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The anterior-posterior fluoroscopic guidance (the AP technique) is a standard method for common femoral artery (CFA) access, but the rate of CFA access with ultrasound vs. the AP technique was not significantly different. We have shown an oblique fluoroscopic guidance (the oblique technique) with a micropuncture needle (MPN) resulted in CFA access in 100 % of patients. The outcome of the oblique vs. AP technique is unknown. We compared the utilities of the oblique vs. AP technique for CFA access with a MPN in patients undergoing coronary procedures. A total of 200 patients were randomized to the oblique vs. AP technique. Using the oblique technique, a MPN was advanced to the mid pubis in the 20° ipsilateral right-or left anterior oblique view with fluoroscopic guidance and the CFA was punctured. In the AP technique, a MPN was advanced to the mid femoral head in the AP view with fluoroscopic guidance and the CFA was punctured. The primary endpoint was the rate of successful access to the CFA. The rates of first pass and CFA access were higher with the oblique vs. AP technique (82 % vs. 61 %, and 94 % vs. 81 %, respectively; P < 0.01). The number of needle punctures was lower with the oblique vs. AP technique (1.1 ± 0.39 vs. 1.4 ± 0.78, respectively; P < 0.01). In high CFA bifurcations, the rate of CFA access was higher with the oblique vs. AP technique (76 % vs. 52 %, respectively; P < 0.01). Vascular complications were lower with the oblique vs. AP technique (1 % vs. 7 %, respectively; P < 0.05). Our data suggest that the oblique technique, compared with the AP technique, significantly increased the rates of first pass and access to the CFA, and decreased the number of punctures and vascular complication. ClinicalTrials.gov Identifier: NCT 03955653. • The AP technique is a standard method for common femoral artery (CFA) access. • It has been reported the rate of CFA access with ultrasound guidance vs. the AP technique was not significantly different. • We investigated the utilities of a novel oblique vs. standard AP technique with micropuncture needle for CFA access. • We showed that the oblique vs. AP technique significantly increased the rate first pass and access and to the CFA. • We also showed that the oblique vs. AP technique decreased the number of punctures and vascular complications. [ABSTRACT FROM AUTHOR]

Large bore arterial hemostasis for emergent MCS initiation in cardiogenic shock and during failures of suture mediated vascular closure devices (VCD) necessitates dry/post-closure technique for successful closure. Use of the alternative MANTA fluoroscopic DOT technique, without depth finder, as post closure and as 'bail-out' in this high-risk patient population is described. All patients who underwent emergent percutaneous transfemoral MCS initiation, without use of upfront sutured-mediated pro-glide VCDs, and procedures where proglide-perclose technique (PPT) failed to achieve hemostasis were post-closed with the alternative MANTA fluoroscopic DOT technique (without depth finder) as primary method or as 'bail-out'. Patient related factors, cardiovascular co-morbidities, clinical indication, distribution of 14F versus 18F MANTA, and types of procedures obtained. Primary outcomes of access site related acute flow-limiting limb ischemia or bleeding requiring intervention analyzed. 27 patients met inclusion criteria; mean age 64 years, majority male 19 (70 %), more than half obese (56 %) with mean BMI 31.06 kg/m2. 22 (81 %) had emergent MCS initiation and 5 (19 %) PPT hemostasis failures. Types of percutaneous MCS support included; 11 (44 %) Impella CP, 2 (7 %) 15F arterial ECMO, 6 (22 %) 17F arterial ECMO, 4 (15 %) 19F ECMO. All achieved hemostasis utilizing alternative MANTA fluoroscopic DOT technique without vascular complications of bleeding or acute ischemic limb. The alternative MANTA fluoroscopic DOT technique (without depth finder) can be successfully applied as post-closure for emergent MCS support delayed hemostasis and as bail-out for per-close suture mediated VCD failures for large bore arterial hemostasis. [Display omitted] • Vascular complications are associated with high morbidity and mortality with pMCS and other large bore arterial procedures. • There is a lack of consistent, efficient and predictable method for post-closure in this patient population. • Post-closure with MANTA fluoroscopic DOT technique for delayed hemostasis and 'bail-out' for pro-glide failures described. [ABSTRACT FROM AUTHOR]

