Anatomical, functional and pain hand assessment after transulnar artery access with ipsilateral RAO for percutaneous coronary interventions

Aims

The purpose of our research comes from the increasing need for an alternative approach when the standard right radial is not accessible, most commonly due to the presence of RAO. The use of this approach is still controversial in the interventional community, due to lack of published studies. Our purpose was to prove its' safety and success.

Material and methods

In the period from September 2019 until April 2021, 103 consecutive patients underwent PCI through primarily chosen TUA with ipsilateral RAO. These patients were included in a prospective single center study of effectiveness and safety. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TUA. Anatomical, functional and pain assessment of the punctured arm was performed at baseline and after the procedure and at follow-up. Using pre-procedural UA angiography, we measured the diameter of the UA and the collateral circulation for the occluded RA by QCA (Quantitative angiography). Values of UA diameter were compared with previous angiographies before RAO. Additional functional assessment of the arm was performed using JAMAR dynamometer for hand strength and self-assessment with QUICK DASH questionnaire. VAS score was used for pain assessment. Clinical and duplex ultrasound evaluation for ulnar patency were examined.

Results

Mean age of patients was 62.9±9 years with 30% females. Previous TRA was present in all patients, 32% of patients had multiple previous TRA (>3), with 10 being the largest number. Procedural success through primary chosen TUA with ipsilateral RAO was 96.2%. In 4 (3.8%) patients we had an inability to puncture the right UA and were transferred to left TRA. Procedural success after UA puncture was 100%. Number of punctures of the UA was 1.6±0.9 (1–6 punctures). Access site bleeding complications were detected in 4% (EASY score >2). On duplex ultrasound follow up, there wasn't a single case of UAO detected. There were no clinical or ischemic hand complications seen during long-term follow up. Local bleeding complications were found to be related to larger number of punctures, time of puncture and longer procedural time (p<0.0001). QCA assessment showed an increasing of UA diameter after RAO of 0.28±0.35 mm (p<0.0001). Dynamometer values of arm strength showed a small decrease in values 12 hours after procedure (72.6±23 vs. 71.9p, p=0.029), but without changes in initial strength on 1, 6 and up to 1 year after procedure. QUICK DASH self-assessment showed no significant changes in the follow-up period.

Conclusion

Transulnar approach with ipsilateral RAO is safe and successful for PCI. The existence of appropriate collateral support for the occluded RA, allows for a safe TUA with ipsilateral RAO. Anatomical, functional and pain assessment of the punctured arm affirmed the safe use of this approach as the best alternative for right TRA and preservation of wrist access benefits.

Funding Acknowledgement

Type of funding sources: None.

Sex differences in transradial access site characteristics and crossover in STEMI

Objective

To assess the differences according to sex in radial artery access site characteristics and crossover and it's influence on the success of ST segment elevation myocardial infarction (STEMI) procedures with primary chosen transradial access site in a large series of patients.

Background

Transradial angiography (TRA) is now the default access site for PPCI, but technically is a more challenging approach mostly due to anatomic challenges connected to the radial artery.

Methods

All 5092 consecutive STEMI patients from our center, in the period from March 2011 until December 2017 were examined. Patient were divided in two groups according to sex. Preprocedural radial artery angiography was performed in all patients. Clinical and procedure characteristics, type of radial anatomy variants, transfer to other access sites, transfer direction and procedure time were analyzed. Access site bleeding complications and in-hospital mortality were also recorded. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another access site to finish the procedure.

