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October 2013Volume 25/ Supplement E

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Vol. 25, Supplement E, 2013 3E

AIM RADIAL ABSTRACTSCoronary Interventional Cardiology and Transradial Approach in BrazilLabrunie A1,2, Andrade PB2,3, Tebet MA4, Nogueira EF1,2, Rinaldi FS2, Ribeiro H5, Andrade MVA2, Barbosa RA2, Mattos LAP4

1Hospital do Coração de Londrina; 2Santa Casa Marília; 3Hospital de Clínicas FAMEMA; 4Rede D’Or (Brazil); 5Quebec Heart-Lung Institute (Canada). Nothing to disclose / No conflicts of interest(Andre Labrunie, MD, PhD, MBA, FESC, Hospital do Coração de Londrina, Paes Leme1351, Londrina, 86010-610 Paraná, Brazil, [email protected])

Brazil: a country of contrastsBrazil is a large country with an area of 8.5 million km (5th largest in the world), and a population of more than 192 million people (5th largest in the world). Its gross domestic product is more than $2.3 trillion (7th largest world economy) with an average income per capita of $12,000 (75th), and the life expectancy is 72.1 years (78th). The Brazilian Public Health System (Sistema Único de Saúde, SUS) is managed and provided by the government (municipal, state, and federal). The public health services are universal and offered to all citizens of the country. Nevertheless, more than 43 million (21.3%) Brazilians have private health care coverage.

Cardiovascular risk and coronary interventional cardiology activityAccording to the Brazilian government, the cardiovascular mortality is 152 deaths per 100,000 inhabitants. There are 463 interventional cardiology centers in Brazil, but only 180 perform interventional coronary procedures (ICPs) for the national health system, which corresponds to 80% of the total volume. Although it is growing, the number of ICPs is still low, with an average of 22 ICPs per 100,000 inhabitants. Hospital global mortality (2005-2008) was 2.33% higher in females (p<0.0001) and at ages >65 years (p< 0.001).

The reimbursement values are different, comparing the public (SUS) and private systems: coronary angiography, $250 versus $500 (public vs private, respectively); ICP, $2,000 vs $3,000; bare metal stent, $855 vs $833, and drug-eluting stent are in process of approval in the SUS, and the average reimbursement in the private system is $3,000.

Organization and training of interventional cardiology in BrazilThe Brazilian Society of Interventional Cardiology (SBHCI) has 580 titular members and 302 aspirant members. There are 30 training centers in activity and the whole practical interventional fellowship takes two years preceded by two years of internal medicine and two years of cardiology. The southeast part of the country accounts for nearly half of the ICPs performed, as it is the region that concentrates the higher number of professionals.

Transradial approach for PCIAnalysis of data spontaneously reported in the National Registry of Cardiovascular Interventions (Central Nacional de Inter-venções Cardiovasculares - CENIC), showed that from 2003 to 2008, the radial approach choice increased from 2.8% to 14%, and was associated with significant reduction of vascular complications in comparison to femoral approach (2.5% vs 3.6%, p<0.0001). The recent ACCEPT (Acute Coronary Care Evaluation of Practice Registry) registry, a project designed and man-aged by the Brazilian Cardiology Society (SBC) that prospectively collected data on patients with acute coronary syndromes, showed 30.3% radial approach for primary ICPs.

The radial approach for coronary interventional cardiology began in the early 90s by pioneers, but remains less used than the femoral approach, and this is possibly explained by the lack of training programs, uncertainties regarding the learning curve, and also the lack of large scale studies corroborating the benefits demonstrated to date.

Interventional Cardiology and Transradial Approach in MexicoAllende R, Baños AZ, De los Ríos O, Carrillo J, Rivera JJ, Pérez-Alva JC, Leiva-Pons JLNothing to disclose / No conflicts of interest

Percutaneous coronary interventions in Mexico have gained importance since they first appeared in 1995, when this practice was not very common. As the benefits of the radial technique have been widely recognized, many Mexican cardiologists have become radialists, and many centers around the country have adopted the radial access as their primary approach. However, medical practice in Mexico is variable; around 41% of the population has social security; 54% of the population is not covered by any medical service; and the remaining 5% has private insurance. Most of the diagnostic and therapeutic coronary proce-dures are performed in social security-linked hospitals or in private practice, while patients cared for in public hospitals have limited access to these techniques.

4E The Journal of Invasive Cardiology®

AIM RADIAL ABSTRACTSThe Mexican Society of Interventional Cardiology (SOCIME) is the main organization dedicated to the lining, control, and registry of endovascular and especially coronary procedures in Mexico. After the launch of the second phase of the registry, a strong effort was given to include as many cases as possible, from public, private, and social security-linked centers. The clinical presentation among more than 10,000 procedures registered includes ST-elevation myocardial infarction (STEMI) in 29.1% of cases, and non-STEMI in 27.2%; the remaining reported cases have been performed in the scenario of coronary artery disease suspected by non-invasive methods in 22.6%, stable angina 18.5%, and “others” in 21.1%.

The proportion of radial operators and centers around the country varies depending on the type of hospital, volume of cases, device availability, and previous training of operators. Since many Mexican interventionalists have trained abroad, especially in Spain, it has been easier for them to adopt the radial approach; some others, previous femoral experts, have gained their expertise on their daily practice. Around the country, the proportion of radial access goes from 0% up to 80%. As reported in the registry, the most frequent arterial access remains the right femoral artery in 75.2%, and radial in 24.7%. Among radial approach, the right radial artery is used in 95.7% and the left in 4.3%. Also from the registry, Mexican operators now perform complex procedures, including primary PCI, left main dilatations, multivascular stenting, and bifurcations by radial access on urgent or elective patients.

The cost for a non-economically protected countryUnlike other countries where the price of stents is controlled, the price of cardiovascular devices is extremely high in relation to the national per capita income in Mexico. The price of a drug-eluting stent may rise up to $3,000, unaffordable for an unpro-tected population. It is then when procedures such as the radial approach, which minimizes bleeding complications, length of hospital stay, and use of material, and reduces general costs, gains more importance, especially in private and public practice. As described by Mexican authors, the transradial approach is an interesting alternative for community hospitals without on-site cardiac surgery to decrease the cost of the procedures and to shorten the length of stay for low risk, well-defined elective patients. Same-day discharge is feasible for patients undergoing high- or low-risk uneventful procedures.

Cardiovascular risk in MexicoAs seen in other developing countries, the prevalence of coronary artery disease in Mexico is rapidly increasing, and will soon reach the global statistics that recognize cardiovascular diseases as the main cause of mortality in general populations. Changes in behavioral and nutritional habits have turned Mexico into the country with the highest prevalence of obesity worldwide.

Interventional cardiology training in MexicoAfter 6 or 7 years of medical school, specialization in interventional cardiology takes 5-7 more years (2-4 years of internal medicine, 3 years of clinical cardiology, and 2 years of interventional cardiology). As in most countries, there are three main, well-defined, recognized specializations in interventional cardiology: pediatric, which includes a congenital/structural heart disease program; adult program, which includes coronary and peripheral training according to the center; and electrophysiol-ogy and cardiac stimulation specialists. The certification of the programs is controlled by the Mexican Council of Cardiology (CMC) that rigorously evaluates the number of procedures performed on each center, as well as the academic formation of the trainees. To remain board-certified by the Council, interventional cardiologists have to perform a certain amount of procedures, participate on clinical trials and publications, and attend regularly to national and international academic meetings on a 5-year period. These requirements for recertification have been evaluated and acknowledged by the American College of Cardiology.

Legislation on interventional cardiologyAlthough the cardiology specialization program in all centers includes interventional cardiology, the CMC allows only trained and board certified cardiologists to perform interventional procedures with legal protection and backup from the council.

References1. Berumen-Domínguez LE, Gral Ojeda-Delgado JL, García-Rincón A, et al. Angioplastia radial ambulatoria, una realidad obligatoria en centros de alta demanda. Rev Sanid Milit

Mex. 2013;67:6-11.2. Esteban Puentes-Rosas, Sergio Sesma, Octavio Gómez-Dantés. Estimación de la población con seguro de salud en México mediante una encuesta nacional. Salud Pública Méx.

2005;47(sup 1):22-26.3. Baños AZ, Ponce de León E, Rivera JJ, et al. Data from the National Registry of Endovascular Interventions (REIE). Sociedad de Cardiología Intervencionista de México (SO-

CIME). En representación de Grupo SOCIME. Preferencia en el acceso arterial durante la fase piloto del registro nacional de intervenciones Endovasculares. Oral presentation on the annual meeting of the Mexican Society of Cardiology, Mexico, 2011.

4. Escárcega RO, Pérez-Alva, Jiménez-Hernández M, et al. Transradial percutaneous coronary intervention without on-site cardiac surgery for stable coronary disease and myocardial infarction: preliminary report and initial experience in 174 patients. IMAJ. 2010;12:592–597.


AIM RADIAL ABSTRACTSTraining for Interventional Cardiology and the Use of Transradial Approach In SingaporeAng CY, Lontoc A, Chiam PTNational Heart Centre SingaporeNothing to disclose / No conflicts of interest

Singapore is a small (240 square miles) island city-state at the tip of the Malaysian peninsula. In 1984, Singapore adopted a system of Medisave accounts, individually owned accounts used to pay for many of the health care expenditures. Another key component is a tiered structure of governmental subsidies based on the setting in which care is delivered and the amenities provided with it. This system has helped to curtail Singapore’s health care costs while maintaining high quality of service that is accessible to all citizens. Percutaneous coronary intervention (PCI) is the most commonly performed revascularization procedure for patients with isch-emic heart disease. In Singapore, PCI has been increasing annually. In 2012 alone, there were about 12,000 diagnostic coronary angiographies and more than 6,000 PCI performed. Primary PCI service is available island-wide around the clock in all cardiac centers in Singapore, and has become the standard of care for all patients with ST elevation myocardial infarction (STEMI). The transradial approach has been shown to result in reduced local access complication rates and major adverse cardiac events,1,2

and is being increasingly performed in Singapore. The number of transradial interventions (TRI) has increased sharply in the past years to account for more than 70% of all PCI procedures performed. TRI has also been used increasingly during primary PCI for STEMI patients and it has achieved similar outcomes including door-to-balloon time when compared to transfemoral approach.3 Another local retrospective data on TRI using novel sheathless radial guide catheters (slender TRI) has shown that both 6.5 Fr sheathless guiders and 5 Fr guiders achieved high procedural success with low radial artery occlusion rates.4

To become an interventional cardiologist, one needs to complete 3 years advanced cardiology specialist training after basic training in internal medicine, followed by 2 to 3 years training in interventional cardiology, performing large number of PCI cases.5 There is no universal PCI training program or specific PCI number criteria for certification. Most centers in general embrace criteria similar to the Core Cardiology Training Symposium (COCATS) guidelines, which was endorsed by the Society for Cardiovascular Angiography and Interventions (SCAI). Certification is granted based on clinical experience (typically at least 2 years) and assessment of competency by respective cardiac catheterization laboratory supervisor or director. Many inter-ventionists have also undergone further interventional cardiology fellowship under government funding in various renowned international cardiac centers before becoming fully credentialed. Thereafter, the physician needs to be consistently performing PCI procedures (typically at least 75 procedures per year) in order to maintain privileges annually. References1. Brueck M, Bandorski D, Kramer W, Wieczorek M, Holtgen R, Tillmanns H. A randomized comparison of transradial versus transfemoral approach for coronary angiography

and angioplasty. JACC Cardiovasc Interv. 2009;2(11):1047-1054.2. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events:

a systematic review and meta-analysis of randomized trials. Am Heart J. 2009;157(1):132-140.3. Agahari F, Lee CH, Xia HY, Tan HC, Low A, Chan M. Radial versus femoral access in primary percutaneous coronary intervention: a matched pairs analysis in an Asian cohort.

Circulation. 2010;122:A20311.4. Chiam PT, Liu B, Wong A, et al. Comparison of novel 6.5 Fr sheathless guiding catheters versus 5 Fr guiding catheters for transradial coronary intervention. EuroIntervention.

2011;7(8):930-935.5. Specialist Accreditation Board, Ministry of Health Singapore. Handbook on the Accreditation of Medical Specialists. 2001.

Interventional Cardiology and Transradial Approach in SpainTizón-Marcos H, Goicolea J, Mauri J, Batalla N, Rumoroso JR, Ruiz-Salmerón R, Valdesuso R, Diaz de Llera LS, Gómez Recio M, Salva-tella N, Miranda F, Trillo R, on behalf of the Spanish Society of Interventional Cardiology (SHCI)Nothing to disclose / No conflicts of interest

The National Health System (SNS) was founded in 1986 and provides a free wide range of medical treatments to the whole population (46.1 million in October 2012). The funding comes from taxes and in 2011 represented the 7.1% of the total GDP. Outside the public system, there are private insurances that cover some procedures partially.

Cardiology training in Spain is performed in University Hospitals. It begins with 6 years of theory and fundamentals on medi-cine and surgery. After this period, medical doctors interested in cardiology must prepare and succeed in the MIR (Médico Interno Residente) written exam. In 2012, there were 11,868 candidates that competed in order to achieve one of the 6,704 MIR positions; 156 of these vacant positions corresponded to the cardiology specialty. Cardiology specific training is based on a recently renewed regulation (SCO/1259/2007) that structures a core of knowledge and procedures that should be acquired


AIM RADIAL ABSTRACTSduring the 5-year training. In the 4th year, the trainee is ought to have at least 6 months of training in invasive cardiology. At the end of this period, the resident is able to perform a diagnostic coronary angiography and collaborate during coronary intervention and valvuloplasty.

The Spanish Society of Interventional Cardiology (SHCI) has recently approved a list of 48 centers (47 in Spain and 1 in Canada) that are accredited to train cardiology fellows in interventional cardiology. Those centers need to have a structured training program, a volume above 500 coronary interventions per year, and at least one experienced interventional cardiologist with more than 1,000 coronary interventions. These selected hospitals must also have primary angioplasty 24 hours/365 days and a cardiac surgery service. Adding to that, the interventional cardiology department needs to have at least 3 scientific com-munications and at least one published paper in peer-reviewed indexed journal. After finishing cardiology formal training, those who want to perform coronary intervention must be included in one of those centers. During a 2-year fellowship they will have to perform at least 250 coronary intervention procedures as first operator.

Whereas there are no recommendations to future Spanish interventional cardiologists on specific training in radial approach, it is actually the most used approach both for coronary angiogram and interventions in Spain. Data on cardiac catheterization procedures is published yearly on the SHCI web (www.hemodinamica.com) since 1992. These data are voluntarily given by 71/72 SNS hospitals and by 38/138 private hospitals. First available published data on radial coronary angiography dates from 2001, when interventional cardiologists stated first coronary angiogram and intervention cases in our country. However, first radial procedures are typically performed initially at mid 90s without specific equipment for transradial approach. These inter-ventional cardiologists first involved in radial techniques got experience outdoors and imported and expanded the technique in Spain. Dedicated courses on radial technique, lectures in international congresses, and on-site training given by experts on radial approach spread the word. That is reflected on the radial use rates: the rate of radial coronary intervention has steadily increased from 6.5% in 2002 to 60% in 2012 (Table 1). In the same direction, there were only 7 centers in 2005 that used radial approach in more than 60% of the cases. However, in 2011 more than 23 centers used it as the first choice (above 85%) and 30 centers used it in more than 60% of the cases. Recently published ESC guidelines on primary PCI recommending radial approach with IIa class and a level B of evidence will hopefully help to still expand its use.

Table 1. Number of cases and rates of radial use

150000125000100000

750005000025000

02001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Total coronary angiogram Radial coronary angiogram

Total coronary interventions Radial coronary interventions


AIM RADIAL ABSTRACTSTraining and Learning Curve

AIM-1 STEMI Patients Undergoing Primary PCI in a Radial Approach Skilled Center can be Equally Treated with Either Femoral, Left, or Right Radial AccessGabric ID, Pintaric H, Babic Z, Trbušic M, Krc mar T, Manola Š, Nikolic -Heitzler V, Radeljic V, Zeljkovic IUniversity Hospital Center Sestre Milosrdnice, Zagreb, Croatia

PURPOSE: In the last few years, our center has become ded-icated to the radial approach with nearly 85% of PCI per-formed with either left or right radial access route. In time radial approach has become the first choice even in patients with STEMI. The aim of the study was to establish whether the type of access had an influence on the procedure success, procedure and fluoroscopy time, and bleeding complication counted as periprocedural blood loss in STEMI patients un-dergoing primary PCI.

METHODS: In this retrospective analysis, we included 767 patients with STEMI treated in our center with primary PCI from January 1, 2011 to January 5, 2013. Radial approach was used in 523 patients (68.2%) (TR group), divided accord-ing to the site of access in either “left” (413 patients; 78.9%) or “right” (110 patients; 21.1%) subgroups. Femoral route was used in 244 patients (TF group).

