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Dahm J.B.,Heart and Vascular Center Neu Bethlehem | van Buuren F.,Heart and Diabetes Center
Indian Heart Journal | Year: 2010

Before ten years, radial artery was discovered as a useful vascular access site for percutaneous coronary procedures. It has the advantage of reduced access site complications but is associated with specific technical challenges in comparison with the transfemoral approach. Although earlier data from a meta-analysis indicated higher procedure failure rates with radial - as compared to femoral access (7.2 vs. 2.4%), more recent data from prospective multicenter studies and large meta analysis showed significantly better outcomes with radial access versus femoral access in contemporary, real-world clinical settings of percutaneous cardiovascular procedures (e.g. PREVAIL-, PRESTO-ACS-studies). This includes also challenging coronary procedures in acute coronary syndromes (NSTEMI and STEMI) where the radial access was associated with fewer bleeding complications leading to better long-term outcomes. Transradial procedure failures can sometimes be due to variation in radial artery anatomy (e.g. vessel diameter, anomalous branching patterns, tortuosity) or risk factors for radial spasms (e.g. smoking, anxiety, vessel diameter, age, gender). Postprocedural radial occlusions (0.6-1.2%) seems strongly be related to these anatomical variances, which possibly may be reduced by the use of smaller catheter, however 5 French lumen diameter guiding catheter include limitations regarding treating options in complex coronary lesion. In conclusion, the transradial access for coronary angiography and interventions is not only to enhance patients comfort, but shows significant better long term results due to less bleeding complications as compared to the femoral access.

Wohrle J.,University of Ulm | Zadura M.,Heart and Diabetes Center | Mobius-Winkler S.,University of Leipzig | Leschke M.,Pneumology and Angiology | And 7 more authors.
Journal of the American College of Cardiology | Year: 2012

Objectives: This study sought to assess the safety and efficacy of paclitaxel-coated balloon (PCB) angioplasty in an international, multicenter, prospective, large-scale registry study. Background: In small randomized trials, PCB angioplasty was superior to uncoated balloon angioplasty for treatment of bare-metal stent (BMS) and drug-eluting stent (DES) restenosis. Methods: Patients treated with SeQuent Please PCBs were included. The primary outcome measure was the clinically driven target lesion revascularization (TLR) rate at 9 months. Results: At 75 centers, 2,095 patients with 2,234 lesions were included. The TLR rate was 5.2% after 9.4 months. Definite vessel thrombosis occurred in 0.1%. PCB angioplasty was performed in 1,523 patients (72.7%) with DES or BMS restenosis and 572 patients (27.3%) with de novo lesions. The TLR rate was significantly lower in patients with PCB angioplasty for BMS restenosis compared with DES restenosis (3.8% vs. 9.6%, p < 0.001). The TLR rate did not differ for PCB angioplasty of paclitaxel-eluting stent and non-paclitaxel-eluting sten restenosis (8.3% vs. 10.8%, p = 0.46). In de novo lesions (small vessels), the TLR rate was low and did not differ between PCB angioplasty with and without additional BMS implantation (p = 0.31). Conclusions: PCB angioplasty in an all-comers, prospective, multicenter registry was safe and confirmed in a large population the low TLR rates seen in randomized clinical trials. PCB angioplasty was more effective in BMS restenosis compared with DES restenosis, with no difference regarding the type of DES. © 2012 American College of Cardiology Foundation.

Dahm J.B.,Heart and Vascular Center Neu Bethlehem | van Buuren F.,Heart and Diabetes Center
Indian Heart Journal | Year: 2010

Transradial access is associated with enhanced patients' comfort, significant lower complication rates in diagnostic coronary angiography and better immediate and long-term outcomes after transradial percutaneous coronary interventions. Access failure has been reported to occur in less than 3-7% of cases due to anatomical circumstances (e.g., anomalous radial branching patterns, tortuosity e.g. radial loops, and small radial artery diameters). Radial coronary angiography and angioplasty entail a secondary learning curve of at least 150 cases in order to become familiar and comfortable with this technique. In contrast to previous established techniques (e.g. Sones-arteriotomy), the patient should be positioned in a comfortable supine position with his right arm next to his hip and the interventionist next to the right side of the patient. 19 gauge needles and 0.018 inch wires enhance the chance of successful cannulation the radial artery. A spasmolytic cocktail (3 mg Dinitrate, 3 mg verapamil, at least 3.000 U Heparine) should always be given intraarterially. Longer sheaths (> 13 cm) are not necessary. Essential for easy passage of the vertebralian artery and the common brachio-cephalic trunc (as the most dangerous part of the procedure) in order to reach the ascending aorta, the patient should be asked for a deep inspiration and/or dorsoflexion of his head. An Amplatz-II catheter can be used for LCA, RCA and in some cases for LV-angiogram. The sheath should always be removed immediately and hemostasis achieved by radial compression (e.g. clamp). There is a close relationship between access failure respective radial spasm or occlusions and anatomical circumstances (i.e., hypoplastic radial artery, radioulnar loop, or small radial diameters: radial diameter-to-catheter ration < 1.0; assessment by Duplex). Although the radial access can be used in the majority of patients, the use is limited in patients with very small radial diameters and/or with complex lesions (e.g kissing balloon, etc).