Results

From the STEMI population in this period the female group had 1326 PPCI treated patients and the male group 3766 patients. The female group of patients was older 65±11 than the male group 59±11 (p<0,0001). BMI was 27 vs. 30 in the male group (p=0.0003). Most common risk factors in both groups were hypertension, smoking and diabetes, with the latter being more frequent in the female group p<0,0001. Radial artery anomalies were more frequent in the female group 8,8% vs 6,5% (p<0,0001), with complex RA loop and tortuous RA having double percentage than in their male counterparts. Primary chosen TRA access site failure occurred in 4.6% (61) vs. 3.5% (97) of STEMI patients (p<0.0001). Most common access site crossover site was right ulnar access in both groups with 57 and 61% accordingly. Access site bleeding complications, were more common in the female group with 4.4% vs. 3.2%, also this difference persisted in EASY score hematoma 3 to 5. Clinical radial artery spasm was significantly more frequent in female patients 5,7% vs. 2.2% (p<0.0001). In-hospital mortality rate was similar in the two group of patients.

Conclusion

Female sex is a significant risk factor for TRA failure in STEMI usually connected to smaller size of RA and the more common finding of radial artery anomalies and spasm.

Funding Acknowledgement

Type of funding sources: None.

The UJI Aerial Librarian Robot: A Quadcopter for Visual Library Inventory and Book Localisation

Over time, the field of robotics has provided solutions to automate routine tasks in different scenarios. In particular, libraries are awakening great interest in automated tasks since they are semi-structured environments where machines coexist with humans and several repetitive operations could be automatically performed. In addition, multirotor aerial vehicles have become very popular in many applications over the past decade, however autonomous flight in confined spaces still presents a number of challenges and the use of small drones has not been reported as an automated inventory device within libraries. This paper presents the UJI aerial librarian robot that leverages computer vision techniques to autonomously self-localize and navigate in a library for automated inventory and book localization. A control strategy to navigate along the library bookcases is presented by using visual markers for self-localization during a visual inspection of bookshelves. An image-based book recognition technique is described that combines computer vision techniques to detect the tags on the book spines, followed by an optical character recognizer (OCR) to convert the book code on the tags into text. These data can be used for library inventory. Misplaced books can be automatically detected, and a particular book can be located within the library. Our quadrotor robot was tested in a real library with promising results. The problems encountered and limitation of the system are discussed, along with its relation to similar applications, such as automated inventory in warehouses.

Transulnar Aproach for PCI after failed ipilateral TRA: 2 sheaths in same arm, is it safe?

Aims

To assess the feasibility and safety of transulnar access (TUA) after failure to cross through ipsilateral radial access (TRA), with two sheaths placed in same arm (RA and UA).

Methods and results

All consecutive patients, with TUA due to inability to cross from ipsilateral TRA in the period from March 2011 until December 2017 were included in the study.

Pre-procedural wrist artery angiography was performed in all patients through radial and afterwards ipsilateral ulnar artery. We examined clinical and procedure characteristics, access site complications and cause of failure of primary chosen TRA. Patients were followed up with a median of 4 years.

From March 2011 untill December 2017, 104 patients had a transulnar artery approach due to inability to cross from ipsilateral radial approach. Mean age of patients was 64±11 years with 48% females. 15% of patients had a PPCI intervention due to STEMI. Cause for crossover to ipsilateral TUA was due to: inability to cross an RA anomaly in 94 patients, inability to cross high degree RA spasm in 8 and in 2 patients due to dissection of the RA. Most common anomaly of the RA that caused inability to cross was full 360 degree RA loop in 53 (56%) patients.

49 Patients (47%) underwent percutaneous coronary intervention, 5 (4,8%) patients carotid artery stenting and 50 (48%) diagnostic coronary angiography through ipsilateral TUA. Procedure duration was 35±16 minutes, contrast volume 120±35 ml and fluoroscopy time was 8±6 minutes.

Access site bleeding complications were present in 7 (6.7%) patients after procedure with Type 4 EASY Score hemathoma present in 3 patients (2.8%) without further consequences. 5.7% of patients had ipsilateral RAO noted on duplex on follow up. There were no ischemic hand complications after intervention and follow up with median of 4 years.

Conclusion

Transulnar artery access due to failed ipsilateral radial access crossing is safe and feasible for angiography and PCI with low rate of complications on long term follow up.