RESULTS: There was no significant difference in procedure success, door-to-balloon time, total procedure time, fluoros-copy time and radiation dose between TR and TF groups. In sub-analysis of TR group, we did not find that left or right side access had any significant influence on any of the analyzed parameters. Also, there were no differences in periprocedural blood loss between TR and TF procedural access route (drop of hemoglobin, TR = 10±10 vs TF = 11±11 g/L, p=0.254), as well as in either left or right TR approach (drop of hemoglo-bin, left = 10±10 vs right = 10±12 g/L, p=0.254).

CONCLUSION: In patients with STEMI undergoing pri-mary PCI in a radial dedicated center, there is no difference in effectiveness, safety, and blood loss between radial and femoral approach. Also there is no significant difference in either left or right radial access type.

AIM-2 The Effect of Body Mass Index on Transradi-al Artery Approach in Patients Undergoing Coro-nary AngiographyLe J, Iqbal S, Miller LH, Bangalore S, Coppola J, Shah BNew York University School of Medicine, New York, NY, USA

PURPOSE: The aim of this study was to determine whether body mass index (BMI) has an effect on radial to femoral ar-tery crossover in patients undergoing coronary angiography via the transradial approach (TRA).

METHOD: We retrospectively evaluated 1,343 consecutive patients who underwent a first coronary angiography proce-dure via TRA at a tertiary center from January 2011 to July 2013. Of this cohort, 7.5% (n=101) were excluded as they underwent planned percutaneous coronary intervention (PCI) without diagnostic coronary angiography, and an ad-ditional 1.0% (n=14) was excluded due to lack of body mass index (BMI) data. BMI was calculated from height and weight measured during the procedure visit and categorized as under-weight (<18.5 kg/m2), normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (>30.0 kg/m2). The primary endpoint of interest was the proportion of patients under-going crossover from TRA to transfemoral approach (TFA) during the procedure and was compared across the 4 BMI categories using the chi-square test.

RESULT: Of the 1,228 patients undergoing coronary angiog-raphy with (31.3%) or without (68.7%) PCI, 2% (n=24) were underweight, 22.8% (n=280) were normal weight, 35.4% (n=435) were overweight, and 39.8% (n=489) were obese. The proportion of patients who underwent crossover from TRA to TFA was 12.1% (n=149), with 24.8% (n=37) due to arterial access failure, 32.2% (n=48) occurring after access but before coronary angiography was performed, 34.9% (n=52) occurring during coronary angiography, 5.4% (n=8) occur-ring between coronary angiography and PCI, and 2.7% (n=4) occurring after a plan for PCI via TRA was made. In addition, 15.4% (n=23) of crossover events occurred due to significant radial artery spasm. Across the BMI spectrum, there was no significant difference between the proportions of crossover events (underweight 4.2%, normal weight 14.6%, overweight 11.3%, obese 11.9%; p=0.33).

CONCLUSION: In a contemporary cohort of patients un-dergoing coronary angiography with or without PCI via TRA, BMI had no effect on proportion of TRA to TFA crossover.

AIM-3 Ulnar Artery. Is It As Safe As the Radial for Cardiac Catheterization?Valdesuso RM, Gimeno JR, Lacunza FJ, Rodriguez RC, Rodriguez JA, Fleites HA, Toruncha AIDC Salud Hospital Albacete, Albacete, Spain

PURPOSE: Analyze complications of ulnar artery (UA) ap-proach (Apr) and propose “How to do” UA puncture (Ptur).

METHODS: We analyzed 1405 consecutive patients in which the UA Apr was attempted from November 2002 until January 2013 in two cath labs. All studies were performed by operators with experience in transradial Apr. Follow-up at 24 hours and 3 months after procedure was indicated. Hematomas (H) and neurological complications related to the UA Ptur recorded.

RESULTS: Of a total of 25,212 patients, 1405 (5.5%) were indented via UA. Mean age was 67±8 years, 66% were males,


AIM RADIAL ABSTRACTS35% were diabetics, and more than 55% had hypertension, hyperlipidemia, or were smokers. Study was completed by UA in 1279 patients (91%). Initially, UA Ptur was attempted at the place where pulse was felt stronger. The main cause of crossovers was the Ptur failure (40% of cases). Out of 1635 procedures performed, 768 (47%) were PCI, 81% through the right UA. 53 H >15 cm were documented; 12 (12%) of them within the first 100 cases; and the rest 41 H, in the next 1305 patients (3.1%) (p<0.05). There was only 1 temporary neurological complication related to the nerve compression by H. The unintentional Ptur of the ulnar nerve (UN) was pain-ful and occurred in 137 (9.7%) patients without neurological sequel. In a multi-variable analysis of first 100 patients, the higher incidence of H was related to Ptur proximal to the wrist folds that led to a difficult compression of the artery.

CONCLUSION: Ulnar Apr could be another access way for cardiac catheterization, despite a higher than radial rate of vas-cular complications. Ptur at the level of the wrist skin fold is strongly recommended to reduce complications. According to the relationship between UA and UN, Ptur must be performed from lateral to medial, avoiding unintentional Ptur of UN.

AIM-4 Temporary Pacemaker from the Forearm: Simple Algorithm of a Useful ToolYadav PK, Baquero GA, Gilchrist ICPenn State University, Hershey, PA, USA

PURPOSE: High-degree atrioventricular block requiring a temporary pacemaker can be seen in acute myocardial infarc-tions. In the acute setting where time is of essence, an already present forearm venous access can easily and rapidly be uti-lized for placement of a transvenous pacemaker.

METHOD: From our 15-year experience in right heart catheter-ization and central venous access via a forearm vein, we describe our algorithm used to place temporary pacing wires (4-7 Fr).

RESULTS: A forearm peripheral IV placed by the nursing staff is prepped in sterile fashion along with the access site for catheterization. The IV is exchanged over a 0.021 wire for a radial sheath and a venogram is performed with 3-5 cc contrast. The clearance of the contrast is slow and leaves a track, which the temporary pacemaker wire can follow un-der fluoroscopy. The relatively straight course of basilic vein (medial) allows easy advancement of the pacemaker. The ce-phalic vein (lateral) may give resistance at the “T junction” (where it joins the axillary vein). This can be easily overcome by a deep breath from the patient and/or half inflation of the pacemaker tip balloon. The balloon is fully inflated once in the subclavian vein; pacemaker is then advanced and placed in the right ventricle.

CONCLUSION: Temporary pacemakers can be placed via a forearm vein and may serve as an alternate to conventional

techniques. This strategy can potentially avoid the bleeding risk of femoral access and pneumothorax of jugular/subclavian access and extend the benefits of transradial catheterization. This single center experience needs to be proven in a larger study before it is broadly accepted.

Hemostasis, Radial Artery Injury, and Occlusion

AIM-5 DRAPE Study: Same Day Dual Radial Artery Puncture Examination in Patients Requiring PCI – Incidence of Radial Artery OcclusionAmruthlal Jain S, Gorges R, Larsen T, Miller R, Alexander PProvidence Hospital, Southfield, MI, USA

OBJECTIVES: This study was designed to investigate the rate of radial artery occlusion (RAO) after same day dual ra-dial artery puncture in patients transferred from a hospital where the diagnostic coronary angiogram was performed via radial approach in a facility without percutaneous coronary intervention (PCI) capabilities to a hospital with PCI capabili-ties to complete the intervention on the same day via the same radial artery.

BACKGROUND: The rate of RAO has been reported be-tween 5% and 10% after single transradial catheterization in the recent literature, with almost 99.9% asymptomatic. The rate of total and subtotal RAO after same day dual puncture is unknown. Only few cases are reported on the safety.

METHODS: 25 patients who underwent dual radial artery puncture for PCI at the Providence Hospital Heart Institute from January 2012 to date were included. All diagnostic cases were performed with a 5 French (Fr) sheath and upgraded to 6 Fr if needed for PCI. Heparin, nitroglycerin, and verapamil were used as per the preference of the interventional cardiolo-gist. They were asked to follow up (December 2012 to date) for evaluation of radial artery patency by palpation of pulse, modified Allen’s test, Barbeau’s test, and duplex ultrasound.

RESULTS: The mean age was 68 years. 8/25 (32%) were fe-males. None experienced symptoms related to RAO. All felt extremely comfortable during the procedure. 3/25 (12%) had a weak distal radial pulse by palpation and 1/25 (4%) had no distal radial pulse. All had modified Allen’s test within 8 sec and type A or B Barbeau’s test (no/transient loss of waveform), both confirming very good collaterals to the hand. 4/25 (16%) had inverse Allen’s test with mean of 12 sec and type C Barbeau’s test (transient loss of waveform with dampened in recovery), both confirming sufficient collaterals recruited to the hand. None had type D Barbeau’s test (complete loss of waveform). These 4 patients were found to have subtotal occlusions by duplex ultrasound. None had total occlusions.

CONCLUSION: This is the first study reporting the dual ra-dial artery puncture and incidence of radial artery occlusions


AIM RADIAL ABSTRACTSin these patient populations. Dual radial artery puncture ap-pears to be a viable and safe strategy if appropriate anticoagu-lation is used and the patients are transferred to a PCI capable hospital for coronary interventions.

AIM-6 How We Can Manage Radial Artery Late Occlusion: Recanalization of Occlusion or “High” Puncture of Radial ArteryBabunashvili AM, Kartashov DS, Dundua DPCenter of Endosurgery, Moscow, Russia

BACKGROUND: Transradial interventions (TRI) are associ-ated with certain risk of radial artery (RA) occlusion, limiting the possibility of re-intervention through the same access site.

METHODS: In case of late radial/ulnar artery (RA/UA) oc-clusion if the distal stump was palpable pulse, puncture, and cannulation of the post-occlusion segment and retrograde RA/UA recanalization and angioplasty was performed using the “Dotter-technique” or plain balloon dilatation or mixed technique. In case of patent preocclusion segment (confirmed by ultrasound), ”high” puncture and cannulation of this seg-ment is possible.

RESULTS: Recanalization of occluded RA/UA was attempted in 61 cases, 49 in chronic total occlusions, and 12 in sub-acute RA/UA occlusions. Immediate success was achieved in 52 cases (85.2%): in 41 out of 49 chronic total occlusion cases (83.7%) and 11 out of 12 cases of subacute occlusion (91.7%). In 24 out of 52 cases of successful recanalization, late reocclu-sions occurred (46.2%). Of these, 2 patients were subjected to repeat successful recanalization of reoccluded artery. In 4 cases we have successfully performed under ultrasound guid-ance “high” puncture and catheterization of proximal (preoc-clusion) segment of RA and coronary intervention thereafter. In these cases, retrograde recanalization of occluded RA was impossible due to lack of collateral pulse on the RA stump.

CONCLUSION: Retrograde recanalization of late radial/ulnar artery occlusion for repeat arterial access is technically feasible and safe. Despite the high risk of reocclusion in the long run, this new technique allows us to solve the problem of access in cases where no other traditional access sites are avail-able. In case of inability of retrograde recanalization of occlud-ed RA (absent of collateral pulse), “high” RA puncture under ultrasound guidance is possible in certain anatomic situations.

AIM-7 Randomized Comparison of Low (2500 IU) versus Standard (5000 IU) Heparin Dose for Preven-tion of Forearm Artery Occlusion after Coronary AngiographyHahalis G, Xanthopoulou I, Koniari I, Tsigkas Gr, Almpanis G, Christodoulou J, Grapsas N, Stayrou K, Alexopoulos DPatras University Hospital, Patras, Greece

PURPOSE: Radial artery occlusion (RAO) remains the “Achilles heel” of transradial coronary procedures. Higher over lower levels of systemic anticoagulation are believed to reduce RAO rates but this is ill supported by scientific evidence.

METHODS: This was a prospective, randomized, single-cen-ter study of parallel design. Patients were enrolled if they were older than 18-years-old, were scheduled for diagnostic coronary angiography, and the interventional cardiologist was willing to proceed with either radial or ulnar access. Patients were ran-domized before diagnostic catheterization in a 1:1 ratio to re-ceive either 2,500 IU or 5,000 IU of unfractionated heparin. Patients were excluded after randomization when crossover to another arterial access site had been required, anything different than 5 Fr sheath size had been inserted, or ad hoc PCI had been performed. Study’s primary endpoint was arterial access site oc-clusion rate, as confirmed by absence of antegrade flow by Dop-pler examination, within 60 days after coronary angiography.

RESULTS: Between June 2010 and January 2013, 1167 pa-tients were randomized to receive either 2,500 or 5,000 IU of heparin. In total 654 patients were excluded after random-ization, leaving 603 patients (2,500 IU N=302 vs 5,000 IU N=301) to test study’s hypothesis. Patients’ baseline and angi-ographic characteristics (74.5% men, 31.3% diabetics, 38.3% with acute coronary syndrome) were well balanced between groups. At a median follow-up of 8 (1-60) days (Doppler available in 97.7% of patients), we observed 60 arterial oc-clusions among the 589 analyzed patients (10.2%). However, the occlusion frequency did not differ between the 2,500 and 5,000 IU heparin arms (12.0% vs. 8.4%, p=0.2).

CONCLUSION: Standard dose of heparin was not found su-perior to low dose, in reducing forearm artery occlusion rate after coronary angiography.

AIM-8 Is the Transradial Approach Always Safe?Hajlaoui N, Ghommidh M, Jedaida B, Ben Mansour N, Lahidheb D, Haggui A, Dahmani R, Fehri W, Haouala HMilitary Hospital of Tunis, Tunis, Tunisia

BACKGROUND: Transradial approach for coronary angi-ography and intervention is actually widely used. The near absence of local vascular complications is one of its advan-tages. In our cath lab, we perform almost 1,600 coronary an-giograms and angioplasties per year, most of them by transra-dial approach. We have reported three cases of major vascular complications in 10 years.

OBSERVATIONS: Case 1: A patient of 84 years, hypertensive, diabetic, under anti-vitamin K for flutter, is hospitalized in our service for re-current angina. The angiography procedure was made by tran-sradial approach. Two days after angiography, the patient de-veloped a blowing hematoma at the puncture point level. An


AIM RADIAL ABSTRACTSultrasound Doppler objectivizes a right radial arterio-venous fistula. A multibarette scan has supported a radio-cephalic fis-tula and a rudimentary ulnar artery. The patient had surgical repair with a total recovery.Case 2: A 73-year-old smoker underwent a coronary angio-gram for effort angina. The procedure was made by transradial catheterization. The patient developed some days after a he-matoma at the puncture point level. An exploration through ultrasound Doppler showed a false aneurysm that was not thrombosed by manual compression. An angioscan confirmed the diagnosis and the patient received a resection of the false aneurysm with a total recovery.Case 3: A 76-year-old man was admitted in our cardiac care unit for inferior ST-elevation myocardial infarction. A thrombolytic therapy was indicated. 30 minutes after, the patient presented signs of shock. He underwent a rescue an-gioplasty by 6 French transradial approach. Angioplasty with a bare metal stent was performed with a good angiographic result. 6 hours after, the patient complained of right fore-arm pain and numbness. Radial artery bleeding with acute compartment syndrome was diagnosed, so he received fasci-otomy. Postoperative evolution was not favorable with per-sistent signs of shock.

CONCLUSION: The transradial catheterization remains an invasive procedure not devoid of risks. The most serious local complications are arteriovenous fistula, aneurysms, and compartment syndrome, which can lead to surgical treatment. Risk factors for occurrence of such complica-tions may include advanced age, longer duration of cath-eterization and comorbidity.

AIM-9 Radial Artery Acute Injury After PCI As-sessed by Optical Coherence TomographyKanovsky J, Poloczek M, Bocek O, Miklik R, Jerabek P, Ondrus T, Novakova T, Spinar J, Kala PUniversity Hospital Brno, Brno, Czech Republic

PURPOSE: To study the frequency of the acute injury of the radial artery (RA) caused during the percutaneous coronary intervention (PCI) in the patients examined and treated for the acute coronary syndrome (ACS). We used frequency-do-main optical coherence tomography (FD-OCT) for the as-sessment, as it is the intravascular imaging method with the highest available resolution.

METHOD: We performed FD-OCT of the RA in 40 pa-tients admitted to the PCI center for non-ST elevation acute myocardial infarction (n-STEMI). We used automated pull-back with the manual injection of the contrast fluid and x-ray contrasting ruler, targeting the segment of 5 cm proximally from the sheath insertion in the vessel. All the FD-OCT re-cordings were assessed by two analysts, evaluating acute dis-section, perforation, or other injury of the RA.

RESULT: We found acute injury of RA in 2 patients (5%), both dissections (one limited on the intimal layer, one involv-ing medial layer of the vessel). Both dissections were of minor importance, asymptomatic with no clinical significance.

CONCLUSION: Acute radial injury during PCI is very rare. Only minor injuries of no clinical importance were found in two patients. Chronic changes of the artery are the subject of further research, as all the patients are scheduled for the follow-up FD-OCT within one year from the base-line examination.

Supported by the Grant of the IGA Ministry of Health of the Czech Republic no. NT/13830.