Various vascular closure devices (VCDs) are commonly used for percutaneous transcatheter aortic valve replacement (TAVR). However, superiority and safety profile among them remain unclear. We compared periprocedural complications among various VCDs in patients undergoing TAVR. PubMed and EMBASE were searched through January 2022 to identify clinical studies comparing any 2 VCDs of Prostar, Proglide and MANTA in patients who underwent TAVR. Studies using surgical cut-down or alternative access other than transfemoral approach were excluded. We analyzed the odds ratios (ORs) of vascular complications (VC), bleeding, acute kidney injury and all-cause mortality using a network meta-analysis. All outcomes were defined by Valve Academic Research Consortium 2 criteria. Two randomized controlled trials and 15 observational studies were identified, yielding a total of 11,344 patients including Prostar (n = 4499), Proglide (n = 5705), or MANTA group (n = 1140). The rates of major VC and life-threatening and major bleeding were significantly lower in Proglide compared to Prostar (OR [95 % CI] = 0.54 [0.32–0.89], 0.68 [0.52–0.90], and 0.49 [0.26–0.95], respectively). There was no significant difference in major VC and bleeding between Proglide and MANTA groups. Proglide was associated with a lower rate of acute kidney injury (0.56 [0.34–0.92]) and red blood cell transfusion (0.39 [0.16–0.98]) compared to Prostar. There was no significant difference in additional interventions and 30-day overall mortality among three groups. In this network meta-analysis of VCD in patients undergoing TAVR, MANTA and Proglide had comparable outcomes while Proglide appears superior to Prostar in terms of major VC and bleeding. • We compared Prostar, Proglide and MANTA in patients who underwent TAVR. • Vascular and bleeding complication were lower in Proglide compared to Prostar. • There was no difference in vascular and bleeding outcomes between Proglide and MANTA. [ABSTRACT FROM AUTHOR]

Background: The distal radial approach (DRA) is a novel catheter cannulation technique to access the distal radial artery for coronary angiography (CAG). It is associated with less occurrence of puncture site occlusion than the conventional transradial approach. However, cannulation failure occasionally occurs due to difficulty in puncturing the smaller distal radial artery. Nitroglycerin is expected to improve the rate of successful DRA via its vasodilative and vasospasm-preventive effects.Methods: The DRA in CAG using transdermal NitroGlycerin patch (DRANG) study is a single-center, double-arm, parallel-assignment, double-blinded, randomized, controlled trial. Eligible patients with angina pectoris who are scheduled to receive CAG via DRA at the National Cerebral and Cardiovascular Center will be enrolled and allocated to the nitroglycerin group (n = 46) or the no-treatment group (n = 46). The nitroglycerin group will receive a transdermal nitroglycerin patch pre-integrated with a covering material that completely conceals the patch on their upper arm on the puncture side. The no-treatment group will receive only the covering material. Applications are performed 2-8 h before puncture while the patient wears an eye mask. Physicians who are blinded to the allocation and have similar experience with DRA puncture will perform DRA using the Seldinger technique with a 22-gauge needle. The primary outcome is the rate of successful palpation-guided distal radial artery cannulation with the first puncture. The secondary outcomes are the rate of successful distal radial artery cannulation, number of punctures, procedure time, use of ultrasound guidance, diameter of the distal radial artery and changes before and after patch application, and occurrence of arterial vasospasm, occlusion, or hypotension.Conclusions: This study will allow us to determine the impact of a transdermal nitroglycerin patch on the rate of successful DRA and validate its effectiveness as a DRA pretreatment.Trial Registration: jRCTs051210128. [ABSTRACT FROM AUTHOR]

