Summary 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. Funding None.
This study aims to evaluate temporal changes in stroke complications and their association with mortality and MACE outcomes in a national cohort of patients undergoing percutaneous coronary ...interventions (PCIs) in England and Wales.
A total of 426 046 patients who underwent PCI in England and Wales between 2007 and 2012 in the British Cardiovascular Intervention Society (BCIS) database were analysed. Statistical analyses were performed evaluating the rates of stroke complications according to the year of PCI and multiple logistic regressions were used to evaluate the odds of 30-day mortality and in-hospital major adverse cardiovascular events (MACE; a composite of in-hospital mortality, myocardial infarction or re-infarction, and revascularization) with stroke complications. Four hundred and thirty-six patients (0.1%) sustained an ischaemic stroke/TIA complication and 107 patients (0.03%) sustained a haemorrhagic stroke complication. Ischaemic stroke/TIA complications increased non-linearly from 0.67 (95% CI 0.47-0.87) to 1.14 (0.94-1.34) per 1000 patients between 2007 and 2012 (P = 0.006), whilst haemorrhagic stroke rates decreased non-linearly from 0.29 (0.19-0.39) to 0.15 (0.05-0.25) per 1000 patients in 2012 (P = 0.009). Following adjustment for baseline clinical and procedural demographics, ischaemic stroke was independently associated with both 30-day mortality (OR 4.92, 3.06-7.92) and in-hospital MACE (OR 3.11, 1.83-5.27). An even greater impact on prognosis was observed with haemorrhagic complications (30-day mortality: OR 13.87, 6.37-30.21), in-hospital MACE (OR 13.50, 6.30-28.92).
Incident ischaemic stroke complications have increased over time, whilst haemorrhagic stroke complications have decreased, driven through changes in clinical, procedural, drug-treatment, and demographic factors. Both ischaemic and haemorrhagic strokes are rare but devastating complications with high 30-day mortality and in-hospital MACE rates.
Abstract Objectives This study sought to define the prevalence and prognostic impact of blood transfusions in contemporary percutaneous coronary intervention (PCI) practice. Background Although the ...presence of anemia is associated with adverse outcomes in patients undergoing PCI, the optimal use of blood products in patients undergoing PCI remains controversial. Methods A search of EMBASE and MEDLINE was conducted to identify PCI studies that evaluated blood transfusions and their association with major adverse cardiac events (MACE) and mortality. Two independent reviewers screened the studies for inclusion, and data were extracted from relevant studies. Random effects meta-analysis was used to estimate the risk of adverse outcomes with blood transfusions. Statistical heterogeneity was assessed by considering the I2 statistic. Results Nineteen studies that included 2,258,711 patients with more than 54,000 transfusion events were identified (prevalence of blood transfusion 2.3%). Crude mortality rate was 6,435 of 50,979 (12.6%, 8 studies) in patients who received a blood transfusion and 27,061 of 2,266,111 (1.2%, 8 studies) in the remaining patients. Crude MACE rates were 17.4% (8,439 of 48,518) in patients who had a blood transfusion and 3.1% (68,062 of 2,212,730) in the remaining cohort. Meta-analysis demonstrated that blood transfusion was independently associated with an increase in mortality (odds ratio: 3.02, 95% confidence interval: 2.16 to 4.21, I2 = 91%) and MACE (odds ratio: 3.15, 95% confidence interval: 2.59 to 3.82, I2 = 81%). Similar observations were recorded in studies that adjusted for baseline hematocrit, anemia, and bleeding. Conclusions Blood transfusion is independently associated with increased risk of mortality and MACE events. Clinicians should minimize the risk for periprocedural transfusion by using available bleeding-avoidance strategies and avoiding liberal transfusion practices.
Long-term follow-up after an acute coronary syndrome (ACS) presents a crucial challenge due to the high residual cardiovascular risk and the potential for major bleeding events. Although several ...treatment strategies are available, this article focuses on patients who have undergone percutaneous coronary intervention (PCI) for ACS, which is a frequent clinical situation. This position paper aims to support physicians in daily practice to improve the management of ACS patients.