AIM-10 Radial Artery Occlusion after Catheteriza-tion: Can We Effectively Prevent It?Skvaril J, Danickova K, Broulikova K, Maly MCentral Military Hospital Prague, Prague, Czech Republic

INTRODUCTION: Radial artery occlusion (RAO), also marked as “asymptomatic loss of pulsation,” represents a spe-cific complication of transradial approach in catheterization. Its character is fortunately benign in most cases. Neither Allen test, nor oximetry/plethysmography are sufficient predictors of hand ischemia in RAO. To prevent occlusion, some devices (TR band) and procedures (Barbeau test, so called ‘’perfusion hemostasis technique’’) were developed. With their applica-tion, the artery compression is possible without interruption of blood flow.

METHODS: The occurrence of RAO was estimated in 2 pe-riods: before and after introduction of the perfusion hemosta-sis technique in our workplace. TR band was used invariably. RAO incidence was evaluated 1 day after procedure and after one month (30 days). Beside physical examination, duplex ul-trasonography of appropriate radial artery and ipsilateral ulnar artery was performed (arterial morphology, possible hemato-ma or fistula, vessel diameter, flow velocity).

RESULTS: In period 1 (804 patients), the incidence of RAO decreased from 10.8% to 5.8% (p<0.001) during 30 days. Similarly, in period 2 (after the perfusion hemostais technique introduction), the decrease was from 5.5% to 2.85% in the cohort of 532 patients. The perfusion hemostasis technique led to a significant decline of RAO incidence immediately as well as after 30 days (p=0.015).

CONCLUSION: The recanalization of RAO happens in ap-proximately one half of the cases, independently of the used method of compression. The technique of perfusion hemosta-sis further decreases the RAO incidence to a half. Long-term incidence of RAO in our cohort of patients remains under 3% level.


AIM RADIAL ABSTRACTSAIM-11 Radial Artery Size Using Vascular Ultra-sound Before and After CatheterizationYadav PK, Lingle KC, Baquero GA, Foy A, Gilchrist IC, Kozak MPenn State University, Hershey, PA, USA

PURPOSE: Transradial cardiac catheterization is becoming more and more common in the United States. This access site is much safer than the femoral approach. However, there have been reports showing that up to 38% of individuals undergoing transradial cardiac catheterizations suffer from radial artery oc-clusion post-procedure. The mechanism of this remains unclear.

METHODS: We obtained radial artery ultrasounds from 50 randomly selected patients immediately before and after transradial catheterization between July 2012 and April 2013. Three different physicians independently measured the diam-eter of the radial artery. RESULTS: Total 50 patients, 62% male and mean age 65 years. The average diameter and area post-procedure was sig-nificantly larger than prior to the procedure (3.1 vs 2.7 mm and 8.0 vs 6.8 mm2; p<0.0001). There was no evidence of post-procedure radial artery occlusion in our patient popula-tion. Three different sheath sizes were used: 6 Fr (82%), 5 Fr (28%), and 4 Fr (8%). Eighty-two percent of the cases were diagnostic and 18% had coronary intervention performed.

CONCLUSION: Despite the literature reports of up to 38% of individuals having radial artery occlusions post-transradial cardiac catheterization, we did not have any radial artery oc-clusions at our institution and we found that the radial artery was in fact larger post-procedure than prior to the procedure. Although this is a small observational study, it leads us to be-lieve that radial artery spasm is not the cause of radial artery occlusion after transradial cardiac catheterization.

Technical Aspects

AIM-12 Effect of Local Heat Application on the Size of Radial ArteryAlqaqaa A, Ahmed A, Yadav P, Foy A, Kozak M, Glichrist ICPenn State University, Hershey, PA, USA

PURPOSE: Small artery diameter along with vasospasm in-duced by radial artery puncture can limit the utility of the ra-dial artery for cardiac catheterization and is often the source of major discomfort for patients. Many studies showed increased blood flow in extremities in response to local warming. This effect is due to vasodilation at the level of the arterioles lead-ing to decreased vascular resistance. We hypothesize that the application of local heat will lead to increased size of larger arteries including the radial artery.

METHOD: 21 adult volunteers (>18 years of age, 5 females, and 16 males) self-identified as being healthy were included in

this study. Two operators measured the diameter of the radial artery, 2 centimeters proximal to the styloid process using stan-dard ultrasound techniques before and 10 minutes after fore-arm heat application. A digitally controlled, moist heating pad was used to warm the forearm to a target skin temperature of 42°C. Paired t-test was used to compare the results.

RESULTS: The mean diameter of the radial artery at baseline was 2.60 mm ± 0.4 mm. The mean diameter post local heat ap-plication was 2.85 mm ± 0.4 mm. The mean increase in diam-eter was 0.25 mm (95% CI: 0.15 to 0.35 mm), p=0.0001. There was no variation in response to heat application based on gender. There were no reported complications of local heat application.

CONCLUSION: Local heat application was associated with statistically significant increase in the size of radial artery. This physiologic response may have important clinical implications on radial arterial access success rate, sheath size, patient com-fort, and occlusion rates; however, this needs to be tested in larger studies.

AIM-13 Initial Experience with the Glidesheath Slender for Transradial Coronary Angiography and Intervention: a Feasibility Study with Prospective Radial Ultrasound Follow-upAminian A, Dolatabadi D, Lefebvre P, Zimmerman R, Brunner P, Michalakis G, Lalmand JCentre Hospitalier Universitaire de Charleroi, Charleroi, Belgium

OBJECTIVE: The aim of this study was to evaluate the feasi-bility and safety of the Glidesheath Slender in routine transra-dial (TR) coronary angiography and intervention.

BACKGROUND: In recent years, the TR approach has gained in popularity because of several advantages, such as re-duced vascular access site complications and immediate patient mobilization. Procedural success has been further improved through technological innovations and the development of less invasive devices. The Glidesheath Slender (Terumo) is a new dedicated radial sheath with a thinner wall and hydro-philic coating. It combines an inner diameter compatible with 6 Fr guiding catheter with an outer diameter close to current 5 Fr sheaths. Its use has the potential to decrease invasiveness and access site complications during TR procedures.

METHODS: 114 consecutive patients undergoing TR coro-nary angiography and/or PCI using the Glidesheath Slender were included in a single center prospective registry of effec-tiveness and safety.

RESULTS: The mean age was 63 ± 11 years and 74 patients were male (65%). 27 patients had acute coronary syndrome (24%). During the procedure, the use of at least one 6 Fr cath-eter was noted in 38 patients (34%). Ad-hoc or planned PCI was performed in 35 patients (31%). In case of PCI, a 6 Fr


AIM RADIAL ABSTRACTSguide catheter was required for the treatment of bifurcation lesions in 16 patients with subsequent kissing balloon infla-tion in 13 patients, the use of a thromboaspiration catheter in 9 patients, the use of rotational atherectomy in 2 patients, and the use of an IVUS catheter in 1 patient. Procedural success was 99.1% with only one case requiring conversion to femoral access. There were 6 minor hematomas but no patient experi-enced major vascular complications. The rate of symptomatic radial spasm was 4.4% (5/114). No case of major sheath kink-ing was noted. Doppler ultrasound examination of the radial artery at 1-month follow-up was available in 113/114 patients with only one case of radial artery occlusion (0.88%).

CONCLUSIONS: Routine use of the Glidesheath Slender for TR coronary angiography and interventions is safe and feasible with a high rate of procedural success and a low rate of radial artery occlusion.

AIM-14 Transradial PCI via 4 French Diagnostic Catheters - Initial ExperienceBernat I, Bertrand OF, Jirous S, Rokyta RUniversity Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic

OBJECTIVES: In case of small radial artery diameter transra-dial PCI requires downsizing of sheaths and guiding catheters. We evaluated the novel strategy of direct stenting via 4 French (Fr) using a stent with new integrated delivery system (IDS).

METHODS and RESULTS: After initial experience with stent-ing via 5 Fr diagnostic catheters we included eight consecutive patients (4 men, 4 women, age 67±8 years) suitable for transradial 4 Fr diagnostic coronary angiography with good quality imag-ing. All patients had history of recent acute coronary syndrome (ACS) without ST segment elevation and indication for PCI by direct stenting de novo lesions in native coronary arteries. Seven of them had ad hoc PCI of one lesion and one elective PCI with 2 lesions. A total of 8 bare metal stents on a wire ISD (Svelte Medical Systems) were implanted to 8 lesions with good angio-graphic results (TIMI III flow and residual stenosis <20%). Post-procedural radial artery compression time was 92±34 min. There was no conversion to conventional PCI or complication during all procedures and in 30 days clinical follow-up.

CONCLUSION: Transradial direct stenting with new IDS via 4 Fr diagnostic catheters is safe and feasible alternative to standard PCI in selected patients with reduction of material used and short radial artery compression time.

Supported by MH CZ – DRO (Faculty Hospital in Pilsen – FNPI, 00669806)

AIM-15 A Unique GuideLiner-Related Complica-tion During a Transradial PCI and its Successful Management

Bhat T, Tamburrino F, Beydoun HStaten Island University Hospital, Staten Island, NY, USA

INTRODUCTION: We are reporting a unique GuideLiner-related complication and its successful management during a radial approach PCI that has not been reported previously.

CASE: A 69-year-old Caucasian male presented to our hos-pital with unstable angina and transradial coronary angiog-raphy was performed. It showed 80% diffuse, highly calcified lesion the mid LAD. A percutaneous coronary angioplasty was planned following the diagnostic procedure through a right radial artery access. The left main was engaged with a 6 Fr XB LAD 3.5 guide catheter. After multiple balloon inflations in the diseased segment we were unable to deliver stent due to calcification and tortuosity. Multiple attempts using different techniques such as buddy wires, placement of Ironman wire (Abbott Vascular), for delivery of stent were unsuccessful. Finally a 6 Fr GuideLiner catheter was used for distal delivery of stent. During the balloon angioplasty there was severe dampening and multiple attempts were made to retrieve the balloon, but seemed to be stuck, and due to severe dampening of the whole system, which in-cludes the guiding catheter, the GuideLiner and the balloon were pulled out from the coronary artery. As we were trying to pull GuideLiner catheter out we discovered that the flex-ible guide extension (distal cylinder) of the GuideLiner was detached from the stainless-steel push tube and was floating into the ascending aorta and fortunately proximal edge was still inside the guiding catheter. In order to retrieve this part, a guidewire was threaded through the guiding catheter and the flexible guide part (distal cylinder) of the GuideLiner. A small balloon was then delivered past the distal tip of the GuideLiner catheter. It was inflated and, while balloon in-flated flexible guide part (distal cylinder) of the GuideLiner, was pulled into the guiding catheter and with no risk of em-bolization into the aorta or coronaries. The whole system was then pulled out without any complications.

DISCUSSION: We believe that in our case the balloon may have gotten stuck at metal transition zone “collar” of the GuideLiner catheter and after multiple attempts, may have led to fracture and dislodgment of the GuideLiner parts as described. To prevent this complication, it has been suggested to lengthen the silicon-coated straight guide extension beyond its existing 20 cm to 30 cm, which would result in the inter-face between the stent balloon and GuideLiner ‘collar’ to be further from the distal aspect of the guide, and more likely to be coaxial within the guiding catheter. This simple modifica-tion could prevent deformation and/or damage to the balloon stent during retraction of the GuideLiner.

AIM-16 A New 5 Fr Guiding Catheter for Left Transradial RCA & SVG-Percutaneous Coronary Interventions: Report of Performance


AIM RADIAL ABSTRACTSDangoisse VCHU Mont Godinne UCL, Yvoir, Belgium

PURPOSE: Success of percutaneous coronary interventions (PCI) through transradial access (TRA) relies on capable guid-ing catheters (GC). Most of the actual GC shapes address the problem of the back up support through optimized contact with the aortic ascending wall. Through a shape modification in the shaft of existing GC, we tried to add a pendular effect in order to make easier and safer the re-cannulation of coronary artery (CA) ostium. We tested the modification for GC used for left and right CA via right TRA, as for right CA (RCA) and saphenous vein graft (SVG) via left TRA. The present communication reports the results of a modified GC aimed at RCA and SVG PCI via left TRA.

METHODS: The new shape was added to the actual 5 Fr Sher-pa NX Active™ GC from Medtronic and the catheter was tested on consecutive patients requiring RCA PCI (n=38) or SVG PCI (n=5) through 5 Fr left TRA. The catheter’s performance was scored on a scale of 5 for ease of RCA/SVG cannulation (“friendly”), degree of support, and level of safety (well aligned in the center of the lumen’s vessel, no induced wall damage). Presence of a pendular effect, fluoroscopy time, volume of contrast used, and crossover to another GC were recorded. RCA cannulation time was also monitored for 22 cases. Level of difficulty of the PCI was evaluated as “easy,” “not easy,“ or ”hardish” using a scoring system based on patient, aorta, coro-nary anatomy, and lesions characteristics.

RESULTS: The RCA PCI population was scored as “difficult” for 25 (66% [mean age 75, mean 25’ of fluoroscopy time]), “not easy” for 11 (29% [mean age 62, fluoroscopy time 17’]), and “easy” for 2 (age 47 and 59, fluoro time 6’30). RCA PCI was successful for 34 patients: 4 cases failed due to inability to cross occlude vessels by wire (3) or balloon (1), despite cross-over to another GC in 2 cases. A total of 8 GC crossovers oc-curred (MRESS [n= 5], RRAD [n=2], and AR1 [n=1] curves). Ease of RCA cannulation was graded ≥3/5 for 24 cases. RCA cannulation was obtained in 30 sec or less for 11 of the 22 re-corded cases and in less than 60 sec for 15 (68 %). For the 28 successful PCIs with the new GC shape, degree of support and safety were respectively scored at 4.5 and 5/5. A pendulum-like effect was present for a third of the cases (10/28). For the 25 PCI classified as difficult, the crossover occurred for 5, sup-port and safety remain at 4.6 and 4.9/5. The pendulum effect was detected for 8 of the 18 (44%) difficult cases performed with the new GC. There was no complication.

All the 5 SVG-PCI were scored as “difficult,” mean age 79, fluoroscopy time 24’: 3 were successful with the new GC, and failed for 2 for which routine GCs had already failed.

CONCLUSION: A pendular effect was visible in 44% of the difficult left TRA RCA-PCI. The GC shape modification pro-

vided a good support, allowing successful PCI for 28 of the 34 successful cases and for 18 of the 25 difficult RCA cases. This GC provides a new alternative to current material.

AIM-17 The Effect of Acquisition Parameters on Radiation Dosage in PCIGladstone PSJ, Kassam S, Li C, Burstein J, Vijayaraghavan RRouge Valley Health System, Toronto, ON, Canada

PURPOSE: The purpose of this study was to measure the effect of changes in acquisition parameters on radiation dos-age in PCI. The installation of a new Philips Allura Clarity cath lab allowed the opportunity to determine if these changes would significantly reduce radiation dose, without affecting the procedure time or volume of contrast used.

METHODS: Rouge Valley Centenary is a busy standalone regional cardiac center performing over 1200 procedures per year. Five operators perform these procedures. One month af-ter installation of a new Philips Allura Clarity cath lab, the acquisition parameters were changed to significantly reduce the dose required. The cine acquisition rate was reduced to 7.5 FPS and the exposure reduced by 70%. The option of higher dose and frame rates remained open to the operator at anytime through a touch screen interface. The patient dose (mGy), fluoro time, and dye used were compared retrospec-tively for both protocols. Two groups, before and after the equipment adjustment, were used as the comparison.

RESULTS: Two sequential groups of 40 PCI patients formed the basis of the study. The mean values for high dose (Hi) and low dose (Low) x-ray settings were compared for absorbed dose (mGy), dye volume (mL), and fluoro time (min). In both groups 55% were primary PCI for code STEMI and 85% were ad hoc procedures. Over 90% were transradial proce-dures. The changes in the x-ray settings resulted in a reduc-tion in average dose from 637 mGy to 199 mGy, a reduction of 69% (p=0.001). The fluoro time remained unchanged at (Hi) 9.9 min and (Low) 7.7 min (p=ns). The dye used was also unchanged at (Hi) 120 mL (Low) 114 mL (p=ns). No patients required urgent surgery and a procedural success of 99% was achieved.

CONCLUSIONS: Radiation exposure during interventional procedure remains a significant risk to patients and particular-ly staff during a professional lifetime. This retrospective review indicates that new cath lab imaging protocols and lower frame rates, can reduce this exposure by over 68% without increas-ing the procedure time or dye consumed.

AIM-18 Is Magnesium Sulfate Efficacious as Classic Cocktails for the Prevention of Radial Vasospasm and Interesting in Hemodynamically Impaired Patients?Hajlaoui N, Ben Mansour N, Jedaida B, Haggui A, Lahidheb D, Dahmani R, Fehri W, Haouala H


AIM RADIAL ABSTRACTSMilitary Hospital of Tunis, Tunis, Tunisia

PURPOSE: To compare a cocktail regimen of magnesium sulfate (150 mg) + heparin (50 mg) (C1) to a cocktail of nitroglycerin (1 mg) + nicardipine (1 mg) + heparin (50 mg) (C2) for the effectiveness to prevent radial vasospasm (RV).