TUA after failed TRA (2 sheaths)

Funding Acknowledgement

Type of funding source: None

P4709Subclavian CTO stenting using bilateral retrograde wrist approach

Aims

To assess the procedural safety and results of subclavian artery stenting using bilateral retrograde radial (TRA) and/or ulnar approach (TUA).

Methods

We report 40 consecutive patients that underwent retrograde opening and stenting of the subclavian artery using wrist approach with contralateral control from the opposite TRA or TUA. Primary outcome was procedural success rate. Secondary outcomes were: presence of procedural complications, restenosis, MI, stroke or death and presence of any type of access site bleeding hemathoma. One year clinical follow up and duplex ultrasonography was done in all patients.

Results

The same technique was used in all patients: 6F guiding catheter Judkins right 4.0 was most frequently used (n=37) for coronary hydrophilic wire retrograde crossing of the occlusion and ballon predilatation. Exchange of wire was made with 0,035 guide wire. Balloon expandable stents were implanted solely through the short hydrophilic sheath, with contralateral contrast check. Contralateral injection strategy was used to confirm proper wire advancement within the lesion and optimal stent positioning. Most frequently used guide wire for CTO opening was CROSS IT 400. The average stent diameter was 7 mm (range 5.0–9.0 mm), and the average stent length was 29, 1 mm (range 15–80 mm).

38 procedures were successfully done using bilateral retrograde radial approach. Only two patients required transfer to transfemoral approach to open the subclavian chronic total occlusion. Minor access site bleeding complications were recorded in 4 patients. There were no other complications. Seven patients were discharged the same day, the others one day after admission. At follow up only one patient had symptomatic in stent restenosis and a balloon angioplasty was done inside the stent 3 years after the primary intervention, the patient was a smoker. One other patient had asymptomatic in stent restenosis documented 6 months after the intervention with duplex follow up.

Conclusions

Bilateral wrist access can be a successful and safe strategy in opening subclavian artery occlusions with a low rate of complications.

P6519Transulnar approach vs. left radial access in STEMI patients: experiences from a single high volume center

Background

Transulnar and left radial artery approach are alternative wrist access sites from right TRA for coronary diagnostic and interventional procedures. Using wrist approach in all STEMI patients can decrease access site bleeding and vascular complications, improve patient outcomes and reduce MACCE, allowing rapid ambulation.

Purpose

To compare the results of the two most common wrist access crossover sites from right TRA in a large single center registry of consecutive STEMI PPCI patients.

Methods

From March 2011 until December 2017, 5048 consecutive STEMI patients that underwent catheterization were included in a single center prospective registry. Right radial access was used in 97% (4891) of patients. From the total number of STEMI patients, Transulnar approach was used in 95 (1.9%) patients. LRA was used in 43 (0.8%), TFA in 8 (0.1%) and TBA in 11 (0.2%). We compared two groups of patients with TUA and LRA by analyzing access site complications, procedural characteristics, procedural and fluoroscopy time.

Results

All procedures were successfully performed through TUA and LRA. Procedural time was slightly longer in STEMI patients with LRA transfer (41±16 vs. 38±16 min), but there was no significant difference between patients with TUA and LRA transfer in terms of fluoroscopy time (10±9.3 vs. 10±6.8 min), procedural success and vascular complications. Patients with TUA had significantly smaller number of anomalies 1% vs. 14% in LRA and were less prone to high degree spasm 1% vs. 4,6%. Both access sites had similar number of patients with multiple access site punctures 7.3% vs. 6.9%. Hand ischemia was not observed in any patient on day 1 after procedure and on 1 month follow-up. None of the patients showed nerve injury. Minor access site hematomas were similar with 2% EASY type 1 hematoma present in both groups.

TUA vs. LRA STEMI STEMI (n=5048) LRA TUA P value ACCESS 43 (0,8%) 95 (1,9%) Anomalies 7 (14%) 1 (1%) P<0,0001 Multiple punctures >3 3 (6,9%) 7 (7,3%) NA High grade spasm 2 (4.6%) 1 (1%) P<0.0001 Procedure time 41±16 min 38±16.4 min 0.0250 Fluoroscopy time 10±6.8 10±9.3 NA STEMI = ST segment elevation myocardial infarction; LRA = Left Radial Access; TUA = Transulnar Access.