A group of recognized international and French experts in the field provides an overview of current evidence-based recommendations - supplemented by expert opinion where such evidence is lacking - and a practical guide for the management of patients with ACS after hospital discharge.
The International Collaborative Group underlines the need of a shared collaborative approach, and a care plan individualized to the patient's risk profile for both ischaemia and bleeding. Each follow-up appointment should be viewed as an opportunity to optimize the personalized approach, to reduce adverse clinical outcomes and improve quality of life. As risks - both ischaemic and haemorrhagic - evolve over time, the risk-benefit balance should be assessed in an ongoing dynamic process to ensure that patients are given the most suitable treatment at each time point.
This Expert Opinion aims to help clinicians with a practical guide underlying the proven strategies and the remaining gaps of evidence to optimize the management of coronary patients.
Background
Old age and the presence of aortic stenosis are associated with the unfolding of the intrathoracic aorta. This may result in increased difficulties navigating catheters from the right ...compared to the left radial approach.
Objective
To investigate whether increasing age or presence of severe aortic stenosis was associated with increased catheterization success rates from left (LRA) compared to right radial artery approach (RRA).
Methods
We compared coronary angiography success rates of RRA and LRA according to different age groups and in a subgroup of patients with severe aortic stenosis.
Results
A total of 21,259 coronary angiographies were evaluated. With increasing age, the first pass success rate from either radial access decreased significantly (
p
< 0.001). In patients aged <85 years, there was no difference between LRA and RRA. However, in patients aged ≥85 years, LRA was associated with significantly higher success rates compared to RRA (90.1 vs. 82.8%,
p
= 0.003). Patients aged ≥85 years received less contrast agent and had shorter fluoroscopy time when LRA was used 86.6 ± 41.1 vs. 99.6 ± 48.7 ml (
p
< 0.001) and 4.5 ± 4.1 min vs. 6.2 ± 5.7 min (
p
< 0.001), mean (±SD). In patients with severe aortic stenosis (
n
= 589) better first pass success rates were observed
via
LRA compared to the RRA route (91.9 vs. 85.1%,
p
= 0.037).
Conclusion
LRA, compared to RRA, is associated with a higher first-pass catheter success rate for coronary artery angiography in patients aged ≥85 years and those with severe aortic stenosis.
Abstract Background Transradial access (TRA) has been associated with reduced access site related bleeding complications and mortality after percutaneous coronary intervention (PCI), although it is ...unclear whether these observed benefits are affected by baseline bleeding risk. We have investigated this association by quantifying baseline bleeding risk, TRA use, and procedure-related outcomes. Methods We studied patients undergoing PCI who were enrolled in the British Cardiovascular Intervention Society (BCIS) database of PCI procedures done in the UK. We calculated baseline bleeding risk using a modification of the Mehran bleeding risk scores in 348 689 PCI procedures, undertaken in patients between 2006 and 2011. Four categories for bleeding risk were defined for the modified Mehran risk score (MMRS): low (<10), moderate (10–14), high (15–19), and very high (≥20). We assessed the effect of baseline bleeding risk on 30-day mortality and its association with access site. Findings TRA was independently associated with a 35% reduction in 30-day mortality (odds ratio OR 0·65, 95% CI 0·59–0·72; p<0·0001), with the magnitude of mortality reduction related to baseline bleeding risk (OR for MMRS<10 = 0·73, 95% CI 0·62–0·86; OR for MMRS≥20=0·53, 0·47–0·61). In patients with a MMRS of less than 10, TRA was used in 71 771 (43·2%) of 166 083 PCI procedures compared with 8655 (40·1%) of 21 559 patients with MMRS of 20 or greater, showing that TRA was used less in those at highest risk from bleeding complications (p<0·0001). Interpretation TRA is independently associated with a reduction in 30-day mortality and the magnitude of this effect is related to baseline bleeding risk, with individuals at highest risk of bleeding complications gaining the greatest benefit from TRA during PCI. Paradoxically, use of TRA was lower in patients most at risk of bleeding complications than in patients with least risk. Our data suggest that optimum access site practice guided by simple assessment of baseline bleeding risk has the potential to substantially improve PCI related patient outcomes. Funding SA is funded by a National Institute for Health Research academic clinical lectureship in cardiology.