Background: Vascular and bleeding complications are common after transcatheter aortic valve implantation (TAVI) and are associated with worse outcomes. The plug-based Manta (M) vascular closure device (VCD) is a novel option to achieve haemostasis for large-bore arterial access sites.Objective: We aimed to compare vascular and bleeding complications between the M-VCD and the established suture-based Perclose ProGlide (P)-VCD.Methods: From February to September 2019 a total of 578 patients underwent transfemoral TAVI at a single high-volume centre. Access site closure was performed using M-VCD in 195 patients (33.7%) and P-VCD in 383 patients (66.3%). We assessed vascular and access site-related complications as well as bleeding events according to the Valve Academic Research Consortium-2 definition.Results: Overall vascular complications occurred less frequently in the M-VCD group (10.7% vs. 19.0%, p = 0.011) driven by a significantly lower rate of major vascular events (2.0% vs. 6.5%, p = 0.025). Access site-related complications were significantly less frequent in the M-VCD cohort (10.7% vs. 16.6%, p = 0.048). The M-VCD was associated with significantly lower rates of major (0.5% vs. 4.4%, p = 0.009) and life-threatening bleeding (0% vs. 2.3%, p = 0.032). In multivariable analysis, the use of M-VCD was the only independent predictor of vascular complications (odds ratio 0.54, 95% confidence interval 0.32-0.91, p = 0.022).Conclusions: The M-VCD was associated with a reduction of vascular and access-site complications as well as severe bleeding after transfemoral TAVI compared to the P-VCD in this observational study. [ABSTRACT FROM AUTHOR]

Background: Women undergoing percutaneous coronary intervention (PCI) are at higher risk for bleeding and vascular complications than men. Multiple approaches have been utilized to reduce bleeding in the modern era of PCI, including radial access, reduced GP IIb/IIIa inhibitor use, increased vascular closure device use, smaller sheath size and novel antithrombotic regimens. Nevertheless, few studies have assessed the impact of these techniques on the gap between men and women for such complications following PCI. We sought to quantify bleeding and vascular complications over time between men and women.Methods: We queried The Dartmouth Dynamic Registry for consecutive PCI's performed between January 2003 and June 2016. Demographic information, procedural characteristics, and in-hospital outcomes were collected and compared between men and women over the years.Results: We reviewed 15,284 PCI cases, of which 4384 (29%) were performed in women. Radial access increased from none in 2003 to nearly 40% in 2016. Use of GP IIb/IIIa and femoral access decreased substantially over the same time. Bleeding and vascular complication rates decreased significantly in women (13.2% to 3%; 6.5% to 0.8%, respectively) and men (3.5% to 0.7%, 3.4% to 0.7%, respectively). The overall bleeding and vascular complication rates decreased more for women than men, narrowing the gender gap.Conclusions: The incidence of bleeding and vascular complications fell between 2003 and 2016 in both men and women. Vascular complications have become less common over time, and based on our analysis, there was no longer any difference between the sexes for this outcome. Bleeding following PCI has decreased in both sexes over time; however, women continue to bleed more than men. [ABSTRACT FROM AUTHOR]

Background/purpose: The MANTA vascular closure device (VCD) is the first commercially available dedicated closure device for large-bore femoral arterial access-site closure and was approved by the United States Food and Drug Administration (FDA) in February 2019. Real-world data on the most commonly reported complications and modes of failure associated with the MANTA closure device are limited. We analyzed post-marketing surveillance data from FDA's Manufacturer and User Facility Device Experience (MAUDE) database for the MANTA VCD (Teleflex, Wayne, Pennsylvania).Methods/materials: Post-marketing surveillance data from the FDA MAUDE database from February 2019 through March 2020 were analyzed, yielding 170 reports.Results: Of the 170 reports of major complications involving MANTA devices, 141 reports involved either injury (136) or death (5) related to the device. Of the 141 reports, bleeding was the most common adverse outcome described (45), followed by vessel occlusion (30) and vessel dissection (21). Device malfunction incidents (29 reports) were reported in 4 main categories: failed deployment (16 reports), malposition of the collagen (9), insufficient information (3), and device dislocation (1).Conclusions: Our analysis of the MAUDE database demonstrates that in real-world practice, the MANTA VCD was found to be associated with complications, including death, vascular injury, and difficulties with the device itself. Ongoing user education, proctoring, and pre-procedural patient selection are important to minimize risks associated with the MANTA VCD. [ABSTRACT FROM AUTHOR]