METHODS: Prospective randomized single blinded trial including patients undergoing transradial coronarography. Radial vasospasm was defined by visual analogic scale >5 or manipulation difficulties reported by the operators.

RESULTS: Seventy patients were included, 35 received C1 and 35 received C2. Four patients were excluded (1 for impossibil-ity of left main cannulation, 1 for extreme arterial tortuosity, 1 for subclavian artery occlusion, and 1 for anaphylactic shock). Sixty-six patients were analyzed. Baseline demographic charac-teristics were similar between C1 and C2 groups. There were no significant differences between groups for procedure dura-tion, quantity of sedative drugs received, type of sheath used, attempts of radial puncture, number of catheters used, quantity of nitroglycerin administrated during procedure, and radiation exposure. RV occurred in 23% of procedures (n=15). 10/34 pa-tients in C1 group presented RV vs 5/32 in C2 group (p=0.13). Conversion to femoral approach occurred in 3 cases, all in C2 group. The mean systolic blood pressure (SBP) was not signifi-cantly different between the two groups before cocktail admin-istration (160 mmHg vs 159 mmHg). After cocktail adminis-tration, the mean SBP was significantly lower in the C1 group (151 mmHg vs 129 mmHg) (p=0.01). Two patients from C2 group presented severe hypotension during the procedure ne-cessitating administration of macromolecular solutes vs any pa-tient in C1 group; the difference is not statistically significant.

CONCLUSION: There was no significant difference between the compared cocktails for the prevention of RV. Although the difference is not significant, magnesium sulfate seems to cause less hemodynamic impairment. Larger studies are needed to determine if magnesium sulfate is the right cocktail for pa-tients at high risk of severe hypotension with nitroglycerine and calcium channel inhibitor cocktail.

AIM-19 A Review of the OCT Registry at The Prince Charles HospitalHlaing SH, Latona J, Sufee I, Savage M, Walters D, Raffel OCThe Prince Charles Hospital, Chermside, Queensland, Australia

AIM: Percutaneous coronary intervention (PCI) has long been performed at The Prince Charles Hospital (TPCH). In September 2009, optical coherence tomography (OCT) was introduced in clinical practice to assess coronary artery lesions during angiography. The aim of this study was to compile and analyze a registry of patients on whom OCT was performed.

METHODS and RESULTS: 130 patients underwent OCT

during angiography between September 2009 and August 2012; however, only 111 patients’ charts were accessible for analysis. Of these 111 patients, 79 were male. Access site was obtained through the right femoral artery in 90 cases, right radial artery in 20 cases and one through the brachial artery.

Indications for OCT included: 25 STEMI, 45 N-STEMI, 19 unstable angina, 11 stable angina, 6 dyspnea, and 5 elec-tive PCI. 59 of these cases had known coronary artery disease, while 52 were newly diagnosed. Diseased vessels included: 7 left main, 69 left anterior descending, 20 circumflex, and 42 right coronary arteries. There were 3 intra-procedural com-plications that were directly related to OCT. This includes 2 patients with chest pain and transient ECG changes and one successfully defibrillated VF arrest. There were no direct post-procedural complications of OCT; however, one patient died from cardiogenic shock secondary to myocardial ischemia.

CONCLUSION: TPCH has introduced and continues to successfully maintain an expanding registry of patients on whom OCT is performed.

AIM-20 Reduction in Total Radiation Dose by Default Reduction in the Digital Fluoroscopy and Cinefluoroscopy RatesGadey G, Jeon C, Piemonte T, Resnic F, Waxman S, Pyne CLahey Clinic, Burlington, MA, USA

PURPOSE: An important determinate of radiation exposure during cardiac procedures using digital pulsed fluoroscopy (DPF) and cinefluorography is the x-ray pulse rate. Most catheterization laboratories have default settings for the pulse rate, which is often set at 15 frames per second (fps). Begin-ning in early 2012, our laboratory decreased the default fluo-roscopy and cinefluorography pulse rates for catheterization procedures from 15 fps to 10 fps. There were no complaints by physicians relating to image quality and the change became permanent. We sought to examine the impact of this default change in pulse rate on patient and physician radiation expo-sure as expressed by the mean x-ray dose.

METHODS: An internal database was used to retrospectively review procedures done with the different default x-ray pulse rates and create 2 comparison groups. Group 1 consists of 491 patients undergoing diagnostic or interventional coronary procedures during a 3-month period in 2012 (DPF rate of 10 fps). Group 2 consists of 524 patients having the same proce-dures during an identical 3-month period in 2011 (DPF rate 15 fps). Non-coronary procedures were excluded from analy-sis. Patient history, demographics, procedure types, fluorosco-py time, and x-ray dose were compared between groups. The primary outcome is the reduction in mean x-ray dose with the reduction in the x-ray pulse rate. The x-ray dose is reported as the Air Kerma (in milligray [mGy]) obtained from the x-ray tube for each procedure. The study was approved by the local


AIM RADIAL ABSTRACTSinstitutional review board.

RESULTS: There are no significant differences between groups 1 and 2 in patient ages, sex, height, weight, or body mass index. There are no significant differences in patient his-tory including any history of prior CHF, MI, or CABG. There are no significant differences between groups in access site (Group 1: 61.3% radial, Group 2: 62.2% radial [p=0.7655]), mean fluoroscopy time (Group 1: 12.8 +/- 12 min, Group 2 13.2+/-12.3 min [p=0.5931]), or mean contrast dose (Group 1:155+/- 98cc, Group 2: 147+/- 86cc [p=0.1523]). There was a significant reduction in mean x-ray dose between groups (Group 1: 1179.1+/- 1147 mGy, Group 2 1763 +/- 1388 mGy, p<0.0001). The unadjusted reduction in radiation dose for Group 1 compared to Group 2 is 39.9% (95% CI, 36.6% to 43.0%, p<0.001). When adjusted for other predictors of radiation dose, the reduction for Group 1 compared to Group 2 remained large and highly significant at 38.3% (95% CI, 36.1% to 40.5%, p<0.0001). CONCLUSION: Reducing the default digital pulse fluoros-copy and cinefluorography rates from 15 fps to 10 fps yields large and significant reductions in total x-ray dose as measured by the Air Kerma. A blinded angiographic quality assessment study evaluating a secondary outcome of image quality is on-going. Strong consideration should be given to reducing de-fault pulse rate settings in all laboratories as part of an overall program to reduce patient and operator radiation exposure.

AIM-21 Optical Coherence Tomography: What is it?Lekganyane CCentre Chirurgical Marie Lannelongue, Le Plessis, France

PURPOSE: The Optical Coherence Tomography (OCT) is a new technique of invasive imaging based on the infrared light applied recently to the coronary. The main part of the histo-logical data was based on a post-mortem study of the coronary arteries. Today the imaging of very high resolution, offers us in vivo superimpose images in the histological sections of the coronary arteries through the diffusion and reflection of an infrared spectrum. METHODS: OCT uses an optical fiber, a case of withdrawal and a console of post-treatment. To make a good image it is important to know how to use this technique and to make a good analysis of OCT image, it is necessary to know the pos-sible interactions between the spectrum of infrared light and the coronary wall. The analysis of the image also includes the detection of artifacts. RESULTS: The analysis of several clinical cases allows us in the long-term to estimate the endothelialization of the stent and in-stent restenosis. OCT allows us the analysis of the ath-erosclerotic plaques and its constituents, for the viewing of thrombus during pain events.

CONCLUSION: OCT is a new technique of invasive imag-ing, which seems today, finds its place in our room of catheter-ization in spite of its high cost. We use this technique within the framework of the follow-up of atherosclerotic plaques and its constituents, stents and medicinal treatments, and too for viewing of thrombus during pain events.

AIM-22 Guiding Catheter for Coronary Intervention Through Radial Approach: Are There Any Differences?Rezek M, Hlinomaz O, Drozdova A, Moravcova H, Sitar J, Novak M, Semenka J, Groch LUniversity Hospital St. Anna, Brno, Czech Republic

PURPOSE: The author is presenting an analysis of PCI pro-cedures during 6 months in aspect of choice of guiding cath-eters and fluoroscopy time in one catheterization laboratory.

METHODS and RESULTS: The procedures were performed by 6 different operators, all of whom have passed the learn-ing curve in radial approach during the past years. The ap-proach has changed from femoral to preferred radial in this catheterization laboratory during the past 5 years (10% radial in the year 2007, 75% radial in 2012). A total number of 436 PCI was analyzed, 300 where performed through the radial approach (68%). There were 130 primary PCIs for STEMI in this analysis and the right radial approach was dominant by 90%. Inter-individual variance among the operators by choos-ing the guiding catheters was noted, but there were no differ-ences in the judged parameters by the operators if choosing radial or femoral approach.

PCIs of left coronary artery

Guiding Catheter No. of procedures

Mean fluoroscopy time

IKARI IL 3.5 (radial) 87 6:22

XB 3.5 Vista (radial) 53 7:01

JL4 Vista (radial) 38 7:32

AL2 (radial) 10 8:16

JL4 Vista (femoral) 62 7:29

XB 3.5 Vista (femoral) 11 8:32

PCIs on right coronary artery

Guiding Catheter No. of procedures

Mean fluoroscopy time

IKARI IR 1.5 (radial) 53 7:55

JR4 Vista (radial) 21 8:28

JR4 Vista (femoral) 33 7:20

AR2 (radial) 10 8:24

CONCLUSION: The slightly worse result by femoral ap-


AIM RADIAL ABSTRACTSproach for left coronary artery may be caused mainly by the fact that most of the operators still prefer femoral approach for more complex procedures. In radial approach, there seems to be a trend to lower fluoroscopy time by using dedicated radial guiding catheters (IKARI) and lower fluoroscopy time for procedures on left coronary artery. The comparison of guiding catheters is very difficult in retrospective analysis. There are many variables that can affect the results, but it appears that there may be some differences among the catheters.

AIM-23 4 Fr in 5 Fr Sheathless Techniques with Standard Catheters for Transradial Coronary Inter-ventionsRimac G, Abdelaal E, Plourde G, MacHaalany J, Roy L, Costerousse O, Bertrand OFIUCPQ, Quebec City, QC, Canada

BACKGROUND: There is a relationship between radial ar-tery injury and stretch during transradial access and the risk of radial artery occlusion (RAO). Hence, smaller sheaths and catheters have been associated with less risks of RAO.

OBJECTIVE: To demonstrate the feasibility and potential benefits of performing sheathless 5 Fr transradial percutane-ous coronary interventions (PCI) using 4 Fr diagnostic cath-eters as dilators.

METHODS and RESULTS: From September to De-cember 2011, we recruited 130 patients who underwent 4 Fr sheathless diagnostic angiography with super torque (Cordis Corporation) catheters followed by ad hoc PCI. To facilitate skin and vessel penetration, the Judkins right catheter (110 cm) was inserted inside the 5 Fr guiding catheter (100 cm) as dilator. The mean age of patients was 63±12 years with 74% of males. The mean weight was 81±15 kg for a BMI of 29±5. In 27% of the cases, radial access for PCI had been used prior to the index procedures. 24% of patients were diabetic and baseline creatinine clear-ance was 94±37 mL/min. Procedures were performed in 24% of the cases for non-STEMI and in 24% for STEMI (primary and rescue). Unfractionated heparin was used in 71%, bivalirudin in 12% and platelet glycoproteins IIb-IIIa inhibitors in 13%. Right radial artery was used in 99%. In 3 cases, no PCI was performed (FFR) and in 2 (1.5%) cases, a sheath was required after guiding catheter insertion due to local bleeding. In 6 cases (4.6%), upscale to 6 Fr sheathed approach was required for chronic total occlusion PCI (n=2), right coronary dissection after diag-nostic 4 Fr sheathless with AL (n=1), thrombectomy (n=1), and insufficient backup support (n=2). No spasm occurred. Overall procedural success was achieved in 114/119 (96%) cases, including left main PCI, bifurcation PCI in 10 (8%) cases, CTO in 5 (4%), and IVUS use in 6 (5%) cases. Im-mediately after hemostasis completion, duplex ultrasound showed normal flow in 76%, occlusive thrombus in 13%,

pseudo-aneurysmal dilatation in 11%, and local hematoma surrounding puncture site in 20%. Hemoglobin dropped from 138±19 g/l to 131±16 g/l 4-6 hours after PCI.

CONCLUSION: Using 4 Fr super torque diagnostic catheters as dilators, most PCI can be performed as 5 Fr sheathless tech-niques with standard guiding catheters. However, sub-optimal transition between diagnostic and guiding catheters creates radial artery trauma leading to frequent occlusive thrombus and hematoma surrounding the radial artery. These results do not suggest significant benefits of 4 Fr in 5 Fr sheathless tech-niques using current catheters. Further studies using dedicated 5 Fr sheathless guiding catheters or development of tapered dilators are required.

AIM-24 How to Limit Radial Artery Spasm During Percutaneous Coronary Interventions? The SPasmo-lytic Agents to Avoid SpasM During Transradial Per-cutaneous Coronary Interventions (SPASM3) StudyRosencher J, Chaïb A, Barbou F, Arnould MA, Huber A, Salengro E, Jégou A, Allouch P, Zuily S, Mihoub F, Varenne OHôpital Cochin, Paris, France

PURPOSE: To compare the efficacy of three vasodilators in preventing radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary interventions (PCI).

METHODS and RESULTS: 731 patients were randomized to receive diltiazem 5 mg, verapamil 2.5 mg, or isosorbide dinitrate (ISDN) 1 mg before coronary intervention. RAS occurred in 20.1% in the whole population and was signifi-cantly reduced by verapamil and ISDN compared to diltiazem (16.2%, 17.2%, 26.6 %, respectively; p<0.006). There was also a trend to less severe pain (more than 8 on a numerical scale from 0 [no pain] to 10 [maximal pain]), and less severe RAS (complete catheter blockage or severe pain), among pa-tients treated by verapamil compared to ISDN and diltiazem (1.3% vs 2.8% vs 2.9%, p=0.43 and 5.1% vs 6.2% vs 9.5%, respectively, p=0.13). No difference was found between the three vasodilators in terms of crossover or safety events. Fe-male gender, failure at first attempt to access the radial artery, emergency procedures, and the use of diltiazem were indepen-dent predictors of RAS.

CONCLUSION: Verapamil and ISDN considerably reduce the incidence of RAS compared to diltiazem during transradial.

AIM-25 Feasibility of the Use of the Tryton™ Dedi-cated Bifurcation Stent via the Transradial Route: A Single Center ExperienceBundhoo SS, Shah A, Uddin M, Ossei Gerning N, Anderson RA, Kinnaird TKUniversity Hospital of Wales, Cardiff, UK

PURPOSE: The use of the transradial access (TR) for the


AIM RADIAL ABSTRACTStreatment of coronary bifurcation lesions (CBL) with per-cutaneous coronary intervention (PCI) can be limited where a two-stent strategy is required as larger sheath and guide catheters are required to facilitate stent delivery. With the development of newer dedicated bifurcation stents, there is an increasing trend of these stents to be adopted in PCI centers to treat CBL. We report our experience of the use of the Tryton™ dedicated side branch bifurcation stent at our default TR cen-ter where 90% of all PCI are carried out via the TR.

METHODS: This was a prospective study of all patients who were found suitable to undergo PCI to CBL using the Try-ton™ stent between September 2009 and June 2013. Data on patient demographics and procedure characteristics was col-lected from the local hospital database.

RESULTS: 36 patients (male 69.4%, age 68.1 years) under-went PCI using the 19 mm long Tryton™ bifurcation stent. Most of the CBL treated were located in the LAD/branch (52.8%), followed by the circumflex/branch (27.8%), left main stem/branch (13.9%), RCA/branch (2.7%), and LIMA graft (2.7%). Tryton™ stents dimensions (side branch/main branch diameters) deployed were (2.5/2.5 mm – 11.1%; 2.5/3.0 mm – 25%; 2.5/3.5 mm – 47.2%; 3.0/3.5 mm – 8.3% and 3.5/4.0 mm – 8.3%). 91.6% of cases were carried out via 6 Fr guide catheters with the remaining cases carried out via the 7 Fr. Mean contrast volume, radiation dose, and fluoroscopy times were 306 mL, 98.8 Gy/cm2, and 28.2 min, respectively. 94.4% of all cases were successfully carried out via the TR route with remaining cases switching to the trans-femoral route to successfully complete the procedure.

CONCLUSIONS: When treating CBL, a wide range of Try-ton™ dedicated side branch stents can be safely and effectively deployed via the TR route using 6 Fr/7 Fr guide catheter sys-tems. This can avoid the use of the transfemoral route and its associated potential vascular complications.

AIM-26 Retrograde Recanalization of Radial Artery Occlusion in Patients with Need for Repeated Wrist ProcedureSpiroski I, Kedev SSt. Cyril and Methodius, University of Skopje, Skopje, Macedonia

PURPOSE: To present a technique of retrograde recanaliza-tion of radial artery occlusion with and without balloon dila-tation in patients with need for repeated wrist procedure.