Dahm J.B.,Heart and Vascular Center Neu Bethlehem | van Buuren F.,Heart and Diabetes Center | Hansen C.,Heart and Vascular Center Neu Bethlehem | Becker J.,Heart and Vascular Center Neu Bethlehem | Wolpers H.-G.,Heart and Vascular Center Neu Bethlehem
Vasa - Journal of Vascular Diseases | Year: 2011

Background: Carotid artery stenting (CAS) from the femoral approach can be anatomically very difficult and the incidence of complications is higher in patients with anatomical variations of the aortic arch, difficulties related to peripheral vascular disease and/or with access site complications. Because the typical morphology in patients with a bovine- or type-III aortic arch applies for an arterial access from the right upper extremity (e.g. radial, brachial) we evaluated success rates and safety of the right transradial access in a prospective study. Patients and methods: Between June 2009 and October 2010, seventeen patients (mean age 74,4 ± 9 years, 10 male) with a bovine- (n = 4) or type-III aortic arch (n = 12) underwent CAS with a planned transradial- (n = 3) or aft er problematic transfemoral access (n = 14). In patients with a type-III aortic arch (n = 13), the right target common carotid artery (CCA) was cannulated from the right radial artery with a 5F IMA diagnostic catheter-, in patients with a bovine aortic arch (n = 4), the left CCA was accessed from the right radial artery with a 5F Amplatz- or Judkins left catheter. In all patients a 6F- (n = 14) or 5F- (n = 3) shuttle sheath was inserted via the diagnostic catheter and a 0.035; extra-stiffguidewire. All interventions were carried out with the use of a peripheral embolization protection device (EPD). Primary study endpoints were procedural success and major adverse cardiac and cerebrovascular events (MACCE), secondary endpoints were access site complications and the mean intervention time. Results: Procedural success could be achieved in all patients (100 %), MACCE and access site complications did not occur in any patient. Mean interventional time was 48 ± 18 min. Conclusions: CAS using the right transradial approach for left CAS in bovine-type aortic arch or the right transradial approach in type-III aortic arch for right CAS appears to be safe and technically feasible. © 2011 by Hans Huber Publishers, Hogrefe AG, Bern.

Sossalla S.,University of Gottingen | Fluschnik N.,University of Gottingen | Ort K.R.,University of Gottingen | Neef S.,University of Gottingen | And 8 more authors.
Circulation Research | Year: 2010

Rationale: Heart failure (HF) is known to be associated with increased Ca/calmodulin-dependent protein kinase (CaMK)II expression and activity. There is still controversial discussion about the functional role of CaMKII in HF. Moreover, CaMKII inhibition has never been investigated in human myocardium. Objective: We sought to investigate detailed CaMKIIδ expression in end-stage failing human hearts (dilated and ischemic cardiomyopathy) and the functional effects of CaMKII inhibition on contractility. Methods and Results: Expression analysis revealed that CaMKIIδ, both cytosolic δC and nuclear δB splice variants, were significantly increased in both right and left ventricles from patients with dilated or ischemic cardiomyopathy versus nonfailing. Experiments with isometrically twitching trabeculae revealed significantly improved force frequency relationships in the presence of CaMKII inhibitors (KN-93 and AIP). Increased postrest twitches after CaMKII inhibition indicated an improved sarcoplasmic reticulum (SR) Ca2+ loading. This was confirmed in isolated myocytes by a reduced SR Ca2+ spark frequency and hence SR Ca2+ leak, resulting in increased SR Ca 2+ load when inhibiting CaMKII. Ryanodine receptor type 2 phosphorylation at Ser2815, which is known to be phosphorylated by CaMKII thereby contributing to SR Ca2+ leak, was found to be markedly reduced in KN-93-treated trabeculae. Interestingly, CaMKII inhibition did not influence contractility in nonfailing sheep trabeculae. Conclusions: The present study shows for the first time that CaMKII inhibition acutely improves contractility in human HF where CaMKIIδ expression is increased. The mechanism proposed consists of a reduced SR Ca2+ leak and consequently increased SR Ca2+ load. Thus, CaMKII inhibition appears to be a possible therapeutic option for patients with HF and merits further investigation. © 2010 American Heart Association. All rights reserved.

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