Quebec Heart Lung Institute


Quebec Heart Lung Institute

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Patel T.,Apex Heart Institute | Patel T.,Sheth Vs General Hospital | Shah S.,Apex Heart Institute | Shah S.,Sheth Vs General Hospital | And 4 more authors.
Catheterization and Cardiovascular Interventions | Year: 2014

Objective To examine the use and outcomes of balloon-assisted tracking (BAT) technique for dealing with complexities of arm and chest vasculature during transradial approach (TRA) at a single high volume radial center. Background TRA has been used for coronary angiography and percutaneous coronary interventions (PCI) around the world. Different techniques have been described to address the anatomical issues and tortuosities for successful completion of coronary angiography and PCI. This study describes the use of BAT technique and associated outcomes during real world clinical practice. Methods Subjects comprised 63 patients, (out of total 8,245 patients between January 2011 and December 2012) in whom we encountered significantly complex anatomical course in radial, brachial, or subclavian region, leading to difficult advancement of a diagnostic or a guide catheter despite trying all standard maneuvers. In all of them BAT technique was used and they were retrospectively analyzed for the purpose of this study. Results About 63 (0.76%) of 8,245 patients met the study criteria. Twenty-five (39.7%) patients had very small RA. Twenty-two (34.9%) had severe RA tortuosity. Four (6.3%) had complex RA loops. Six (9.5%) had severe RA spasm and six (9.5%) had severe subclavian tortuosity and/or stenosis. We encountered technical failure in three (4.8%) patients (two had very small RA and one had 360 degree RA loop). Conclusion BAT technique was useful to address the anatomical issues and tortuosities of radial, brachial, and subclavian vasculature during TRA. Copyright © 2013 Wiley Periodicals, Inc.

Caputo R.P.,St Josephs Hospital | Tremmel J.A.,Stanford University | Rao S.,Duke University | Gilchrist I.C.,Ms Hershey Medical Center | And 7 more authors.
Catheterization and Cardiovascular Interventions | Year: 2011

In response to growing U.S. interest, the Society for Coronary Angiography and Interventions recently formed a Transradial Committee whose purpose is to examine the utility, utilization, and training considerations related to transradial access for percutaneous coronary and peripheral procedures. With international partnership, the committee has composed a comprehensive overview of this subject presented herewith. © 2011 Wiley Periodicals, Inc.

Bernat I.,University Hospital | Horak D.,Regional Hospital Liberec | Stasek J.,University of Hradec Kralove | Mates M.,Na Homolce Hospital Prague | And 16 more authors.
Journal of the American College of Cardiology | Year: 2014

Objectives This study sought to compare radial and femoral approaches in patients presenting with ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI) by high-volume operators experienced in both access sites. Background The exact clinical benefit of the radial compared to the femoral approach remains controversial. Methods STEMI-RADIAL (ST Elevation Myocardial Infarction treated by RADIAL or femoral approach) was a randomized, multicenter trial. A total of 707 patients referred for STEMI <12 h of symptom onset were randomized in 4 high-volume radial centers. The primary endpoint was the cumulative incidence of major bleeding and vascular access site complications at 30 days. The rate of net adverse clinical events (NACE) was defined as a composite of death, myocardial infarction, stroke, and major bleeding/vascular complications. Access site crossover, contrast volume, duration of intensive care stay, and death at 6 months were secondary endpoints. Results The primary endpoint occurred in 1.4% of the radial group (n = 348) and 7.2% of the femoral group (n = 359; p = 0.0001). The NACE rate was 4.6% versus 11.0% (p = 0.0028), respectively. Crossover from radial to femoral approach was 3.7%. Intensive care stay (2.5 ± 1.7 days vs. 3.0 ± 2.9 days, p = 0.0038) as well as contrast utilization (170 ± 71 ml vs. 182 ± 60 ml, p = 0.01) were significantly reduced in the radial group. Mortality in the radial and femoral groups was 2.3% versus 3.1% (p = 0.64) at 30 days and 2.3% versus 3.6% (p = 0.31) at 6 months, respectively. Conclusions In patients with STEMI undergoing primary PCI by operators experienced in both access sites, the radial approach was associated with significantly lower incidence of major bleeding and access site complications and superior net clinical benefit. These findings support the use of the radial approach in primary PCI as first choice after proper training. © 2014 by the American College of Cardiology Foundation Published by Elsevier Inc.