Vascular complications during transcatheter aortic valve implantation (TAVI) are relatively common, and some of them related to the transfemoral secondary access. The use of the transradial access (TRA) as an alternative vascular approach for transfemoral TAVI could reduce these complications, however, the treatment of potential vascular peripheral issues from this access has been scarcely described. The advance of a wire from the TRA to the primary transfemoral access at the beginning of the procedure could help the management of eventual vascular complications. A new TRA technique during transfemoral TAVI procedures is described, reporting the results in the first forty-two patients in one center. [ABSTRACT FROM AUTHOR]

Objectives: This study investigated the feasibility and safety of transulnar access (TUA) and efficacy of novel TR band modification for dual site hemostasis in patients with failed ipsilateral transradial approach.Background: Failed transradial access requires cross over to alternative access site. There is paucity of data on feasibility and safety of ipsilateral TUA due to concern of potential risk of hand ischemia.Methods: We retrospectively reviewed ten patients who underwent coronary angiography and intervention via ulnar artery in the setting of failed ipsilateral transradial access. Patent hemostasis for both ulnar and radial arteries was achieved with novel modification of the TR band to compress both arteries at the same level of puncture sites.Results: TUA after failed ipsilateral transradial access was successful in all ten cases. All patients were followed within 7 days and there were no adverse complications such as ulnar artery occlusion, nerve injury, or hand ischemia.Conclusion: TUA maybe a safe and viable option when cross over is necessary from failed ipsilateral transradial access. Modification of the TR band for both radial and ulnar access site can achieve patent hemostasis effectively at the level of both puncture sites. [ABSTRACT FROM AUTHOR]

Background: Endovascular procedures nowadays are generally performed via the femoral and radial artery. Although not routinely used by many, there is still an essential role for vascular interventions via brachial access. The technological advancement of endovascular devices leads to a significant increase of the variety of percutaneously treatable vascular pathology. The brachial artery approach nowadays is becoming crucial for complex procedures either as single access or in the context of mandatory double vascular approach for many complex interventions.Objective: To evaluate the safety and efficacy of brachial artery access for diagnostic arteriography and endovascular interventions in different vascular territories in a single-center setting on the basis of a retrospective analysis of prospectively collected data in a large patient cohort.Methods: Between 01/2013 and 09/2016, 11,274 endovascular procedures were performed in our hospital, 847 (7.5%) of them via brachial access, presenting the database for this study. All demographic, clinical, and periprocedural data were obtained prospectively and included in the computerized hospital records, and on this basis, a retrospective analysis was performed.Results: While the radial access was the most used and constant for coronary and noncoronary interventions in our center (71%) in this period, the use of brachial access increased (from 4% to 12%) causing the femoral to decrease (from 27% to 16%). We used the brachial approach for diagnostic purposes in 162 patients (19%) and for head to toe endovascular interventions (including angioplasty, stenting, thrombolysis, or as adjunctive access) in 685 patients (81%). For 53 patients (6.2%), this was the only possible access for endovascular intervention. Overall access site-related complications occurred in 25 patients (2.9%), in 19 of them (2.2%) required surgical correction, for brachial artery thrombosis or pseudoaneurysm. The other six were managed conservatively. No permanent neurological deficits of the arm or severe bleeding were observed. Minor complications, mostly hematomas, occurred in 62 patients (7.3%), but they required no further treatment.Conclusion: Brachial artery access expands our capability to perform complex procedures by allowing us to reach arterial targets in all territories. Complications of brachial vascular access are gradually decreasing together with the decrease of the crossing profile of the devices used in practice. However, when they occur, they often require surgical treatment. The growing experience of the team not only while obtaining the access but also while achieving adequate hemostasis ("patent hemostasis") is of great importance for minimizing the complications. [ABSTRACT FROM AUTHOR]