This paper suggests a novel clustering method for analyzing the National Incident-Based Reporting System (NIBRS) data, which include the determination of correlation of different crime types, the ...development of a likelihood index for crimes to occur in a jurisdiction, and the clustering of jurisdictions based on crime type. The method was tested by using the 2005 assault data from 121 jurisdictions in Virginia as a test case. The analyses of these data show that some different crime types are correlated and some different crime parameters are correlated with different crime types. The analyses also show that certain jurisdictions within Virginia share certain crime patterns. This information assists with constructing a pattern for a specific crime type and can be used to determine whether a jurisdiction may be more likely to see this type of crime occur in their area.
Objectives This study sought to investigate the influence of access site utilization on mortality, major adverse cardiac and cardiovascular events (MACCE), bleeding, and vascular complications in a ...large number of patients treated by primary percutaneous coronary intervention (PPCI) in the United Kingdom over a 5-year period, through analysis of the British Cardiovascular Intervention Society database. Background Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing PPCI. A significant proportion of such bleeding complications are related to the access site, and adoption of radial access may reduce these complications. These benefits have not previously been studied in a large unselected national population of PPCI patients. Methods Mortality (30-day), MACCE (a composite of 30-day mortality and in-hospital myocardial re-infarction, target vessel revascularization, and cerebrovascular events), and bleeding and access site complications were studied based on transfemoral access (TFA) and transradial access (TRA) site utilization in PPCI STEMI patients. The influence of access site selection was studied in 46,128 PPCI patients; TFA was used in 28,091 patients and TRA in 18,037. Data were adjusted for potential confounders using Cox regression that accounted for the propensity to undergo radial or femoral approach. Results TRA was independently associated with a lower 30-day mortality (hazard ratio HR: 0.71, 95% confidence interval CI: 0.52 to 0.97; p < 0.05), in-hospital MACCE (HR: 0.73, 95% CI: 0.57 to 0.93; p < 0.05), major bleeding (HR: 0.37, 95% CI: 0.18 to 0.74; p < 0.01), and access site complications (HR: 0.38, 95% CI: 0.19 to 0.75; p < 0.01). Conclusions This analysis of a large number of PPCI procedures demonstrates that utilization of TRA is independently associated with major reductions in mortality, MACCE, major bleeding, and vascular complication rates.
Smart, ultra-scaled, always-on wearable (and implantable) sensors are an exciting frontier of modern medicine. Among them, minimally invasive microneedles (MN) is an emerging technology platform for ...theragnostic applications. Compared to traditional continuous glucose measurement (CGM) devices, these MNs offer pain-less insertion and simple operation. These MN systems, however, rely on analyte diffusion from the interstitial fluid (ISF) to the sensing site, and thus, (a) introduce a substantial and intrinsic diffusion delay in sensor response, and (b) reduce the analyte concentration to which the sensor must respond. A diversity of experimental platforms has been proposed to improve performance, but their optimization relies on empirical iterative approaches. Here, we integrate the theory of transient flux balance and the biomimetic concepts from ion uptake by bacteria to derive a generalized physics-guided model for MN sensors. The framework suggests strategies to minimize response time and maximize extracted analyte concentration in terms of the geometric and physical properties of the system. Our results show that there exists an intrinsic trade-off between response time and extracted analyte concentration. Our model, validated against numerical simulations and experiment data, offers a predictive design framework that would significantly reduce the optimization time for MN-based sensor platforms.
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