Rao S.V.,The Duke Clinical Research Institute | Cohen M.G.,University of Miami | Kandzari D.E.,Scripps Research Institute | Bertrand O.F.,Quebec Heart Lung Institute | Gilchrist I.C.,Penn State Hershey Medical Center
Journal of the American College of Cardiology | Year: 2010

Periprocedural bleeding complications after percutaneous coronary intervention (PCI) are associated with increased short- and long-term morbidity and mortality. Although clinical trials have primarily assessed pharmacological strategies for reducing bleeding risk, there is a mounting body of evidence suggesting that adoption of a transradial rather than a transfemoral approach to PCI may permit greater reductions in bleeding risk than have been achieved with pharmacological strategies alone. However, despite a long history of use, a lack of widespread uptake by physicians coupled with the technological limitations of available devices has in the past confined transradial PCI to the status of a niche procedure, and many operators lack experience in this technique. In this review, we examine the history of the transradial approach to PCI and discuss some of the circumstances that have hitherto limited its appeal. We then review the current state of the peer-reviewed literature supporting its use and summarize the unresolved issues affecting broader application of this technique, including lack of operator familiarity and an insufficient evidence base for guiding practice. Finally, we describe potential directions for future investigation in the transradial realm. © 2010 American College of Cardiology Foundation.

Pancholy S.B.,Wright Center for Graduate Medical Education | Bertrand O.F.,Quebec Heart Lung Institute | Patel T.,Seth Nhl Municipal Medical College
American Journal of Cardiology | Year: 2012

Systemic anticoagulation decreases the risk of radial artery occlusion (RAO) after transradial catheterization and standard occlusive hemostasis. We compared the efficacy and safety of provisional heparin use only when the technique of patent hemostasis was not achievable to standard a priori heparin administration after radial sheath introduction. Patients referred for coronary angiography were randomized in 2 groups. In the a priori group, 200 patients received intravenous heparin (50 IU/kg) immediately after sheath insertion. In the provisional group, 200 patients did not receive heparin during the procedure. After sheath removal, hemostasis was obtained using a TR band (Terumo corporation, Tokyo, Japan) with a plethysmography-guided patent hemostasis technique. In the provisional group, no heparin was given if radial artery patency could be obtained and maintained. If radial patency was not achieved, a bolus of heparin (50 IU/kg) was given. Radial artery patency was evaluated at 24 hours (early RAO) and 30 days after the procedure (late RAO) by plethysmography. Patent hemostasis was obtained in 67% in the a priori group and 74% in the provisional group (p = 0.10). Incidence of RAO remained similar in the 2 groups at the early (7.5% vs 7.0%, p = 0.84) and late (4.5% vs 5.0%, p = 0.83) evaluations. Women, patients with diabetes, patients having not received heparin, and patients without radial artery patency during hemostasis had more RAO. By multivariate analysis, patent radial artery during hemostasis (odds ratio [OR] 0.03, 95% confidence interval [CI] 0.004 to 0.28, p = 0.002) and diabetes (OR 11, 95% CI 3 to 38,p <0.0001) were independent predictors of late RAO, whereas heparin was not (OR 0.45 95% CI 0.13 to 1.54, p = 0.20). In conclusion, our results suggest that maintenance of radial artery patency during hemostasis is the most important parameter to decrease the risk of RAO. In selected cases, provisional use of heparin appears feasible and safe when patent hemostasis is maintained. © 2012 Elsevier Inc. All rights reserved.

Plante S.,Southlake Regional Health Center | Cantor W.J.,Southlake Regional Health Center | Goldman L.,Southlake Regional Health Center | Miner S.,Southlake Regional Health Center | And 4 more authors.
Catheterization and Cardiovascular Interventions | Year: 2010

Background: Anticoagulant therapy is required to prevent radial artery occlusion (RAO) after transradial catheterization. There is no data comparing bivalirudin to standard heparin. Methods: We studied 400 consecutive patients. In case of diagnostic angiography-only (n = 200), they received an intravenous bolus of heparin (70 U kg-1) immediately before sheath removal whereas in case of angiography followed by ad hoc percutaneous coronary intervention (n = 200), they received bivalirudin (bolus 0.75 mg kg -1, followed by infusion at 1.75 mg/kg/h). RAO was assessed 4-8 weeks later using two-dimensional echography-doppler and reverse Allen's test with pulse oximetry. Results: At follow-up, 21 of the 400 (5.3%) patients were found to have RAO with no significant difference between the two groups (3.5% bivalirudin vs. 7.0% heparin, P = 0.18). Patients with RAO had a significantly lower weight compared to patients without RAO (78 ± 13 kg vs. 86 ± 18 kg, P = 0.011). By multivariate analysis, a weight <84 kg (OR: 2.78, 95% CI 1.08-8.00, P = 0.032) and a procedure duration ≤20 min (OR: 7.52, 95% CI 1.57-36.0, P = 0.011) remained strong independent predictors of RAO. All cases of radial occlusion were asymptomatic and without clinical sequelae. Conclusion: Delayed administration of bivalirudin or heparin for transradial catheterization provides similar efficacy in preventing RAO. Because of its low cost, a single bolus of heparin can be preferred in case of diagnostic angiography whereas bivalirudin can be contemplated in case of ad hoc percutaneous coronary intervention. Copyright © 2010 Wiley-Liss, Inc.