Objectives: To determine the incidence, prognosis, and predictors of major Valve Academic Research Consortium (VARC-2) vascular complications (VCs) and percutaneous vascular closure device failure (PCDF) following contemporary percutaneous transfemoral transcatheter aortic valve replacement (TF-TAVR).Background: Limited data exists on the incidence and predictors of VCs and PCDFs following percutaneous TF-TAVR using contemporary 14-16 French (F) sheaths.Methods: We recorded clinical and procedural characteristics, computer tomography (CT) angiographic data, 30-day VCs, mortality, and length of stay (LOS) in all consecutive percutaneous TF-TAVRs at a single center from June 2016 to October 2018. CT measures included common femoral artery (CFA) and external iliac artery (EIA) diameters, sheath to CFA and EIA ratios (SFAR and SEIAR), depth of CFA, extent and location of CFA calcification and pelvic vessel tortuosity (2 bends ≥90°). Multivariable regression was used to predict major VCs and percutaneous closure device failure (PCDF), respectively.Results: The final sample consisted of 303 percutaneous TF-TAVRs. Median age was 80 years, 51% were male, 86% Caucasian, 33% had diabetes mellitus (DM) and mean STS score was 5.8 ± 3.8%. Baseline characteristics were similar in patients with vs. without VCs, other than coronary artery disease (CAD) (69% vs. 54%, respectively; p = 0.029) and DM (21% vs. 36%, respectively; p = 0.02). There were 65 (21%) vascular complications: 19 major VCs [6.3%], 29 minor [VCs 9.6%] and 17 PCDFs [5.6%]. Overall, 30-day mortality was low (2.6%). Major VCs were associated with higher mortality (42% vs. 0%, p < 0.0001) while minor VCs (3% vs. 0%, mortality p = 0.99) and PCDFs (3% vs. 0% mortality, p = 0.99) were not. PCDFs were associated with a longer median LOS (4 vs. 3 days, p = 0.02). The independent predictors of major VCs were pelvic vessel tortuosity (OR 3.1; 95% CI 1.1-9.2) and presence of CAD (OR 8.2; 95% CI 1.8-37). Female gender showed a strong trend toward increased risk (OR 3.4; CI 0.84-14; p = 0.086). There were no independent predictors of PCDF.Conclusion: Contemporary percutaneous TF-TAVR is associated with a low risk of mortality, major VCs and PCDFs. Major VCs confer increased mortality and PCDFs prolong LOS. Pelvic vessel tortuosity and a history of CAD predict major VCs; there were no predictors of PCDFs. These results provide a contemporary update on the incidence and implications of these important vascular complications in the current era of percutaneous TF-TAVR using 14-16F vascular sheaths. [ABSTRACT FROM AUTHOR]