TUA vs.LRA STEMI

Conclusion

Both transulnar and left radial access are safe and feasible alternatives to the default right radial approach, decreasing the need of TFA crossover in STEMI patients.

[Expression of human papilloma virus (HPV) and P16ink4a in cervical intraepithelial neoplasia (CIN) and papilloma]

p16ink4a Is a tumor-supressor gene and a key regulator of the cell cycle. The neoplastic cervical epithelium (squamous and cylindric) intensely expresses the cyclin-dependent kinase inhibitor p16ink4a. It was shown that the expression of p16ink4a in the squamous cervical cancer was induced by HPV. The aim of our study was to reveal the frequency of expression of p16ink4a and of HPV in the different grades of CIN and in the papilomatous cervical lesions. We used biopsy material (n=11) and cone biopsies (n=10), collected from women with different grades of CIN and with papillomatous lesions, having different grades of koilocytotic dysplasia. The biopsy material, collected from one woman with squamous cervical cancer was also studied. Using the immunohistochemical procedure we determined the expression of p16ink4a and HPV in the changed squamous cervical epithelium.

RESULTS

We found that the neoplastic epithelium in CIN II and CIN III intensely expressed p16ink4a. We observed positive immune reaction for HPV in only 22.7% from the cases with papillomatous lesions, having koilocytic dysplasia. In conclusion we can state that p16ink4a could be used as a marker for the exact determination of CIN lesions in the cervix uteri. The koilocytic dysplasia, determined histologically was not always HPV-positive.

[A case of a papillary cystadenoma of boundary malignancy in a 29-year old female patient with high surgical risk]

A case of papilloferous serous cystadenoma of boundary malignancy in a 29-year old female patient, with VCS syndrome--status post phlebothrombosis ileofemoralis dextra. Thrombosis vena cava superior is presented.

[A case of a papilloferous cystadenoma of boundary malignancy in a 29-year-old female patient with high surgical risk]

A case of papilloferous serous cystadenoma of boundary malignancy in a 29-year old female patient, with VCS syndrome--status post phlebothrombosis ileofemoralis dextra. Thrombosis vena cava superior is presented.

[Clinical signs, diagnostics and treatment of the benign mesenchymal (submucosal) tumors of the gastrointestinal tract]

Benign mesenhimal tumors (submucosal) of the gastrointestinal tract are rarely found. They develop in the submucosa of the digestive tract. The tumors are covered by normal mucosa, have slow growth and tendency to ulcerations and bleeding. The clinical manifestations are not characteristic and depend on tumors size localization and complications, which often lead to diagnostic difficulties. The three cases of benign mesenchimal tumors localized in the stomach, colon and rectum, surgically removed during 2001/2002 year are represented. Typical clinical symptoms include abdominal pain, gastrointestinal bleeding and anaemia. The presented clinical cases are of great interest, because of the very low grade of incidence, non-specific clinical manifestations and different diagnosis. Expressive intraoperative histological confirmation of the diagnosis is absolutely necessary. Recurrences are not found in the treated patients.

[Mola hydatidosa of the uterine tube]

A case of only rare localization of hydatidiform mole in fallopian tube is described. This localization is, recent clinical as ectopic pregnancy. In the last 25 years (1974-1999) was described only 30 cases of tubal localysation of hydatidiform mole.

[Application of Nd YAG laser for the treatment of preneoplastic lesions of the uterine cervix]

The authors represented the data of treatment for CIN with Nd YAG laser by 266 women Two laser methods was use--direct by 93 women and indirect by 173. The effect of treatment with direct Nd YAG laser application for all cervieaf lesions ist 100%. There was no one patients with relapse by use the second method the effect ist for 92 to 96.7%. The persistence of lesion ist 3 to 7%, and relapse--3%.