Bertrand O.F.,Quebec Heart Lung Institute | Rao S.V.,Duke Clinical Research Institute | Pancholy S.,Mercy Hospital | Jolly S.S.,McMaster University | And 5 more authors.
JACC: Cardiovascular Interventions | Year: 2010

Objectives The aim of this study was to evaluate practice of transradial approach (TRA). Background TRA has been adopted as an alternative access site for coronary procedures. Methods A questionnaire was distributed worldwide with Internet-based software. Results The survey was conducted from August 2009 to January 2010 among 1,107 interventional cardiologists in 75 countries. Although pre-TRA dual hand circulation testing is not uniform in the world, >85% in the U.S. perform Allen or oximetry testing. Right radial artery is used in almost 90%. Judkins catheters are the most popular for left coronary artery angiographies (66.5%) and right coronary artery angiographies (58.8%). For percutaneous coronary intervention (PCI), 6-F is now standard. For PCI of left coronary artery, operators use standard extra back-up guiding catheters in >65% and, for right coronary artery 70.4% use right Judkins catheters. Although heparin remains the routine antithrombotic agent in the world, bivalirudin is frequently used in the U.S. for PCI. The incidence of radial artery occlusion before hospital discharge is not assessed in >50%. Overall, approximately 50% responded that their TRA practice will increase in the future (68.4% in the U.S.). Conclusions TRA is already widely used across the world. Diagnostic and guiding-catheters used for TRA remain similar to those used for traditional femoral approach, suggesting that specialized radial catheters are not frequently used. However, there is substantial variation in practice as it relates to specific aspects of TRA, suggesting that more data are needed to determine the optimal strategy to facilitate TRA and optimize radial artery patency after catheterization. © 2010 American College of Cardiology Foundation.

Bertrand O.F.,Laval University | Bagur R.,Quebec Heart Lung Institute | Costerousse O.,Quebec Heart Lung Institute | Rodes-Cabau J.,Quebec Heart Lung Institute
Indian Heart Journal | Year: 2010

Background: Little data are available on the immediate and late results of transradial percutaneous coronary intervention (PCI) compared to standard femoral approach in high-risk patients. Our objective was to compare our experience in > 80 years old patients undergoing left main PCI with transradial and femoral approach. Methods: This was a retrospective analysis of octogenarians patients treated for left main PCI in our center. In-hospital and late results were assessed. Results: From 2002 to 2008, one hundred and three octogenarians underwent PCI for left main disease. Ninety (87%) patients were treated by transradial approach and 13 (13%) by femoral approach. Patients were older in the radial group (85 ± 3 years vs 82 ± 3 years, p = 0.0067). All patients were preatreated with aspirin and clopidogrel. Patients received heparin-only in 90 % of transradial cases and 85% of femoral cases (p = 0.63), bivalirudin in 10% vs 15% (p = 0.63) and platelets glycoprotein IIb/IIIa inhibitors in 33% vs 23% (p = 0.54), respectively. Patients received 3 ± 2 stents in both groups with no difference in the rate of drug eluting stents (44% vs 69%, p = 0.14). Angiographic success was obtained in 98% vs 92% (p = 0.34) respectively with similar fluoroscopic time, procedure duration and contrast volume. Procedures were performed in 5-6Fr in 93% of transradial cases and 85% of femoral cases (p = 0.14). At 30 days, death (6% vs 15%, p = 0.21), myocardial infarction (12% vs 15%, p = 0.67) and revascularization (1% vs 0%, p = 1.00) were similar in transradial and femoral cases, respectively. Bleeding requiring transfusion occurred in 14% of radial cases compared to 23% in femoral cases (p = 0.42). Access site complications, mostly hematoma occurred less frequently after transradial than femoral approach (6% vs 31%, p = 0.014). At follow-up, cardiac death (17% vs 15%, p = 1.00), MI (23% vs 23%, p = 1.00) and revascularization (11% vs 0%, p = 0.35) remained similar in both groups. Conclusions: The majority of octogenarians with left main disease can be treated by transradial approach with similar acute and long-term results than femoral approach but with less risk of bleeding and access site complications.