Background: Real world safety and effectiveness of MANTA vascular closure device (VCD) for large bore arteriotomy closure after decannulation of mechanical circulatory support (MCS) devices is not known.Methods: All consecutive patients who underwent large bore arteriotomy closure with MANTA VCD following decannulation of MCS between February to October 2019 at a large tertiary care academic medical center were included. Safety and effectiveness of MANTA VCD was assessed on immediate post-closure angiogram for 23 access sites, and immediate post-closure duplex arterial ultrasound or manual vascular examination for 1 access site each. Technical success was defined as achievement of arteriotomy closure in absence of major bleeding or access site endovascular or surgical intervention.Results: A total of 25 MANTA VCD were placed in 22 unique patients by 7 different operators. A 14 Fr or 18 Fr MANTA VCD was used in 15 (60%) and 10 (40%) of deployments, respectively via transfemoral (n = 23, 92%) or transaxillary (n = 2, 8%) access. Technical success was achieved in 24 of 25 (96%) cases. Minor access site bleeding occurred in 3 patients (12%) and failure of MANTA VCD with major access site bleeding occurred in 1 patient (4%) requiring endovascular balloon tamponade. No cases of retroperitoneal bleeding, collagen plug embolization, covered stent placement, or surgical vascular repair were observed.Conclusion: In this single center experience, the use of MANTA VCD for large bore arteriotomy closure following percutaneous decannulation of MCS devices appears to be safe and effective. Larger multicenter studies of efficacy, safety, and cost-effectiveness are needed. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of the study was to evaluate the efficacy and safety of the "percutaneous direct puncture of occluded superficial femoral artery (SFA)" technique for recanalization of SFA, after failure of antegrade recanalization in patients with limited access to retrograde popliteal and crural arteries.Material and Methods: Between April 2014 and November 2017, 10 patients with CLI (Critical limb ischemia) underwent endovascular recanalization with direct percutaneous puncture of occluded SFA after failed antegrade recanalization. All patients had a long segment (39,9 ± 2.8 cm) occluded SFA without stump causing failed antegrade recanalization with a cannulated guidewire in the SFA origin. After unsuccessful attempts with the antegrade approach, the retrograde direct puncture technique of the occluded SFA was performed and followed by antegrade recanalization. Patients were followed up clinically with Doppler ultrasonography and according to the Rutherford scale at 1, 3, 6 and 12 months after discharge.Results: Technical success was achieved in 8/10 patients (80%).The mean follow-up period was 25,1 ± 9,6 months. One patient underwent major amputation, resulting in 90% limb salvage rate at 12 and 24 months. Amputation-free survival estimated by Kaplan-Meier analysis was 60% at 12 and 24 months. Primary patency rates were 62.5% at 12 and 24 months and secondary patency rates were 87.5% at 12 and 24 months.Conclusion: Treatment of SFA occlusions without a stump in CLI patients via the percutaneous direct puncture of occluded SFA approach improved technical success and clinical recovery, especially in cases unsuitable for conventional antegrade and retrograde approaches. [ABSTRACT FROM AUTHOR]

Background: Transcatheter left atrial appendage occlusion (LAAO) has become a suitable alternative to anticoagulation in patients with atrial fibrillation (AF). However, volume-outcome relationships at the individual operator level have not been studied.Methods: Study population included 425 consecutive patients with AF undergoing LAAO from August 2015 to November 2018 by seven operators at BUMC-Phoenix. Operator volume was divided in tertiles by those with <40 cases/year (2 operators), 41-80 cases/year (3 operators) and >80 cases/year (2 operators). Patient data including comorbidities, labs, medications, procedural characteristics and outcomes were collected. The primary composite outcome was major adverse cardiac events (MACE) including mortality, stroke, bleeding and vascular complications.Results: Mean age was 75 ± 8 years and 251 (59%) were males. Mean CHA2DS2-VASc score was 4.5 ± 1.3 points and mean HASBLED score was 3.9 ± 1.0 points. MACE outcome was similar in the three operator groups in both unadjusted (p = 0.83) and adjusted (OR = 0.59: 95% Confidence Interval [CI]: 0.15-2.29, p = 0.45) analysis. The occurrence MACE was also similar between Interventional Cardiologist (IC) and Electrophysiologist (EP) operators in an unadjusted (p = 0.24) and adjusted (OR = 0.60: 95% CI: 0.21-1.68, p = 0.33) analysis. The secondary outcome of technical success did not differ among the three tertiles (p = 0.37) and among IC & EP operators respectively (p = 0.24) as well.Conclusion: Operator experience does not affect MACE and technical success even after adjusting for comorbidities. These results suggest a lower learning curve for LAAO with high technical success achievable even by low volume operators. [ABSTRACT FROM AUTHOR]