METHODS: In our transradial registry during the period of March 2011 – June 2013, we have documented 10,487 transradial procedures. In 317 patients we have found ra-dial artery occlusion (RAO). In 281, ipsilateral transulnar approach (TUA) was performed. We selected the other 36 consecutive patients for retrograde recanalization of RAO. The selected patients were either with present ipsilateral ul-

nar occlusion or contralateral wrist approach was not avail-able. We performed retrograde recanalization of RAO in 14 patients with balloon dilatation and in 17 patients (from our early practice) without balloon dilatation. In 5 patients (14%), we didn’t manage to cross the occluded segment with the wire. Primary outcome was successfully completed procedure. Secondary outcomes were procedural complica-tions: forearm pain, access site bleeding events, clinically evident hand ischemia. Patients with documented ana-tomic variations of radial artery from previous transradial procedure, such as tortuosity of the vessel and high take off, were excluded from this group. All patients had palpable pulse distal of previous puncture site. We’ve punctured the radial artery with an inner metallic needle and a plastic cannula. Using radial angiography performed with plastic cannula, we were able to go through the occluded segment with different types of guide wires. After the balloon dilata-tion, successful catheterization, and/or percutaneous coro-nary intervention were achieved.

RESULTS: The primary outcome was achieved in 26 of 31 patients (83.9%). In patients where we performed balloon dilatation, the primary outcome was achieved in 14 of 14 pa-tients (100%). Forearm pain was present in 13 cases (41.9%). Minor access site bleeding occurred in 5 patients (16.1%) and there was no single case of clinically evident hand ischemia.

CONCLUSION: Retrograde recanalization of the radial ar-tery occlusion is safe and feasible. Balloon dilatation of radial artery occlusion is a key factor for successful catheterization and/or percutaneous coronary intervention. Left TRA or TUA remain a viable option in selected patient.

Complex PCI

AIM-27 Radial Approach for Angioplasty of Distal Un-protected Left Main in the Setting of Acute Coronary SyndromeHajlaoui N, Ben Mansour N, Lahidheb D, Jedaida B, Haggui A, Dahmani R, Fehri W, Haouala HMilitary Hospital of Tunis, Tunis, Tunisia

BACKGROUND: Percutaneous coronary intervention (PCI) has become the treatment of choice for patients with acute coronary syndrome (ACS). Nevertheless, patients with un-protected left main (ULM) disease still represent a challenge for the interventionalist, especially in the setting of an ACS. Radial access (RA) is currently the recommended approach for coronary intervention, but cases of ULM angioplasty per-formed from a RA in patients with myocardial infarction are rarely reported.

CASE REPORT: We report the case of a 38-year-old diabetic man admitted in our coronary care unit for a non ST-elevation myocardial infarction. After treatment with aspirin, loading


AIM RADIAL ABSTRACTSdose of clopidogrel and enoxaparin, a coronary angiography was rapidly performed. A 6 Fr radial route was used. Angiogra-phy showed a subocclusive stenosis of mid and distal left main, with ostial occlusion of left anterior descending artery (LAD). The right coronary artery was dominant with collaterals for LAD. In this setting of ACS with hemodynamic instability (80 mmHg systolic blood pressure) we decided to perform an an-gioplasty of left main and LAD/circumflex (Cx) bifurcation. From the same radial access, and using an EBU 3.5 guiding catheter, a guide wire was placed into the Cx. We performed a direct stenting of left main/Cx axis with 3 x 26 mm drug eluting stent (DES). A second wire was placed into the LAD and struts of the first stent opened with a 2.5 x 20 mm bal-loon. A second 3 x 22 mm DES was placed into LAD using a T-stenting technique because of a 90° LAD/Cx takeoff angle. A final kissing balloon with non-compliant balloons was per-formed (3.5 x 15 mm into Cx and 2.5 x 20 mm into LAD). The final result was good with TIMI 3 flow on both LAD and Cx. The patient was discharged 6 days after procedure and no complication was reported on 6 months follow-up.

CONCLUSION: This case report shows that distal left main PCI in ACS via RA is feasible. The strategy for LAD/Cx bi-furcation management depends of anatomy and has to be carefully chosen. The second message is that radial access to reduce hemorrhagic complications is possible for this kind of complex procedures.

AIM-28 PCI as a Bridge to Surgery in Type A Aortic DissectionHorak D, Hrabos V, Nedbal P, Hlubocky J, Lindner JRegional Hospital Liberec, Liberec, Czech Republic

CASE: A 77-year-old female had been referred to our institution for acute coronary syndrome with evolving cardiogenic shock with profound ST depressions in V leads on ECG. Due to sys-tolic murmur on brief physical exam, there was echo study per-formed showing moderate mitral and aortic regurgitation and mild aortic dilatation to 40 mm. Due to ongoing hypotension, selective coronarography via right radial artery was performed finding ostial left main stenosis. Glycoprotein IIb/IIIa inhibitor was given and two stents placed in the left main. Patient condi-tion dramatically improved immediately after stent placement. Because operator felt unsure about fluoroscopic appearance of left main lesion and even native appearance of aorta, aortogra-phy had been performed revealing aortic dissection type A. Our institution does not have on-site cardiosurgery, so cooperating cardiosurgery (approx. 100 km away) had been informed about the patient and helicopter transport was arranged. Patient was operated a couple of hours after making the diagnosis. Bentall operation was performed and due to bleeding, next day delayed suture was performed. After 10 days, the patient was back in our institution and recovering well without overt neurologic deficit with good left ventricular function.

CONCLUSION: There are multiple records in literature about aortic dissection mimicking acute coronary syndrome. In our case the late diagnosis led to PCI that stabilized hemo-dynamically unstable patient and allowed relatively safe trans-port to distant cardiosurgery for definitive treatment.

AIM-29 Repositioning of PTCA Wire Using OCT Technique and Radial Access SiteMiklik R, Kala P, Kanovsky J, Poloczek M, Jerabek P, Bocek OFaculty Hospital Brno, Brno, Czech Republic

INTRODUCTION: Optical coherence tomography (OCT) technique is a wise tool to visualize anatomical relations and intracoronary stent struts position and may help optimize complex percutaneous coronary intervention (PCI) proce-dures. It might detect possible radial artery injuries after such intervention.

CASE REPORT: A 64-year-old female presented with acute inferolateral non-STEMI acute coronary syndrome, Killip I, left ventricular ejection fraction of 60%, with Hodgkin lym-phoma and hypertension in medical history. Her diagnostic angiogram revealed 2VD – 90% culprit bifurcation lesion of LCx-OM1 (medina 1,0,0), then 80% proximal LAD and 90% D1 indicated for staged PCI procedure. Using a 6 Fr guide catheter XB 3.5 Vista introduced via right radial ar-tery selectively into LCx, two wires were placed in LCx and OM1 and lesion predilatation with a 2.25 mm balloon was performed, followed by a 3.0/14 biolimus eluting stent im-plantation (on the LCx- OM1 wire) with its distal part end-ing just before carina, jailing the wire in LCx. Using OCT technique, we successfully repositioned the LCx wire avoiding crossing through the stent struts and then post-dilated with a non-compliant 3.25/12 balloon first from LCx into OM1 and then from LCx into LCx so no struts were touching carina and were widely spread open both into LCx and OM1. OCT check showed malapposition of proximal part (0.4 mm) of the stent resulting in another high-pressure post-dilatation with optimal OCT and angiographic result. Finally, as another staged procedure is planned via radial artery, we performed radial OCT imaging after guide catheter had been pulled off with no signs of arterial injury.

CONCLUSION: We demonstrated that OCT technique could be easily used to guide repositioning of wires during a complex bifurcation intervention. OCT visualization of radial artery after such procedure might detect acute iatrogenic in-juries caused by catheter manipulation and exclude this artery from subsequent interventional procedures.

Supported by a Grant from the Ministry of Health of the Czech Republic, NT 13830-4.

AIM-30 Is Percutaneous Coronary Intervention of Un-protected Left Main Coronary Artery via Transradial


AIM RADIAL ABSTRACTSApproach Feasible for Skilled Transfemoral Operators? Initial Experience in an Unselected PopulationTomassini F, Gagnor A, Montali N, Gambino A, Bollati M, Infan-tino V, Tizzani E, Varbella FInfermi Hospital, Rivoli, Italy

BACKGROUND: The feasibility and efficacy of percutane-ous coronary intervention (PCI) of unprotected left main coronary artery (ULMCA) via transradial access (TRA) is still a matter of concern, mainly in an unselected population.

METHODS: We collected data about all PCI performed in patients with ULMCA stenosis by a TRA-dedicated operator, and analyzed clinical and procedural characteristics as well as in-hospital and long-term outcomes.

RESULTS: From January 2008 to December 2011, 49 PCI were performed, 27 (55%) via TRA and 22 (45%) via transfemoral access (TFA). Most patients in both groups underwent PCI for acute coronary syndrome (66.7% in TRA group vs 77.3% in TFA group, p=0.73). Patients in TRA group were more hyper-tensive (81.5% vs 40.9%, p=0.008) and had a higher left ventric-ular ejection fraction (54.6±10.3 vs 46.1±12.8, p=0.01). There were no significant differences in procedural success (100% in TRA group vs 90.9% in TFA group, p=0.38), as well as in proce-dural time, in fluoroscopic time and in contrast volume. Bleed-ing complications occurred in 1 patient in TFA group (4.5%) vs none in TRA group (p=0.91). In-hospital Major Adverse Cardiac Events (MACE) occurred in 1 patient (3.7%) in TRA group vs 3 (13.6%) in TFA group (p=0.48). At a follow-up of 32±13 months, MACE occurred in 4 cases (14.8%) in TRA group vs 7 cases (31.8%) in TFA group (p=0.28).

CONCLUSIONS: The PCI of ULMCA via TRA is feasible with good results, provided that a rigorous learning curve was followed and a TRA volume caseload was maintained.

AIM-31 Double Transcarpal Arterial Puncture for Cardiac Catheterization in Patients with Challenging ApproachValdesuso R, Gimeno JR, Lacunza FJ, Rodriguez RC, Rodriguez JA, Fleites HA, Toruncha AIDC Salud Hospital Albacete, Albacete, Spain

PURPOSE: To report the feasibility of simultaneous radial-ulnar arteries puncture during cardiac catheterization.

METHODS: From 2008 to 2013, 12 patients with unsuccess-ful transradial (TR) procedures (due to severe spasm, high origin, and diffuse calcification), after placing 5 Fr sheath in the right radial artery, underwent ipsilateral ulnar artery (UA) puncture. Saturation by pulse oximetry was measured in the index and mid-dle fingers after 1 min compression of the UA. Main reasons for ipsilateral attempt were: morbid obesity (6 patients) and severe peripheral arterial disease (4 patients). Two patients with satura-

tion <95% (in one of the fingers) were excluded and performed by humeral artery. Pulse oximetry was placed at middle finger during procedures. Both sheaths were removed after completion of procedures. Simultaneous manual compression of both arteries with Spongostan was ended with the usual TR bandage.

RESULTS: In 10 eligible patients (8 male; mean age 66±8.5 years), radial and ulnar puncture was performed. There were 6 diagnostic + PTCA using 6 Fr, and 4 diagnostic with 5 Fr sheaths. Procedure mean time (from sheath place in UA) was 37±18 min. Mean saturation during procedures was 98±1.3%. Procedure success rate was 100%. No complications were re-ported at discharge (24 hours after procedure).

CONCLUSION: Double transcarpal puncture can be per-formed in well-selected patients after careful evaluation of pal-mar arch integrity by pulse oximetry. This method is easy, not time consuming, and can be performed without releasing the hand. Only patients (after initial radial or ulnar failure) with a difficult arterial access and/or corporal anatomy should be evaluated for this approach that must always be performed by skillful and fast operators.

AIM-32 Safety and Efficacy of Transradial Rota-tional AtherectomyZeb M, Iqbal J, Edwards T, Winterton S, Witherow FDorset County Hospital Foundation Trust, Dorchester, UK

PURPOSE: Rotational atherectomy is an effective method of debulking atherosclerotic lesions in coronary arteries. Traditionally this has been performed via a transfemoral (TF) approach to facilitate larger (7 Fr and 8 Fr) guiding catheters and temporary pacing via the femoral vein. Larger lumina 6 Fr, along with 7 Fr and 8 Fr sheathless guides allow rotablation to be performed transradially (TR), re-sulting in fewer complications and enabling safer use of glycoprotein IIB/IIA inhibition.

METHODS: Prospective data was collected for all patients treat-ed with rotational atherectomy from 2007 to 2013 at our center.

RESULTS: During the study period, 66 patients underwent rotational atherectomy to 99 vessels and 136 lesions. The mean age was 74±8.9 (range 50-95) years; 47 (71%) were male. Temporary pacing wire was not used in any of the pro-cedures, cases involving RCA, or dominant Cx were pretreat-ed with 1.2 mg of atropine. TR was used in 45 cases (68%) and TF in 21 (32%). Overall procedural complication rates in both groups were extremely low with only 1 death in the TF group and no complications in the TR group. In com-parison with TF, TR resulted in no significant difference in fluoro time, procedural time, glycoprotein IIB/IIA inhibition use, IABP use, and stent deployment rates despite 6 Fr guides being used in 75% of TR cases and 52% of TF cases; (all p=NS). 17 patients (TR=14 [31%], TF=3 [14%], p=0.001)


AIM RADIAL ABSTRACTSwere discharged on the same day. Mean follow-up duration was 38±21 (range 4.3-68) months, during which 6 patients had MI (unrelated to rotablated vessel), 1 patient had CVA, and 7 patients died, in TR group. While in TF group, 5 pa-tients had MI (one rotablated vessel).

CONCLUSION: Rotational atherectomy via the radial ap-proach is safe and effective, and can facilitate day case proce-dures. Temporary pacing during rotablation is an unnecessary and potentially harmful procedure especially when using gly-coprotein IIB/IIIA inhibitors.

Bleeding and Anticoagulation

AIM-33 Bivalirudin or Heparin and Provisional IIb/IIIa Inhibitors in Primary Angioplasty Performed Through Transradial ApproachSciahbasi A, Rigattieri S, Cortese B, Belloni F, Russo C, Silva P, Fer-raironi A, Tespili M, Angeletti C, Ricci R, Bondanini F, Loschiavo PSandro Pertini Hospital - ASL RMB, Rome, Italy

PURPOSE: The beneficial effect of bivalirudin therapy in the setting of percutaneous coronary interventions (PCI) for acute ST-elevation myocardial infarction (STEMI) seems to be con-fined to patients treated through transfemoral approach and data on transradial approach are limited. Aim of our study was to evaluate bleeding complications and clinical outcomes of patients with acute STEMI who underwent PCI through transradial approach combined with bivalirudin therapy.

METHODS: We retrospectively evaluated primary PCI performed through transradial approach since January 2008 to June 2013. Patients were divided in two groups according to the use (Group 1) or not (Group 2) of bi-valirudin therapy during the procedure. The primary end-point of the study was the rate of major bleeding (accord-ing to TIMI criteria) and the major adverse cardiac events (MACE) defined as death, re-infarction, and new revascu-larization within 30 days. We also evaluated a net clinical outcome endpoint defined as the combination of the hem-orrhagic and ischemic endpoint.

RESULTS: During the 5 years analyzed, 1009 patients underwent primary PCI through transradial approach and these patients were included in the registry. Among these patients, 154 patients were treated with bivalirudin (males 79%, mean age 65±14 years) and 855 with hepa-rin (males 82%, 63±12 years, p=0.10). In Group 1 the use of glycoprotein IIb/IIIa inhibitors was only 4% compared to 55% (p<0.001) in Group 2. There were no significant differences between the two groups for major bleedings (0.65% in Group 1 and 1.17% in Group 2, p=0.88) nor for minor bleedings (1.3% in Group 1 and 1.5% in Group 2, p=0.83). There were also no significant differences in MACE between the two Groups (10.4% in Group 1 and

7.1% in Group 2, p=0.27). The 30-day mortality rate was 3.9% in Group 1 and 5.4% in Group 2 (p=0.56). Final-ly there were no significant differences in the clinical net outcomes between the two groups (7.8% in Group 1 and 11.6% in Group 2, p=0.21).

CONCLUSION: In this group of patients with acute STE-MI who underwent primary PCI through transradial ap-proach, the use of bivalirudin therapy was not associated with a significant reduction in major bleeding or MACE compared to a heparin therapy and provisional use of glyco-protein IIb/IIIa inhibitors.

AIM-34 Comparison of Radial and Femoral Access for Coronary Angiography within South Australian Public Cardiac Catheterization Facilities: A New World Radial ExperienceWorthley MI, Tavella R, Worthley SG, Chew DP, Arstall M, Zeitz CJ, Beltrame JFRoyal Adelaide Hospital, Adelaide, Australia

PURPOSE: Radial artery access for diagnostic coronary an-giography has seen a rapid uptake within the past few years. Although this technique has been shown to have favorable outcomes, no Australian data exists to date comparing the outcomes between radial and femoral approaches.

