) for the presence of ASC. We assessed the incidence, in-hospital outcome, treatment of complications and predictors for ASC. Overall, 12,901 patients underwent PCP during a 40 months period. Of those, 2890 (22.4%) patients had postprocedural clinical symptoms of ASC and were evaluated using DUS. An ASC was found in 206 of the DUS examined patients (corresponding to 7.1% of the 2890 DUS examined patients). In 6.7% of all valvular/TAVI procedures, an ASC was documented, while coronary, electrophysiological and peripheral PCP had a comparable and low rate of complications (1.2–1.5%). Pseudoaneurysm (PSA) was the most frequent ASC (67.5%), followed by arteriovenous fistula (13.1%), hematoma (7.8%) and others (11.7%). Of all PSA, 84 (60.4%) were treated surgically, 44 (31.6%) by manual compression and 11 (7.9%) conservatively. Three (0.02%) patients died due to hemorrhagic shock. In conclusion, femoral ASC are rare in the current era of PCP with PSA being the leading type of ASC. Nonetheless, patients with predisposing risk factors and postprocedural suspicious clinical findings should undergo a DUS to early detect and mitigate ASC-associated outcome.

Impact of radial access on contrast-induced acute kidney injury in patients with coronary artery bypass grafts

PURPOSE

We investigated the impact of radial access on contrast-induced acute kidney injury (CI-AKI) in patients with coronary artery bypass graft (CABG) undergoing cardiac catheterization.

METHODS

This retrospective monocenter study included 527 CABG patients undergoing cardiac catheterization via radial (58.1%, N = 306) or femoral access (41.9%, N = 221). Primary outcome measure was CI-AKI defined in accordance with the KDIGO criteria. Independent predictors for CI-AKI were assessed. 1-year mortality was assessed depending on the occurrence of CI-AKI.

RESULTS

In total, 99 CABG patients (18.8%) developed CI-AKI within 48 h after cardiac catheterization. Compared to patients without CI-AKI, amount of contrast media used (203.1 ± 102.6 ml vs. 204.2 ± 98.2 ml; P = 0.892) as well as procedural times (87.9 ± 44.8 vs. 79.8 ± 37.0; P = 0.190) were similarly. Regarding vascular access, there was no significant difference in the incidence of CI-AKI between radial and femoral approach (19.0% vs. 18.6%; p = 0.907). However, poor left ventricular ejection fraction (odds ratio [OR] = 1.72, P = 0.026), chronic kidney disease (OR = 2.30, P = 0.001) and acute coronary syndrome (OR = 1.64, P = 0.043) were independent predictors for CI-AKI. The occurrence of CI-AKI was significantly associated with an increased 1-year mortality (hazard ratio [HR] = 2.52, P = 0.003).

CONCLUSIONS

With 18.8%, CI-AKI is a frequent complication in CABG patients undergoing cardiac catheterization. Radial access did not decrease the risk when compared to the femoral approach.

Angiographic evaluation of radial artery injury after transradial approach for percutaneous coronary intervention

The transradial approach for percutaneous coronary intervention (TRA-PCI) has been increasingly gaining popularity in clinical practice. However, its association with risk for long-term radial artery injury has not been yet thoroughly defined. We retrospectively examined the patients undergoing radial artery angiography (RAG) after TRA-PCI to determine the incidence and risk factors of radial artery injury. The study included 558 patients undergoing follow-up radial artery angiography at 12 month after TRA-PCI. Radial artery injury occurred in 140 patients (25%) with 3 distinct morphological patterns: focal radial artery stenosis (RAS) P.7,7: in 7 patients (1%), diffuse radial artery stenosis (RAS) in 78 patients (14%), and radial artery occlusion (RAO) in 55 patients (10%). Patients with RAS/RAO were more likely to be female, had smaller height and body weight, smaller body mass index and smaller body surface area (BSA) as compared with those without RAS/RAO. Multivariable logistic regression analysis identified BSA (odds ratio, 1.34 per 0.1 m² increase; 95% confidence interval, 1.07-1.71; p = 0.01) and a history of TRA-PCI (odds ratio, 2.35; 95% confidence interval, 1.16-5.08; p = 0.017) as independent predisposing factors of radial artery injury. In a sub-analysis of 323 patients undergoing both pre-PCI RAG and follow-up RAG, pre-PCI radial diameter as well as BSA and a history of TRA-PCI were independently associated with radial artery injury. Long-term injury after TRA-PCI is considerably common and care should be paid for RAS/RAO, especially for those patients with lower BSA, history of TRA-PCI and small radial artery diameter.