Plourde G.,Quebec Heart Lung Institute | Pancholy S.B.,Wright Center for Graduate Medical Education | Nolan J.,Staffordshire University | Jolly S.,Hamilton Health Sciences | And 8 more authors.
The Lancet | Year: 2015

Background Transradial access for cardiac catheterisation results in lower bleeding and vascular complications than the traditional transfemoral access route. However, the increased radiation exposure potentially associated with transradial access is a possible drawback of this method. Whether transradial access is associated with a clinically significant increase in radiation exposure that outweighs its benefits is unclear. Our aim was therefore to compare radiation exposure between transradial access and transfemoral access for diagnostic coronary angiograms and percutaneous coronary interventions (PCI). Methods We did a systematic review and meta-analysis of the scientific literature by searching the PubMed, Embase, and Cochrane Library databases with relevant terms, and cross-referencing relevant articles for randomised controlled trials (RCTs) that compared radiation parameters in relation to access site, published from Jan 1, 1989, to June 3, 2014. Three investigators independently sorted the potentially relevant studies, and two others extracted data. We focused on the primary radiation outcomes of fluoroscopy time and kerma-area product, and used meta-regression to assess the changes over time. Secondary outcomes were operator radiation exposure and procedural time. We used both fixed-effects and random-effects models with inverse variance weighting for the main analyses, and we did confirmatory analyses for observational studies. Findings Of 1252 records identified, we obtained data from 24 published RCTs for 19 328 patients. Our primary analyses showed that transradial access was associated with a small but significant increase in fluoroscopy time for diagnostic coronary angiograms (weighted mean difference [WMD], fixed effect: 1·04 min, 95% CI 0·84-1·24; p<0·0001) and PCI (1·15 min, 95% CI 0·96-1·33; p<0·0001), compared with transfemoral access. Transradial access was also associated with higher kerma-area product for diagnostic coronary angiograms (WMD, fixed effect: 1·72 Gy·cm2, 95% CI -0·10 to 3·55; p=0·06), and significantly higher kerma-area product for PCI (0·55 Gy·cm2, 95% CI 0·08-1·02; p=0·02). Mean operator radiation doses for PCI with basic protection were 107 μSv (SD 110) with transradial access and 74 μSv (68) with transfemoral access; with supplementary protection, the doses decreased to 21 μSv (17) with transradial access and 46 μSv (9) with transfemoral. Meta-regression analysis showed that the overall difference in fluoroscopy time between the two procedures has decreased significantly by 75% over the past 20 years from 2 min in 1996 to about 30 s in 2014 (p<0·0001). In observational studies, differences and effect sizes remained consistent with RCTs. Interpretation Transradial access was associated with a small but significant increase in radiation exposure in both diagnostic and interventional procedures compared with transfemoral access. Since differences in radiation exposure narrow over time, the clinical significance of this small increase is uncertain and is unlikely to outweigh the clinical benefits of transradial access. © 2015 Elsevier Ltd.

Rao S.V.,Duke Clinical Research Institute | Bernat I.,University Hospital | Bertrand O.F.,Quebec Heart Lung Institute
European Heart Journal | Year: 2012

The adoption of transradial coronary angiography and coronary intervention is growing because of emerging data on its potential advantages over the femoral approach. As the adoption of radial procedures increases, it is important to understand the remaining challenges of both the technique and its implementation. In this review, we discuss four important issues related to transradial procedures-radial access site bleeding, radial artery injury and occlusion, radiation exposure, and implementation of a successful transradial primary percutaneous coronary intervention (PCI) programme. Although the radial artery is superficial and haemostasis can be achieved readily, access site bleeding can occur that, if left unchecked, can lead to forearm haematoma and, rarely, to compartment syndrome. Radial artery injury and occlusion are consequences of radial access, and randomized trials show that use of smaller diameter sheaths, adequate anticoagulation, and post-procedure 'patent' haemostasis reduce the risk of occlusion. The published literature demonstrates an association between transradial procedures and increased radiation exposure; therefore, reduction of radiation dosing during transradial procedures should be a priority for operators and catheterization laboratories. The potential reduction in mortality seen with transradial primary PCI must be balanced against the clinical imperative of timely reperfusion. Operators and catheterization laboratories should not begin a transradial primary PCI programme until sufficient radial experience has been gained in the elective setting. In addition, a protocol for femoral bailout should be considered to maintain door-to-reperfusion metrics. © 2012 The Author.

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