METHODS: The Coronary Angiogram Database of South Australia (CADOSA) is a comprehensive registry of all public cardiac catheterization procedures performed within South Australia. Patients undergoing coronary angiogram +/- PCI were included in this analysis. Registry data for 2012 was utilized to assess the prevalence and angiographic procedure complications of radial and femoral access approaches.

RESULTS:

CADOSA Population Radial, n=1953 (53%)

Femoral, n=1719

p-value

Age 63±13 65±13 <0.001

Male Gender 1330 (69%) 1092 (64%) 0.004

Angiogram for ACS 1047 (55%) 1092 (55%) 0.92

Atherosclerotic CAD 1407 (74%) 1251 (74%) 0.879

PCI Performed 734 (38%) 666 (39%) 0.475

PCI for STEMI 318 (18%) 266 (15%) 0.063

Death 22 (1%) 25 (1%) 0.231

Stroke 5 (0.3%) 10 (0.6%) 0.129

Access Site Complication

13 (0.6%) 39 (2%) <0.001

Bleeding within 72 hours

18 (1%) 71 (4%) <0.001


AIM RADIAL ABSTRACTSCONCLUSION: While routine radial access angiography re-mains less than ten years old in South Australia, it is now the preferred access site in the state. It is more often performed in younger, male patients and is the preferred approach for pri-mary PCI. Radial access is also associated with less access site complications and in-hospital bleeding events.

Non-Coronary Intervention

AIM-35 Transradial Access for Embolization of Uterine Fibroids: Initial Clinical ResultsBabunashvili AMCenter of Endosurgery, Moscow, Russia

AIM: To assess the feasibility and efficacy of transradial access for uterine fibroid embolization.

METHODS: Left radial access was used for selective cath-eterization of left and right uterine arteries in 20 patients with special design 5 Fr 135 cm length catheter. Selective emboliza-tion was performed using established technique. RESULTS: Selective catheterization of both uterine arteries using a single catheter was successful in all patients. In two pa-tients, catheter was exchanged with 4 Fr microcatheter due to inability of deep engagement of catheter tip into uterine artery because of spasm of radial artery. Median time for comple-tion of procedure was 29.6±8.2 min, fluoro time was 14.8±4.3 min, radiation exposure dose 524±205 mGy comparing to 19.6±2.2 min, 9.8±3.2 min and 248±123 mGy, respectively, for transfemoral approach. All patients were active immediate-ly after procedure without vascular access site complications. CONCLUSION: Transradial access for embolization of uter-ine fibroids is feasible, safe, and an effective procedure using a single catheter. Early ambulation and less risk of vascular ac-cess site complication are “traditional” advantages of transra-dial access in these patients. Further evaluation of transradial access for uterine fibroid embolization procedure is needed.

AIM-36 Introduction of the Transradial Technique into a Busy Metropolitan Interventional Radiology Practice: The First 300 CasesFischman AM, Patel RS, Fung JW, Lamberson NB, Ort M, Kim E, Nowakowski FS, Lookstein RAIcahn School of Medicine at Mount Sinai, New York, NY, USA

PURPOSE: There is a paucity of experience in the interven-tional radiology community with transradial approach (TRA) for peripheral interventions and complex embolization proce-dures. Benefits of this technique over transfemoral approach (TFA) include lower morbidity and mortality, including sig-nificant bleeding complications, increased patient comfort, decreased costs compared to femoral closure devices, and im-mediate ambulation in an outpatient setting. We describe our

initial experience with TRA in a busy interventional radiology (IR) practice.

METHODS: Over a 17-month period, 300 procedures were performed in 230 patients (180 male, 50 female; mean age 65) using a TRA. Procedures included: hepatic chemoembo-lization (TACE) (n=143), hepatic radioembolization (Y90) (n=117), uterine fibroid embolization (n=13), visceral and re-nal angioplasty/stenting (n=12), splenic embolization (n=3), internal iliac artery embolization (n=2), other peripheral embolization (n=6), iliofemoral angioplasty/stenting (n=2), subclavian angioplasty/stenting (n=1), AAA endoleak em-bolization (n=1). Various embolization materials were used including: n-BCA, Onyx liquid embolic system, calibrated microspheres, drug-eluting microspheres, Yttrium-90 loaded microspheres, gelfoam, microcoils, and Amplatzer plugs.

A Barbeau test was performed using a pulse oximeter prior to all procedures. A Glidesheath was placed in the radial artery (RA) using US guidance in every case (left: n=299, right: n=1). Sheath sizes included 4 Fr (n=25), 5 Fr (n=259), and 6 Fr (n=16). A solution of 3000 U heparin, 2.5 mg verapamil, and 200 mcg nitroglycerin was administered interarterially following sheath placement. At completion, a TR-band was placed for radial compression. Technical success, 30-day ma-jor and minor adverse events, and equipment costs per case were evaluated.

RESULTS: Technical success was obtained in 97% of pro-cedures (291/300). Radial loops were encountered in 9 cases (3%). 1/9 loops were unable to be successfully navigated (11%). There were no major adverse events at 30 days. Mild pain and weakness in the left hand was observed in 3 cases (1%), which resolved with NSAIDs. Asymptomatic RA thrombosis was ob-served in 6 cases (2%). Minor grade I hematomas were observed in 20 procedures (6.7%), which resolved spontaneously. RA pseudoaneurysm was seen in 1 case (0.3%), which was suc-cessfully treated with thrombin injection. Equipment costs per case were less expensive by an average of $97/case as com-pared to TFA standard controls.

CONCLUSIONS: TRA is feasible, safe, effective and less costly for peripheral interventions and various embolization procedures in IR.

AIM-37 Transradial Access for Iliac Artery Interven-tions Using Sheathless Guiding: Pilot StudyRuzsa Z, Nemes B, Tóth K, Berta B, Kovács N, Vámosi Z, Merkely BSemmelweis University, Budapest, Hungary

PURPOSE: The purpose of this pilot study was to evaluate the acute success and complication rate of the transradial ac-cess for iliac artery stenting using sheathless guiding.

METHODS: The clinical and angiographic data of 19 con-


AIM RADIAL ABSTRACTSsecutive patients with symptomatic iliac artery stenosis treated via transradial access using 8.5 Fr sheathless guiding between 2012 and 2013 were evaluated in a pilot study. There were no exclusion criteria. All patients underwent duplex ultrasound before and after the intervention. Primary endpoint: major adverse events (MAE), rate of major and minor access site complications. Secondary endpoints: angiographic outcome of the iliac artery intervention, consumption of the angioplas-ty equipment, fluoroscopy time and x-ray dose, procedural time, cross over rate to another puncture site, and hospitaliza-tion in days. Transradial cases were performed by two opera-tors skilled in transradial technique.

RESULTS: Procedural success was achieved in 19 patients (100%) and the crossover rate was 0%. Major access site complication was not detected. Minor access site complica-tion was encountered in 2 patients (10.5%) (1 asymptom-atic radial artery occlusion and one puncture site hema-toma). The incidence of MAE was 0%. Mean procedure time was 20±6.5 min, mean fluoroscopy time was 373±254 min, and DAP was 742±695 Gycm2. Mean contrast vol-ume was 82±42 mL. Hospitalization day was 1 day in the investigated population.

CONCLUSION: Iliac artery stenting can be safely and ef-fectively performed using radial access and sheathless guiding with acceptable morbidity and high technical success.

AIM-38 Transradial Renal Artery StentingRuzsa Z, Tóth K, Kovács N, Bánsághi Z, Szolics A, Jambrik Z, Varga I, Merkely BSemmelweis University, Budapest, Hungary

INTRODUCTION: Percutaneous interventional procedures in the renal arteries are usually performed using a femoral or brachial vascular access. The transradial approach is becoming more popular for peripheral interventions, but limited data exists for renal artery angioplasty and stenting.

METHODS: We have analyzed retrospectively the clinical, angiographic, and technical results of renal artery stenting performed from radial artery access between 2010 and 2012 in two catheterization laboratories. In 24 patients with hemo-dynamically relevant unilateral renal artery stenosis (mean di-ameter stenosis, 81%±12%; right, n=8; left, n=16), interven-tional treatment with PTA and stenting was performed using a left (n=4) or right (n=20) radial artery access. The access site was an operator decision.

RESULTS: The radial artery anatomy was identified with aortography using 100 cm pigtail catheter. After engagement of the renal artery ostium with a 6 Fr Multipurpose (length, 125 cm; Cordis) or 6 Fr JR5 guiding catheter (length 100 cm, Boston and Medtronic) the stenosis was passed with a 0.014″ guidewire followed by stent implantation (Express SD, Bos-

ton Scientific; Herculink, Abbott). Direct stenting was suc-cessfully performed in 23 cases. Predilatations were required in two cases. A primary technical success (residual stenosis <30%) could be achieved in all cases. There were no major periprocedural complications. In one patient asymptomatic radial artery occlusion was detected (4.1%).

CONCLUSION: Transradial renal artery angioplasty and stenting is technically feasible and safe.

AIM-39 Randomized Comparison of Transradial and Transfemoral Approach for Carotid Artery Stenting: RADCAR studyRuzsa Z, Nemes B, Pintér L, Berta B, Tóth K, Teleki B, Nardai S, Jambrik Z, Kolvenbach R, Hüttl K, Merkely BSemmelweis University, Budapest, Hungary

BACKGROUND and PURPOSE: Carotid artery stenting (CAS) is emerging as an attractive alternative to surgical end-arterectomy for the treatment of carotid artery disease. Tran-sradial angiography and intervention results in fewer vascu-lar complications, earlier ambulation, and improved patient comfort. Limited data exist on radial access in carotid artery stenting. This multicenter prospective randomized study was performed to compare the outcome and complication rate of transradial (TR) and transfemoral (TF) CAS.

MATERIALS and METHODS: The clinical and angiograph-ic data of 260 consecutive patients at high risk for carotid end-arterectomy (CEA) treated by CAS with cerebral protection between 2010 and 2012 were evaluated in a prospective ran-domized multicenter study. 158 symptomatic patients with >70% carotid stenosis and 102 asymptomatic patients with >80% stenosis were enrolled. Patients were randomized to TR (n=130) or TF (n=130) groups and several parameters were evaluated to assess the advantages and drawbacks of the dif-ferent accesses: Primary endpoint: MACCE, rate of major and minor access site complications. Secondary endpoints: angio-graphic outcome of the CAS, consumption of the angioplasty equipment, fluoroscopy time and x-ray dose, procedural time, crossover rate to another puncture site, and hospitalization in days. Transradial cases were performed by three operators skilled in transradial technique. All femoral access sites were closed with femoral closure device.

RESULTS: Procedural success was achieved in 260 patients (100%); the crossover rate was 10% in the TR (2 failed punc-ture, 1 radial artery spasm, 1 radial artery loop, and 7 can-nulation problems) and 1.5% in the TF (2 iliac artery ste-nosis) group (p<0.05). Major access site complication was encountered in 1 patient (0.9%) (1 symptomatic radial artery occlusion) in the TR and in 1 patient (0.8%) in the TF group (p=ns). The incidence of MACCE was 0.9% in the TR and 0.8% in the TF group (p=ns). Procedure time (1744±742 vs 1665±744 sec, p=ns) and fluoroscopy time (613±289


AIM RADIAL ABSTRACTSvs 579±285 sec, p=ns) was not significantly different, but the radiation dose was significantly higher in the TR group (223±138 vs 182±106 Gycm2, p<0.05). The consumption of diagnostic catheters and buddy wires was significantly higher in the TF group. Hospitalization days were significantly lower in the TR group (1.17±0.40 vs 1.25±0.45, p<0.05).

CONCLUSIONS: The transradial approach for carotid ar-tery stenting has the same efficacy and safety as transfemoral, however the crossover rate is higher with transradial access. There are no differences in total procedure duration, fluoros-copy time between the two approaches, but the radiation dose is significantly higher in the radial group. In both groups, vas-cular complications occurred rarely.

Nurse and MD Session

AIM-40 Usefulness of Quality Control Techniques to Reduce Vascular Complications after Coronary Angiography and InterventionsGarcimartín P, González P, Maull E, Encinas S, Pueyo MJ, Sánchez D, Simó M, Bartolomé YHospital del Mar, Barcelona, Spain

PURPOSE: 1. Evaluate the efficacy of different procedures in order to reduce the incidence of vascular complications in patients undergoing coronary angiography and angioplasty. 2. Evaluate the effectiveness of training sessions given to hospi-talization unit nurses to fulfill the recommendations (hemo-stasis device retrieval and first mobilization after procedure).

METHODS: Observational and prospective study that included 3250 patients in three periods: 1070 patients (March 2006 to January 2008), 967 patients (February 2008 to December 2010), and 1213 patients (January 2011 to June 2013). The sample in-cluded all patients except those who were discharged before the second nurse visit 12-24 hours after the procedure. The collected data were: gender, hospitalization unit, type of procedure, vascu-lar approach, hemostasis method, vascular complications, timing of hemostasis, mobilization after the procedure, and recommen-dations fulfillment. Vascular complications were divided into immediate (0 to 3 hour post-procedure) and late (from 3 to 24 hours post-procedure). Statistical analysis was performed with Chi-squared and Kappa correlation and the statistical signifi-cance was set at 5% (p<0.05). Data was analyzed with SPSS software version 21.0.

RESULTS: Men underwent more frequently coronary angi-ography and interventions during the three periods (69.9%, 69.7%, and 70.2%). The number of angioplasty cases pro-gressively increased from 45.5% in the first period, 44.6% in the second, and 50% in the third. Radial approach was the main choice in the three periods: 54.2%, 70%, and 92% (p<0.05). Immediate vascular complications rate was reduced within the three periods: 4.7%, 5.7%, and 2.3%

(p<0.05). Late vascular complications rate progressively de-creased: 15.5%, 5.5%, and 3.5% (p<0.05). The retrieval of hemostasis device recommendations fulfillment rate show an improvement (Kappa index 0.799, 0.828, 0.922) as well as those concerning patient mobilization after procedure (Kap-pa index 0.583, 0.782, 0.953).

CONCLUSIONS: The procedures designed to reduce the incidence of complications have been effective, but the de-termining factor is the use of radial approach. Conventional compression methods are more effective in reducing the incidence of complications than using mechanical devices, which use has decreased. The training sessions given to hos-pitalization unit nurses have improved the recommendations fulfillment (hemostasis device retrieval and first mobilization post-procedure).

AIM-41 Radial Access: Not Just For Cardiology Anymore: A Nursing PerspectiveOrt MMount Sinai Medical Center, New York, NY, USA

PURPOSE: Improving the patient’s procedural experience by utilizing radial access for transarterial chemoemboliza-tion, as well as employing improved efficiency of financial and human resources.

METHODS: Monitoring the number of post-procedural complications associated with radial access. Surveying the nurses who are direct caregivers pre-, intra-, and post-proce-durally as to their observation of patient responses to radial ac-cess versus femoral access. Monitoring the number of nursing hours required to recover a patient post-procedurally.

RESULTS: 201 radial cases done: 167 male, 34 female rang-ing in age from 39 to 89 years.

Complications: 4 patients developed radial artery thrombosis. 12 patients developed grade 1 hematomas. 1 patient devel-oped a pseudoaneurysm. No patient required surgical inter-vention secondary to a complication.

Twelve interventional nurses were surveyed as to the patient’s individual experiences; 100% agreed the patient’s experience was improved both intra- and post- procedurally. Patient had significantly less pain at the insertion site as compared to femoral access as well as fewer complaints as sequelae of ly-ing supine for 3 to 6 hours. Additionally, the unit was able to conserve from 1 to 3 nursing hours per patient in the recovery period. The procedure itself required no additional resources. Financially radial access resulted in an approximate cost sav-ings of $100.00 per case.

CONCLUSIONS: Patient safety and comfort are always paramount; hence the most significant reason for transradial


AIM RADIAL ABSTRACTSaccess. Radial access significantly reduces the odds of major bleeding by 70% as compared to femoral access. Patients are able to ambulate and sit up post-procedurally improving over-all comfort and decreasing possibilities of back pain and uri-nary retention. Patients overall perceptions of their procedural experience are improved. Although, nursing neurovascular checks are done as frequently, they are less invasive and allow for increased patient privacy. Also, because stasis is generally safely achieved more expeditiously, there is significant cost saving in nursing recovery hours.

Radial Approach and Controversies

AIM-42 A Randomized Trial Comparing 7.5 and 15 Frames per Second for Fluoroscopy During Transra-dial Coronary Angiography and InterventionsAbdelaal E, Plourde G, MacHaalany J, Arsenault J, Rimac G, Ribeiro H, Allende R, Déry JP, Barbeau G, De Larochellière R, Nguyen CM, Costerousse O, Bertrand OFIUCPQ, Quebec City, QC, Canada

BACKGROUND: TRA for cardiac catheterization is poten-tially associated with increased radiation exposure for opera-tor and patient. Low rate fluoroscopy has potential to reduce radiation exposure.

OBJECTIVES: This study sought to determine the efficacy of low rate fluoroscopy at 7.5 frames per second (FPS) in com-parison with conventional 15 FPS for reduction of operator and patient radiation dose during cardiac catheterization and percutaneous coronary intervention (PCI) via the transradial approach (TRA).