Cardiac Catheterizations in Patients With Prior Coronary Bypass Surgery: Impact of Access Strategy on Short-Term Safety and Long-Term Efficacy Outcomes

Little data are available on access strategy outcomes for cardiac catheterizations in patients with prior coronary artery bypass graft surgery (CABG). We investigated the effect of transradial access (TRA) and transfemoral access (TFA) on short-term major vascular complications (MVC) and long-term major adverse cardiovascular events (MACE). In this single-center, retrospective cohort study, 1084 patients met our inclusion criteria (TRA = 469; TFA = 615). The cumulative incidence for the primary safety endpoint MVC at 30 days (a composite of major bleeding, retroperitoneal hematoma, dissection, pseudoaneurysm, and arteriovenous fistula) was lower with TRA (0.7% vs 3.0%, P < .01) and this difference remained significant after propensity score adjustment (odds ratio: 0.24; 95% CI, 0.07-0.83; P = .024). The cumulative incidence for the primary efficacy endpoint MACE at 36 months (a composite of all-cause mortality, myocardial infarction, stroke, and urgent target vessel revascularization) was 28.6% with TRA and 27.6% with TFA, respectively. Kaplan-Meier curves showed no difference for the primary efficacy endpoint (P = .65). Contrast use (mL) was significantly lower with TRA (130 [100-180] vs 150 [100-213], P < .01). In conclusion, in patients with prior CABG, TRA was associated with significantly fewer short-term MVC and contrast use, but not with a difference in long-term MACE, compared with TFA.

Latest developments in chronic total occlusion percutaneous coronary intervention

INTRODUCTION

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.

AREAS COVERED

We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.

EXPERT OPINION

After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

Complex high-risk and indicated percutaneous coronary intervention for stable angina: Does operator volume influence patient outcome?

BACKGROUND

Complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) is an emerging concept that is poorly studied.

OBJECTIVE

To define temporal changes in CHIP-PCI volumes, and the relationship between operator CHIP-PCI volume and patient outcomes.

METHODS AND RESULTS

Data were analyzed on all CHIP-PCI procedures undertaken for stable angina in England and Wales between 2007 and 2014. Operator volume data was available for 2012-14. CHIP-PCI was defined by patient characteristics (age ≥80years, left ventricular (LV) ejection fraction <30%, previous CABG, or chronic renal failure) and/or by procedural characteristics (left main PCI, chronic total occlusion PCI, LV support, use of rotational atherectomy or laser atherectomy). CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Between 2012 and 2014, a total of 30,268 CHIP-PCI cases were performed. Total operator volume varied from 1 to 580 cases with median total operator volume of 29 cases. Higher operator volumes were associated with a greater degree of patient comorbidity and increasing procedural complexity. After adjustment for baseline difference, in-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) were associated with increasing operator CHIP-PCI volumes. However, the frequency of in-hospital death (P = .394) and 12-month mortality (P = .638) were similar across the volume quartiles. Higher volumes quartiles were associated with a greater likelihood of same day discharge (P < .001).

CONCLUSIONS

CHIP-PCI cases are an increasingly large population in contemporary PCI practice. Higher operator volumes were not associated with improved 12-month survival.

CONDENSED ABSTRACT

Data were analyzed on all complex high-risk and indicated revascularization using percutaneous coronary intervention (CHIP-PCI) procedures in England and Wales between 2007 and 2014. CHIP-PCI as a percentage of total PCI increased from 28.1% in 2007 to 36.2% in 2014 (P < .001). Median total operator volume was 29 cases with higher volumes associated with more patient comorbidity and increasing procedural complexity. In-hospital major bleeding (P < .001 for trend), access site complications (P < .001) and coronary perforation (P = .002) all associated with increasing operator CHIP-PCI volumes. However, trends for in-hospital death (P = .394), and 12-month mortality (P = .638) were similar across the volume quartiles.

Outcomes of percutaneous coronary intervention (PCI) among patients with connective tissue disease: Propensity match analysis

BACKGROUND

Inflammation is the hallmark of coronary artery disease (CAD) and CTD. There are reports of increased prevalence of CAD among patients with CTD such as Rheumatoid Arthritis. However, there is a paucity of data regarding the outcomes of PCI among patients with CTD.