[Colposcopic findings in HPV lesions of the uterine cervix]

Colposcopics Finding in HPV Lessions of Uterine Cervix, Busalov S, Todorova M, Vasilev I, Galabova M. Medical Faculty, Thracian University Stara Zagora. For 10 years period 6690 colposcopics examinations were provided. In 247 patients (3.69%) is determined atypical colposcopics findings suspected for HPV infection and is done target biopsy of PVCU. According to hystological results the cases are divided in 2 groups: with CIN and without CIN. The most frequently observed lesions of the uterine cervix in HPV infection are: flat papilloma--65.9%, inverting papilloma--25%, exotic papilloma--4.25% and mixed papilloma--4.79%. In 188 (75.8%) patients HPV lesions are without association with CIN and in 59 (23.7%)--they are in association with various CIN diseases. The most common age is to 35 years old.

[Inborn laryngeal cysts - description of a case with fatal outcome]

The authors describe a case of a newborn baby with inborn laryngomucocaele, living 14 days after birth. The newborn baby was looked after with artifical lentilation. Because of the inability of self breathing the baby underwent tracheostomia. The autopsy revealed the presence of laryngomucocaele.

[Prenatal diagnosis of bilateral fetal renal polycystosis]

Congenital abnormalities of the renal and urinary tract (CARUT) of the foetus constitute about 20-30% of all abnormalities. The frequency of infant mortality of genito-uretral malformations is about 10 to 100,000 lye-burts. The early and opportune antenatal diagnosis of these abnormalities by ultrasound examination of the foetus improves considerably the prognosis of children having such divergences in their renal and urinary tract. The authors represent a clinical case of antenatal diagnosis of a foetus with congenital bilateral renal polycystosis in the first half of the period of pregnancy and emphasize the importance of systematic ultrasonographic screening of the pregnant patients. A bibliographical survey of the CARUT is made together a review of the potentialities of ultrasonographic screening for diagnosing in time for due action in the presence of any abnormalities of the renal and urinary tract.

[The basement membrane proteins collagen type IV and laminin and the preinvasive reorganization of the stroma in carcinoma in situ of the cervix uteri]

The migration of tumor cells through the basal membrane (BM) is a key event in the cascade of tumor infiltration and metastasizing. The aim of the present study is to investigate BM proteins larniriin and collagen IV in cervical carcinoma in situ and the preinvasive reorganization of the underlying stroriia. 15 worileri with biopsy diagnosis of cancer in situ are studied. The immunohistochemical PAP-reaction on fresh and parafiri sections is used. Light microscopically there are features of characteristic reorganization of the stroma lying under the neoplasia: neocapillarization next to BM and lack of vascular proliferation far away front it; localized swelling and expressed iriflariiriiatory irifiltrate in these regions. The immunolocalization of laminin and collagen type IV is important for the assessment of BM under the intraepithelial cancer.

Dependence of the sympatho-adrenal activity on the nutritional status in corticosterone treated rats

1. An integrated sympatho-adrenal (SA) activity, expressed in terms of urinary catecholamines (CA) excretion, and direct sympathetic activity in the interscapular brown adipose tissue (IBAT), expressed in terms of noradrenaline (NA) turnover, were studied in corticosterone treated stock fed and sucrose overfed rats. 2. Corticosterone in stock fed rats significantly decreased both the rate of IBAT NA turnover and its mass as well as urinary NA excretion but did not change either IBAT NA content, urinary adrenaline excretion or adrenal CA content. 3. Sucrose overfeeding significantly increased SA activity, i.e. the rate of NA turnover in the IBAT and urinary excretion of CA. However, corticosterone did not inhibit the sucrose-induced sympathetic nervous system activation but potentiated the activity of adrenal medulla. 4. The results suggest that the effect of corticosterone treatment on the SA activity in rats is dependent, in addition to other factors, on the nutritional status of the animals.