METHODS: Three hundred sixty-three patients undergoing TRA cardiac catheterization with or without PCI were ran-domized prior to procedure to low rate fluoroscopy at 7.5 FPS (n=182) vs conventional 15 FPS (n=181). Both 7.5 and 15 FPS fluoroscopy protocols were configured with a dose per pulse of 40 nGy. Cine acquisitions were performed at 15 FPS in both groups. Primary endpoints were fluoroscopy time, operator radiation dose (measured with a dosimeter attached to the left side of thyroid shield), and patient radiation dose, expressed as dose-area product (DAP) in μGy.m2.

RESULTS: Mean age of study population was 65±11 years, and body mass index was 29±6. A total of 174 patients un-derwent diagnostic coronary angiography (CA) (85 [47%] in 7.5 FPS group, and 89 [49%] in the 15 FPS group) and 179 underwent PCI (93 [51%] in 7.5 FPS and 86 [48%] in 15 FPS group). Ten patients (3%) had graft revision. Base-line and procedural characteristic were uniformly distributed between the 2 groups. Fluoroscopy time was similar with 7.5 FPS and 15 FPS for diagnostic CA (3.2±1.9 vs 3.2±2.0 min, p=0.83) and PCI (12±8 vs 13±10 min, p=0.30), respectively. For diagnostic CA, 7.5 FPS was associated with 40% absolute

reduction in operator dose compared to 15 FPS (20±14 μSv vs 32±25 μSv, p=0.0008); and 20% reduction in patient DAP (2413±1345 μGy.m2 vs 3020 ± 1638 μGy.m2, p=0.0081). For PCI, 7.5 FPS was associated with 28% absolute reduction in operator dose (45±34 μSv vs 63±40 μSv, p=0.0089) compared to 15 FPS; and 20% reduction in patient DAP (6102±3092 μGy.m2 vs 7545±4763 μGy.m2, p=0.0184).

CONCLUSIONS: Low rate fluoroscopy at 7.5 FPS is associ-ated with significant reduction in radiation exposure to opera-tor and patient during transradial coronary angiography and PCI compared to conventional 15 FPS. This simple measure should routinely be adopted to minimize radiation exposure.

AIM-43 Radial vs Femoral Approach for PCI and In-Hospital Outcomes in Normal-Weight, Obese, and Morbidly Obese PatientsBaquero GA, Yadav PK, Rhodes D, Gilchrist ICPenn State Heart and Vascular Institute, Hershey, PA, USA

PURPOSE: Obesity is a rapidly increasing epidemic associat-ed with increased risk for cardiac disease and more likelihood of requiring invasive cardiac procedures. Available literature evaluating outcomes of percutaneous coronary interventions (PCIs) in this patient population is limited. The aim of this study was to analyze and compare our experience of transra-dial vs transfemoral approach in normal weight, obese, and extremely obese patients undergoing PCIs.

METHODS: We retrospectively reviewed all patients who underwent PCIs in our institution between 2001 and 2012. Patients were classified according to their weight and access site as follows: normal weight (NW=BMI ≤24 kg/m2), obese (O=BMI ≥24 ≤40kg/m2), and morbidly obese (MO=BMI ≥40kg/m2), and radial vs femoral. In-hospital complications including major adverse cardiac events (MACE), vascular and bleeding complications, cerebrovascular events (CVAs), as well as immediate (<24h) and 30 days all-cause mortality were evaluated.

RESULTS: A total of 5899 PCIs took place within the studied period, out of which 440 (7.4%) patients were MO, 4713 (80%) were O, and 746 (12.6%) were NW. Transradial ac-cess was performed in 2541 (43%) patients (MO=222/9%; O=2.049/81% and NW=270/10%) whereas femoral access was obtained in 3358 (57%) (MO=218/7%; O=2,664/79%, and NW=476/14%). Radial access was associated with 2 com-plications (1 MACE and 1 immediate death) within the MO group, 17 documented complications (2 MACE, 4 bleeding, and 11 <30 days deaths) among the O group and 7 complica-tions (1 vascular, 4 bleeding, and 2 <30 days deaths) in the NW group when compared to 6 (1 MACE, 1 vascular, 3 bleeding, and 1 immediate death; p=0.146), 143 (12 MACE, 26 vascular, 66 bleeding, 4 CVEs, 17 immediate deaths, and 18 <30 days deaths; p=0.001), and 29 (1 MACE, 4 vascu-


AIM RADIAL ABSTRACTSlar, 20 bleeding, 1 immediate deaths, and 3 <30 days deaths; p=0.032) femoral access complications in these groups respec-tively. Comparison of radial access complications between the MO and O groups vs the NW patients also revealed statisti-cal significance (p=0.009). No significant difference was noted when analyzing this data in patients that underwent femoral access (p=0.405).

CONCLUSION: In comparison to traditional femoral ap-proach, transradial access for PCI appears to be associated with fewer vascular and bleeding complications as well as mortality rates in obese patients. Obese and morbidly obese patients are more prone on developing radial access complications when compared to normal weight patients.

AIM-44 Transradial vs Femoral Approach for Diag-nostic Angiography and PCI in the Very ElderlyBaquero GA, Yadav PK, Gilchrist ICPenn State Heart and Vascular Institute, Hershey, PA, USA

PURPOSE: As the population progressively ages, the num-ber of elderly suffering from ACS requiring intervention will continue to increase. Transradial approach is associated with

fewer vascular and bleeding complications with some stud-ies showing prolonged intervention times compared with the transfemoral approach. There is limited data available com-paring the safety of transradial approach in the elderly popula-tion. The aim of this study was to compare our experience of transradial vs transfemoral approach in patients >80 years of age undergoing angiography and percutaneous coronary in-terventions (PCIs).

METHODS: We retrospectively reviewed all patients older than 80 years of age who underwent angiography and PCIs in our institution between 2001 and 2012. Patients were classified according to access site (radial vs femoral). In-hos-pital complications including major adverse cardiac events (MACE), vascular and bleeding complications, cerebrovascu-lar events (CVAs), acute renal failure, as well as immediate and 30 days all-cause mortality were evaluated. RESULTS: Between 2001 and 2012, 1874 patients (age 84±4; range 80-108) had diagnostic and PCI procedures (1283 an-giograms; 591 PCIs) performed in our institution. Transradial approach accounted for 777 (41%) procedures (diagnostic 552/71%; PCIs 225/29%, Table 1). Within the PCI group,

Table 1. Patient characteristics and procedures.

Access site Age Gender Angio-grams

PCIs TotalProce-dures

Female Male

Radial 84±3.3 334 443 552 225 777

Femoral 84±4 504 593 731 366 1097

Total 84±3.5 838 1036 1283 591 1874

Table 2. In-hospital complications/mortality.

In-hospitalComplications/Mortality

Angiography PCIs Total Procedures

Radial Femoral P-value Radial Femoral P-value Radial Femoral P-value

Total complications 13 18 0.901 8 23 0.176 21 41 0.217

MACE 1 1 0.841 1 0 0.201 2 1 0.375

Vascular needing intervention 0 4 0.081 0 3 0.173 0 7 0.025

Vascular not needing intervention 1 2 0.734 2 4 0.810 3 6 0.619

Bleeding at access site 1 5 0.191 0 4 0.115 1 9 0.042

Bleeding (other) not related to access site

5 5 0.654 1 11 0.031 6 16 0.174

Composite vascular + bleeding com-plications

7 16 0.218 4 21 0.021 11 37 0.008

Acute renal failure/new dialysis 2 1 0.407 1 1 0.727 3 2 0.399

CVA 3 0 0.045 1 2 0.865 4 2 0.209

Total mortality 23 32 0.853 10 19 0.683 33 51 0.678

Immediate mortality (<24h) 4 7 0.899 2 13 0.045 6 20 0.055

30 days mortality 19 25 0.982 5 8 0.976 24 33 0.920

AIM-44 Tables


AIM RADIAL ABSTRACTSa total of 23 (10%) patients (5:2 to ipsilateral brachial and 3 to contralateral radial arteries; 18 to ipsi/contralateral femoral arteries) required a change of access site due to requirement of intra-aortic balloon pump in 2, severe radial spasms in 5, ra-dial occlusions in 13, and 3 for unknown/unreported causes. Within this group, only 14 (4%) required to be converted from femoral to a different approach (p=0.001). Overall bleeding and vascular complications, as well as immediate mortality were higher within the transfemoral group (Table 2).

CONCLUSIONS: The transradial approach is clinically fea-sible in the elderly over 80 years of age undergoing diagnostic angiography and PCIs. Due to a relatively low adverse event rates, statistical differences between radial and femoral groups could not be defined. Nevertheless, as seen in younger patient cohorts, conversion to an alternative access site is more com-mon with transradial, while it is reassuring to see trends such as less vascular site complication and lower rates of adverse events in this elderly cohort. Further work with properly pow-ered trials are needed.

AIM-45 The Incidence of Acute Kidney Injury After Cardiac Catheterization or PCI: A Comparison of Radial vs Femoral ApproachDamluji A, Cohen MG, Smairat R, Steckbeck R, Moscucci M, Gilchrist ICUniversity of Miami Hospital, Miller School of Medicine, Miami, FL, USA

PURPOSE: Contrast induced acute kidney injury (CI-AKI) is a well-documented complication of catheterization procedures with iodinated contrast agents. Compared to the transfemoral approach, transradial access has been associated with lower in-cidence of chronic kidney disease. We sought to assess the inci-dence of CI-AKI after cardiac catheterization or percutaneous coronary interventions (PCI) according to arterial access site.

METHODS: A total of 1637 consecutive adult patients un-derwent cardiac catheterization or PCI at a single teaching hospital between April 1, 2009 and September 30, 2012. AKI was defined as a rise in serum creatinine >0.5 (mg/dL) or 50% from the baseline value. The independent effect of arterial ac-cess site on CI-AKI was evaluated using multivariable logistic regression analysis.

RESULTS: Transfemoral and transradial access were used in 641 (39%) and 996 (61%) patients, respectively. In the transfemoral and transradial groups, median age was 60 and 62 years (p=0.01); male gender was present in 72% and 79% (p=0.01); and median BMI was 29.7 and 29.9 kg/cm2 (p=0.35), respectively. The total contrast volume was 165 mL in transfemoral and 180 mL in transradial procedures (p<0.001). The GFR was >60 mL/min/1.73 m2 in 72% and 84% (p<0.001) of transfemoral and transradial patients, re-spectively. The overall incidence of CI-AKI was 3.7%. Tran-sradial patients were less likely to develop CI-AKI compared

with transfemoral patients (2.5% vs 4.5%, p<0.001). After adjustment for multiple confounders, transfemoral was no longer associated with an increased CI-AKI risk [OR=1.53, 95% CI 0.83 to 2.84, p=0.169], but a trend remained.

CONCLUSIONS: Our pilot results suggest that despite in-creased contrast volume use, transradial access was not asso-ciated with an increased risk of CI-AKI in a large cohort of patients undergoing cardiac catheterization and intervention procedures. The effect of transradial access on the incidence of AKI should be further prospectively studied.

AIM-46 Assessment of Femoral vs Radial Access in Patients in a High Volume CenterGoldsmit A, Sánchez J, Zaidel E, Sztejfman M, Trucchi D, Sztejf-man C, Bettinotti MSanatorio Guemes, Caba, Argentina

OBJECTIVE: Radial access has shown clear benefits regarding days of hospitalization, bleeding, mortality, patient comfort, etc. However, relatively few patient cases have been reported, leading to a sound decision favoring radial versus femoral PTCA and angiography. The purpose of this work is to get a better understanding regarding these cath lab decisions.

METHODS: This is a prospective study that includes patients as treated in the Sanatorio Guemens cath lab between Decem-ber 2012 and February 2013. Basal features, fluoroscopy time, incidence, and radial to femoral conversion were studied.

RESULTS: 131 endovascular procedures were recorded, 98 (74.8 %) through radial access (Table 1) and the remainder through femoral. Average age of the patients was 63 years, most of them being males (70%). 33 patients were carried out through a different access than radial (25.3%). This deci-sion was due to: radial pulse absence in 1 patient; requiring an IABP in 1 patient; hematoma in radial site puncture in 1 patient, and 1 patient showing weak radial pulse. In all other cases, reasons backing no radial access were not sufficiently supported or reflect a personal bias of the operator (Table 2).

The exposure time radiation and contrast material was similar both in radial and femoral procedures. Radial spasm moderate to severe was observed in 5 patients, 4 coronary and 1 neck vessel angiography, and conversion to femoral access was done in only 2 subjects, due to severe spasm of the radial artery.

CONCLUSION: In spite of the low incidence of radial spasm, the conversion to femoral was negligible and in all cases due to severe radial spasm. Radial access strategies prove to be effective and no additional radiation exposure was required. The numbers of angioplasties where radial access was used was similar to the cases treated through femoral access. Also, that number proved to be inferior to the one obtained for MMII angiography, reasons backing other access different than radial were not sufficiently


AIM RADIAL ABSTRACTSsupported or reflect a personal bias of the operator, in spite of all arguments and new guidelines supporting that technique.

AIM-46 Tables

Table 1

Type of Procedure

Radial Access

Non-Radial Access

Total (N)

Coronary Angioplasty

17 (51%) 16 (49%) 33

Coronary Angiography

71 (88.75%) 9 (11.3%) 80

Leg Angiog-raphy

1 (14.2%) 6 (85.8%) 7

Carotid Angiography

7 (77.8%) 2 (22.2%) 9

Aortogram 1 (100%) 0 1

Renal Angiography

1 (100%) 0 1

98 33 131

Table 2

Clinical Aspect

Radial Access

Non-Radial Access

N total

Stable Angina

44 (80%) 11 (20%) 55 (42%)

Non-ST Elevation

32 (85%) 7 (15%) 39 (29.7%)

ST Elevation 7 (50%) 7 (50%) 14 (10.6%)

History of CHF

1 (100%) 0 1 (0.7%)

By Graft Evaluation

14 (63%) 8 (37%) 22 (16.7%)

Total 98 33 131

AIM-47 Is Transradial Approach Safe in the Elderly? A Tunisian registryHajlaoui N, Sherian LS, Ghommidh M, Ben Mansour N, Lahidheb D, Jedaida B, Haggui A, Dahmani R, Fehri W, Haouala HMilitary Hospital of Tunis, Tunis, Tunisia

BACKGROUND: The population of elderly patients has a greater incidence of cervical atheroma with a greater theoreti-cal risk of mobilization of cervical atheroma during transradial procedures. We examined the safety of transradial procedures in such population in our daily practice.

METHODS: We consulted the registry of the military hospi-tal of Tunis, and we studied 100 random patients aged more than 75 years who underwent percutaneous coronary angio-gram or coronary intervention.

RESULTS: One hundred patients (55 men and 45 women) were studied. The mean age was 79 years ranging 75 to 87 years. 64% of patients were hypertensive, 37% diabetics, 30% smokers, 29% had dyslipidemia, 4% in end stage re-nal disease, and 3 patients (3%) on anticoagulant therapy for atrial fibrillation. Coronary angiography was indicated for acute coronary syndrome in 49 patients, stable angina in 45 patients, and for preoperative assessment of valvular heart disease in 6 patients. The radial access was performed in 35 patients, 3 of whom underwent angioplasty with implantation of stent. There were no local complications or stroke in this group. In the transfemoral approach group (65%), 4 patients (6.2%) had small hematoma in the site of puncture and no other complication was noted.

CONCLUSIONS: In this registry, we haven’t observed more incidence of mobilization of cervical atheroma in the elderly when we used the transradial approach. The transradial ap-proach can be performed in elderly patients with less local complications, earlier ambulation, and shorter hospital stay compared to the standard transfemoral approach. The risk of embolic stroke due to mobilization of cervical atheroma is theoretical and not verified in our daily practice at least.

AIM-48 Transradial Coronary Intervention in Pa-tients with Cardiac Arrest due to Acute Myocardial InfarctionMizuguchi Y, Takahashi A, Yamada T, Taniguchi N, Nakajima S, Hata TSakurakai Takahashi Hospital, Kobe, Hyogo, Japan

BACKGROUND: The latest ACCF/AHA/SCAI guideline recommended transradial percutaneous coronary intervention (TRI) for the patients with acute myocardial infarction (AMI) for the reduction in vascular complication. However, even for skilled operators, the feasibility of TRI for those who compli-cated with cardiac arrest during radial puncture is uncertain because of technical difficulty and possible adverse effect on the procedure time when compared with transfemoral coro-nary intervention (TFI).

METHODS: We retrospectively analyzed 20 consecutive patients with AMI who required extra corporeal membrane oxygenator because of cardiopulmonary arrest resistant to conventional cardiopulmonary resuscitation in the emer-gency room between March 2005 and February 2012. All patients undergoing TRI were performed with a skilled op-erator who performs TRI over 400 cases per year. The radial arteries were not palpable in all the patients before puncture. The percutaneous access sites, the time to cardiopulmonary resuscitation, the door to balloon time, and 30 days survival were investigated.