METHODS

Using the National Inpatient Database, patients that underwent PCI between 2007 and 2015 were identified using ICD-9-CM codes. Propensity match analysis with 1: 3 matching of patients with and without CTD was performed. Outcomes were acute kidney injury (AKI), access site complication (ASC), ventricular fibrillation (VF), cardiogenic shock (CS), Stroke, In-hospital mortality and hospital length of stay (LOS) compared between both groups.

RESULT

We identified 17,422 patients with CTD and matched with 52, 266 patients without CTD. Patients were predominantly female (63.1%) and white (77.2%), with a mean age of 63 ± 12.1 years. AKI (8.3% vs. 6.6%, p < 0.001), ASC (3.2% vs. 2.7%, p = 0.01) and hospital stay (4.2 ± 4.8 vs. 3.8 ± 5.2, p < 0.001) were higher among patients with CTD. There was no statistically significant difference in rates of VF, CS, stroke, and In-hospital mortality among the two groups. However, in subgroup analysis, rates of VF were lower among patients with Systemic Lupus Erythematosus (SLE) (1.5% vs. 2.2%, p = 0.006).

CONCLUSIONS

Patients with CTD undergoing PCI have a higher rate of AKI, Access site complications, and prolonged hospital stay.

Temporal trends in the practice of the transradial approach for percutaneous coronary intervention in a large tertiary center

OBJECTIVE

The transradial approach (TRA) has increasingly been adopted for the use of percutaneous coronary interventions (PCI), with reported clinical benefits. Little is known regarding the change in outcomes over time.

PATIENTS AND METHODS

From our large single-center PCI registry, we have analyzed 15 429 patients in two periods - 2008-2012 (period 1) and 2013-2017 (period 2). We examined the proportions of use of TRA, the influence on in-hospital outcomes, and adjusted long-term effects.

RESULTS

The rate of TRA rose from 15.9% in period 1 to 69.1% in period 2, including in specific situations such as acute coronary syndrome, chronic total occlusion, bifurcation, calcified lesions, and unprotected left main PCI. In-hospital rates of bleeding were lower for TRA versus transfemoral artery (1.8 vs. 5.1%, overall, P < 0.001), as were rates of additional bleeding events in the following 12 months (1.3 vs. 2.4%, P < 0.001). Following multivariate analysis, use of TRA was associated with a lower 30-day and 4-year rate of the composite outcomes of death, myocardial infarction, target vessel revascularization, or coronary artery bypass surgery [at 4 years, hazard ratio (HR) = 0.86; 95% confidence interval (CI): 0.77-0.96; P = 0.007, during period 1 and HR = 0.62; 95% CI 0.55-0.7; P < 0.0001 during period 2]. Interaction analysis showed a stronger effect at the latter period (HR = 0.69, 95% CI: 0.59-0.81, P < 0.001).

CONCLUSION

Over a decade of follow-up, TRA has gained acceptance for different PCI scenarios, including complex patients - a course which is associated with consistent short and long-term clinical benefits.

Radial Versus Femoral Access in Chronic Total Occlusion Percutaneous Coronary Intervention

Background:

Radial access (RA) is increasingly used in chronic total occlusion (CTO) percutaneous coronary intervention with encouraging results. However, there are concerns about its safety and efficacy because of higher complexity and the need for strong guide catheter support.

Methods and Results:

We performed a systematic review and meta-analysis of all studies published through November 2018 reporting the outcomes of RA versus femoral access in CTO percutaneous coronary intervention. Outcomes included major bleeding, access-site complications, in-hospital major adverse events, and technical success. Nine observational studies with 10 590 patients (10 617 lesions) were included in the meta-analysis. CTO lesions attempted using RA had lower Japan-CTO score (2.3±1.2 versus 2.5±1.3; P <0.001). Use of RA was associated with similar technical success (78.7% versus 78.5%; odds ratio, 1.11; 95% CI, 0.94–1.31; P =0.24; I 2 =23%), lower risk of access-site complications (0.73% versus 1.79%; odds ratio, 0.34; 95% CI, 0.22–0.51; P <0.001; I 2 =0%) and major bleeding (0.18% versus 0.9%; odds ratio, 0.22; 95% CI, 0.10–0.45; P <0.001; I 2 =0%), and similar risk of in-hospital adverse events and in-hospital mortality (odds ratio, 0.36; 95% CI, 0.12–1.07; P =0.07; I 2 =0%) as compared to femoral access. Results were similar when analyzing radial-only versus any femoral access and when excluding the largest study.

Conclusions:

As compared with femoral access, RA is used in CTO percutaneous coronary intervention of less complex lesions and is associated with fewer access-site complications and major bleeding and comparable technical success.