RESULTS: TRI was performed in 13 patients and 7 other patients underwent TFI. There were no significant differences


AIM RADIAL ABSTRACTSin the time-to-admission time (26.8±14.6 vs 17.0±13.3 min), time-to-ECMO (41.8±18.8 vs 39.0±16.6 min), door-to-nee-dle time (42.3±13.9 vs 49.3±16.5 min), and door-to-balloon time (61.4±19.1 vs 79.3±21.0 min) between TRI and TFI groups. 30-day survival rate was 7 of 20 (38%) in all patients, 4 of 13 (31%) in TRI group, and 3 of 7 (43%) in TFI group.

CONCLUSIONS: This cohort study demonstrates equivalent efficacy of TRI to TFI for the patients complicated with cardiac arrest due to AMI when performed by a skilled operator.

AIM-49 Radiation Exposure During Transradial Diagnostic Coronary Angiography With Multi- or Single-Catheter UsePlourde G, Abdelaal E, MacHaalany J, Rimac G, Roy L, De Laro-chellière R, Larose E, Nguyen C, Barbeau G, Gleeton O, Proulx G, Rinfret S, Déry JP, Boudreault JR, Rouleau J, Rodés-Cabau J, Noël B, Costerousse O, Bertrand OFIUCPQ, Quebec City, QC, Canada

BACKGROUND: With transradial approach, diagnostic coronary angiography (DCA) is routinely performed with routines using single- or multi-catheters. However, it remains unknown whether these strategies are associated with different radiation exposure.

OBJECTIVE: To compare fluoroscopy times and dose-area-product (DAP) during transradial DCA using 4 different rou-tines (Judkins, Amplatz, Barbeau, Multipurpose).

METHODS and RESULTS: From November 2012 to July 2013, we recruited 1384 patients who underwent transradial DCA followed by a left ventriculography or aortography. The analysis was performed on an intent-to-treat basis, and based on the initial catheter used. The first routine consisted of Jud-kins left and right catheters, whereas the 3 others included Amplatz, Barbeau, or Multipurpose as single catheters (Cordis Corporation). A majority of patients (n=1,209) underwent their “intended” routine, whilst 13% (n=175) had a crossover to another routine during the procedure. See Table 1 for base-line and procedural characteristics.

CONCLUSION: Overall, fluoroscopy time was lowest with multipurpose single-catheter routine. However, radiation ex-posure to patients was most reduced with standard routine us-ing Judkins left and right catheters. Further randomized stud-ies are required to assess patient and operator exposure using universal and standard diagnostic catheters.

AIM-50 Vascular Access Route (Radial vs Femoral) and Radiation Exposure in Percutaneous Coronary Interventions and Diagnostic AngiographyRigattieri S, Sciahbasi A, Mussino E, Drefahl S, Pugliese FRSandro Pertini Hospital, Rome, Italy

PURPOSE: Radial access (RA) is being increasingly used in inter-ventional cardiology, since it is associated with less vascular compli-cations and bleedings compared to femoral access (FA). Neverthe-less RA has some limitations, such as a steep learning curve and,

AIM 49 Table

Variable Alln = 1,384

Routine #1(JL/JR)

n = 1,193

Routine #2(AL)

n = 56

Routine #3(Barbeau)

n = 90

Routine #4(Multipurpose)

n = 45

P value

Baseline characteristics

Males, n (%) 935 (68) 794 (67) 32 (57) 84 (93) 25 (56) <0.0001

Age (years) 64 ± 11 64 ± 11 65 ± 12 63 ± 11 67 ± 91 0.2714

Weight (kg) 81 ± 18 81 ± 18 80 ± 19 85 ± 16 79 ± 15 0.1346

Height (cm) 168 ± 9 168 ± 9 166 ± 10 172 ± 8 166 ± 10 <0.0001

BSA (m2) 1.95 ± 0.26 1.95 ± 0.26 1.93 ± 0.28 2.03 ± 0.23 1.92 ± 0.22 0.0293

Procedural characteristics

Fluoroscopy time (min) 2.7 [2.0-3.9] 2.7 [2.0-3.9] 4.0 [3.0-5.7] 3.0 [2.2-4.2] 2.1 [1.6-2.5] <0.0001

Dose-area-product (cGy•2)

3,099 [2,128-4,408]

3,007 [2,061-4,363]

3,622 [2,592-4,866]

3,874 [2,694-5,503]

3,220 [2,338-4,251]

<0.0001

“Intended” routine only, n (%)

1,209 (87) 1,070 (90) 44 (79) 51 (57) 44 (98) 0.0004

Crossovers, n (%) 175 (13) 123 (10) 12 (21) 39 (43) 1 (2) 0.0004

“Intended” routine only n = 1,209 n = 1,070 n = 44 n = 51 n = 44

Fluoroscopy time (min) 2.6 [2.0-3.7] 2.6 [2.0-3.6] 3.9 [2.7-4.9] 2.8 [2.0-3.7] 2.0 [1.6-2.5] <0.0001

Dose-area-product (cGy•2)

3,001 [2,037-4,269]

2,923 [2,013-4,211]

3,410 [2,456-4,872]

3,818 [2.594-5,238]

3,242 [2,330-4,382]

0.0022


AIM RADIAL ABSTRACTSpossibly, an increased radiation exposure, which has been reported in the literature, although there are conflicting data.

METHODS: We designed a single-center, retrospective study aimed to compare radiation exposure during percu-taneous coronary interventions (PCI) and diagnostic coro-nary angiography (CA) according to the vascular access route (RA vs FA). We included all patients undergoing PCI or CA in our laboratory from May 2009 to May 2013 for whom radiation exposure data were available. Radiation exposure data, expressed as dose area product (DAP, cGy.cm2) were obtained by the x-ray system. Stepwise multiple linear re-gression analysis was performed in order to compare radia-tion exposure between RA and FA adjusting for clinical and procedural confounders.

RESULTS: DAP values were available for 1396 out of 4110 procedures. RA was used in 1153 procedures (82.6%) and was right-sided in 82.3% of cases. The overall rate of RA in the cath lab was 68%, 69%, 75%, and 87% for each of the 4 years considered, respectively. Clinical and procedural characteris-tics were different between RA patients and FA patients, indi-cating a selection bias towards the use of FA in sicker patients. Indeed, RA patients were younger, less frequently female, and had higher BMI as compared to FA patients. The rates of PCI, ad hoc PCI, bypass angiography, thrombus aspiration, primary/rescue angioplasty, as well as the number of stents im-planted, fluoroscopy time, and contrast dose were significantly higher in FA. Median DAP value was 7635 cGy.cm2 (IQR 4393 – 12976) in RA vs 9670 cGy.cm2 (5555-14310) in FA (p<0.001). The linear regression model showed that vascular access route was not an independent predictor of increased DAP (Beta 0.054, 95% C.I. -0.024 - 0.133; p=0.175). Age, BMI, primary PCI, ad hoc PCI, number of stents, bypass an-giography, and the use of IVUS/pressure wire were associated with higher radiation exposure, whereas being female was as-sociated with a lower DAP.

CONCLUSION: After adjusting for clinical and procedural confounders, RA was not found to be associated with in-creased radiation exposure as compared to FA in an experi-enced radial center.

AIM-51 Vascular Access Site and Door-to-Balloon Time in Primary PCIRigattieri S, Sciahbasi A, Pugliese FR, Loschiavo PSandro Pertini Hospital - ASL RMB, Rome, Italy

PURPOSE: Radial approach (RA) in primary angioplasty (pPCI) is associated with lower rates of mortality and bleeding as compared to femoral approach (FA). However, RA is tech-nically more demanding, and one could expect an increase in the door-to-balloon interval (DTB) with a RA strategy. In the literature there are conflicting reports about this issue. We aimed to assess the impact of RA on DTB as compared to FA.

METHODS: We retrospectively considered all pPCI pro-cedures performed at our hospital in a 4-year window (May 2009 to June 2013) according to the following inclusion crite-ria: 1) procedures performed by skilled RA operators (overall RA rate >60% in the previous 5 years); 2) availability of DTB.

RESULTS: We identified 208 procedures (204 pPCI and 4 res-cue PCI) performed by 2 operators: SR (179 procedures from May 2009 to June 2013) and AS (29 procedures from June 2012 to June 2013). We identified 138 procedures performed by RA (66.3%), 70 by FA. RA patients were younger (63.6±13.4 vs 68.7±13.1; p=0.009) and had a greater body mass index (28.0±5.2 vs 25.6±4.2; p=0.004) as compared to FA patients; female gender was more prevalent in FA patients (37.1% vs 16.7%; p=0.001).

On the contrary, there were no statistically significant dif-ferences regarding the following parameters: rate of manual thrombus aspiration, rate of intra-aortic balloon, number of diseased vessels, rate of anterior myocardial infarction, prev-alence of cardiovascular risk factors and diseases (hyperten-sion, diabetes, dyslipidemia, smoking, peripheral arteriopathy, previous myocardial infarction), dye dose, radiation dose (as assessed by Dose Area Product), procedural and fluoroscopy time, number of diagnostic and guiding catheters, number of stents implanted. Procedural success was 96.4% with RA and 90.0% with FA (p=0.064). DTB was comparable in RA and FA (median and inter-quartile range were, respectively, 95 min [80-154] and 93 min [69-126], p=0.326).

As far as in-hospital outcomes are concerned, overall mortal-ity was 5.3% and it was significantly higher in FA patients as compared to RA patients (10.0% vs 2.9%; p=0.047), whereas the length of stay was comparable (6 days [5-9] in RA and 6 days [5-12] in FA; p=0.770).

CONCLUSION: In a center with expert radial operators, RA for pPCI is not associated with a prolongation in the DTB interval as compared to FA.

AIM-52 Percutaneous Coronary Intervention Using Rotational Atherectomy: A Multicenter Comparison of Radial vs Femoral ApproachBundhoo SS, Scott P, Hanratty C, Ossei-Gerning N, Byrne J, Anderson RAUniversity Hospital of Wales, Cardiff, UK

PURPOSE: Rotational atherectomy (RA) is a well-established adjuvant device for use during percutaneous coronary inter-vention (PCI). The femoral artery has historically been the arterial access of choice for RA, facilitating the use of large-bore guide catheters. Transradial access has become a default for many European centers, but the use of RA has previously been limited. We present a large, contemporary, multicenter comparison of radial and femoral RA PCI.


AIM RADIAL ABSTRACTSMETHODS: Patients from three regional cardiology centers from the United Kingdom undergoing RA PCI from 2008 to 2012 were included in the study. Patients were separated into access site used, and procedural and clinical outcomes were compared. MACE was reported at 30 days.

RESULTS: 685 patients underwent RA PCI (radial n=398 and femoral n=287) during the study period. There was a predominance of male patients in the radial group (75.4% vs 63.4%, p<0.001) and more likely to have left ventricular impairment (32.8% vs 15.4%, p<0.001). No other difference in baseline demographics was seen between the two groups. Procedural success was identical in both cohorts (98.5 vs 97.5, p=0.62) but radial cohort received more drug-eluting stents (91.2% vs 85.3%, p=0.03). Guide catheter size in the radial cohort was smaller (6.55 vs 6.95, p<0.001), average burr size was similar. The femoral group underwent more left main-stem PCI (14.2% vs 21.8%, p=0.01) and additional imaging (23.2% vs 32.9%, p=0.03). The procedural time (76.3 min vs 92.6 min, p<0.001) and time to first balloon inflation (39 min vs 54 min, p<0.001) were significantly lower in the ra-dial cohort, as was mean length of stay (1.4 days vs 2.9 days, p=0.008). Bleeding and vascular access complications were similar between the two groups as was 30-day MACE (radial 6.45% vs femoral 4.08%, p=0.15).

CONCLUSIONS: This is the largest comparison to date of radial versus femoral rotablation. Our data demonstrate that radial RA PCI can be performed safely, with smaller guide catheters and a similar procedural success. Procedural time and time to first balloon inflation was significantly less in the radial cohort, whereas 30-day MACE rates and access-asso-ciated complications were similar between both groups. Our results show that radial access is a safe, effective, and perhaps more efficient method for performing RA.

AIM-53 What Happens When Transradialists Use Transbrachial ApproachTrbušic M, Gabric ID, Planinc D, Krc mar T, Pintaric HUniversity Hospital Centre Sisters of Mercy, Zagreb, Croatia

PURPOSE: Radial arterial approach has become the de-fault option for coronary procedures in our cath lab (>90%). However, there are situations when radial arterial approach is not possible (e.g. congenital anomalies, tortuous configura-tions, radioulnar loop, weak or absent radial pulse secondary to previous puncture or catheterization). In such situations, a common second-line approach is used (femoral or ulnar). Many clinicians considered transbrachial (TB) angiography as a high-risk and obsolete procedure. In literature, the compli-cations rate was unacceptably high (up to 36%). The aim of this retrospective investigation was to evaluate the safety and efficiency of TB approach as alternative to radial approach, especially after unsuccessful radial artery puncture.

METHOD: Between April 2011 and 2013 TB coronary an-giography in the antecubital region was performed in 22 pa-tients with stable and unstable angina or valvular heart disease. In 11 patients, diagnostic procedure was followed by coronary intervention. Reasons for TB approach were weak radial pulse (10 cases) or unsuccessful radial artery puncture (12 cases). Procedures were performed by three experienced transradial invasive cardiologists (transradial success more than 95%). The catheter size was 6 Fr in all patients. Anticoagulation pro-tocol was used following guidelines (aspirin, clopidogrel, un-fractionated heparin) but without glycoprotein IIb/IIIa recep-tor inhibitors. Major complications were defined as vascular complications requiring blood transfusion or surgery or per-manent neurological deficit in the lower limb. Minor compli-cations were defined as vascular complications not requiring blood transfusion or surgery and transient neurological defi-cit in the lower limb. Standard post-procedural protocol was removal of artery sheath 6 hours after puncture and manual puncture site compression for 10 minutes.

RESULTS: Overall success rate was 95.5% (21/22). There were no major complications and we noticed only two minor complications (9%), both hematomas.

CONCLUSION: TB approach, when used by dedicated tran-sradialists, seems to be easily feasible, safe, and effective. Lo-cal vascular complications could be avoided by cautious and sensitive puncture technique. Other important factors are use of 6 Fr catheters, defensive anticoagulation, and careful obser-vation by the nursing team after sheath withdrawal. TB ap-proach has all advantages of the arm approach over the femo-ral (early ambulation, patient preference, suitable for patients with severe occlusive aortoiliac disease and for patients with difficulty lying down).

AIM-54 Patients Having PCI via Femoral Approach in Centers that are Default Radial Centers: Results and Insights From a Single-Center ExperienceBundhoo SS, Uddin M, Shah A, Ossei Gerning N, Kinnaird TD, Anderson RAUniversity Hospital of Wales, Cardiff, UK

PURPOSE: Increasingly the transradial route (TR) is pre-ferred over the transfemoral route (TF) for PCI. However even in high volume default TR centers a small cohort of patients are required to undergo TF PCI. Our study examined the clinical, procedural characteristics, and outcomes of patients undergoing PCI via the TF in a single high volume UK center.

METHODS: This was a prospective study examining the PCI procedure and outcomes of all patients undergoing PCI be-tween January 2009 and December 2012. Patient demograph-ics, procedure details, and outcomes were all collected from internal and national databases.


AIM RADIAL ABSTRACTSRESULTS: 5379 patients were examined, 10.4% (n=561) of patients undergoing PCI via the TF and 89.6% via the TR. The TF group included more often females (35.8 vs 24.6% when compared to TR cohort, p<0.0001), older (64.9 vs 63.0 year, p<0.0002), and lighter (80.7 vs 83.7 kg, p<0.0001). There was a greater proportion of patients with a history of previ-ous revascularization by PCI (27.5% vs 18.1%, p<0.0001) or CABG (14.6 vs 4.8%, p<0.0001) in the TF group. Car-diogenic shock and use of intra-aortic balloon pump was also greater in the TF group (7 vs 1% and 6.5 vs 0.5%, respec-tively, p<0.0001). Complex procedures including use of rota-tional atherectomy (4.1 vs 0.7%), saphenous vein graft PCI (9.1 vs 3.0%), and chronic occlusion PCI (21.1 vs 6.8%) were also performed more frequently in the TF group (p<0.0001

for all). In-hospital mortality (2.0 vs 0.46%, p<0.0001), vas-cular complications (3.2 vs 0.6%, p<0.0001), and bleeding (1.0 vs 0.02%, p<0.0001) were all more common in the TF group. PCI success was less common (88.2 vs 94.6%) in the TF group despite similar number of lesions attempted (1.54 vs 1.57, p=ns) and vessels treated (1.27 vs 1.27, p=ns).

CONCLUSION: In a high volume default TR PCI center, the small cohort of patients that continue to have PCI via the TF route are more likely to undergo complex coronary intervention and have higher subsequent vascular complications and mortal-ity. Best practice for such patients in future will require opti-mization of pharmacotherapy strategies, procedural techniques, and utilization of emerging interventional equipment.


AIM RADIAL ABSTRACTS

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