Objective: Several patients undergoing transfemoral transcatheter aortic valve replacement (TAVR) have complex peripheral arterial disease (PAD) that increases risk of vascular complications and failure of vascular closure device (VCD). Endovascular bailout of failed VCD is performed through contralateral femoral access. Further due to multiple different anatomic reasons the contralateral femoral access and "up and over" approach is unavailable for endovascular bailout of the VCD failure. We evaluated a novel bailout technique of obtaining an additional access in ipsilateral common femoral artery (CFA) or superficial femoral artery (SFA) distal to the main CFA access used for TAVR device.Methods: We prospectively identified patients who were at high risk for VCD failure and had unavailable contralateral CFA approach from the pre-TAVR evaluation with multislice CT angiography. The data was collected prospectively for the TVT registry and retrospectively reviewed. All patients had an additional distal access obtained in the CFA or proximal SFA under direct fluoroscopy guidance after achieving main CFA access for TAVR. Using an inner 0.021″ micro-dilator from the 4-Fr micropuncture mini stick max access kit (AngioDynamics, Marlborough, MA) and a 200 cm long 0.018″ wire, the distal access was secured in place through the TAVR procedure. After completing the TAVR if the VCD gained successful hemostasis, the 0.021″ dilator was removed with manual pressure. If the VCD failed to achieve hemostasis, the distal access was upsized to a 7 Fr sheath for carrying out endovascular repair of the TAVR access. If the distal access was upsized to 7 Fr, that access was treated with VCD. The patients were monitored for acute in-hospital complication and followed for 6 months.Results: During 2017 & 2018, 97.4% of 186 TAVRs were performed via femoral approach at our center. Six patients met the criteria for high-risk access and non-availability of the contralateral "up and over" approach. Of the 6 patients enrolled in this prospective study, 3 required endovascular management of TAVR access because of failed VCDs and were treated with covered stents using the distal ipsilateral access. The remaining 3 patients had successful use of VCDs for the TAVR access and the prophylactic access with 0.021″ dilator was managed with manual pressure. None of the six patients suffered any further vascular complication or bleeding. At the 6-month follow up no vascular complications or clinically driven events were identified from the TAVR access or additional distal ipsilateral access.Conclusion: This novel technique of prophylactic ipsilateral distal femoral access can provide an alternative bailout strategy for patients at high risk of closure device failure and unavailable contralateral femoral approach during transfemoral TAVR. [ABSTRACT FROM AUTHOR]

Objectives: This study investigated the feasibility, safety, and the acute outcome of primary retrograde tibio pedal approach (TPA) in the treatment of peripheral arterial disease (PAD) with femoropopliteal (FP) chronic total occlusion (CTO).Background: With maturing in endovascular technology and further development in new devices, endovascular therapy has become a comparable and preferred treatment for patients with PAD. The retrograde TPA has not been studied to treat FP CTO extensively.Methods: We performed a retrospective analysis of 98 consecutive patients who underwent peripheral angiogram and intervention of 123 FP CTO lesions from June 1st, 2016 to June 30th, 2018 in a single center. Peripheral angiography and percutaneous balloon angioplasty was done primarily via retrograde TPA. Demographic data, procedural success rate, peri-procedural major adverse complications, and 30-day outcomes were recorded.Results: Out of 123 procedures, the dorsalis pedis artery/distal anterior tibial artery was the most common TPA site (59%) followed by the posterior tibial artery in 27% patients and peroneal artery in 14% patients. In 40 (33%) FP CTO lesions, additional transradial accesses were needed for controlled antegrade and retrograde tracking (CART) technique. Overall procedural success was achieved in 122 FP CTO (99%) lesions. No patients had significant access site bleeding, hematoma, worsening kidney dysfunction or acute limb ischemia within 30-day following this procedure.Conclusions: The primary retrograde TPA for FP CTO lesions is safe and feasible. With a combination of tibio pedal and transradial approach, our procedural success rate is very high for FP CTO intervention. [ABSTRACT FROM AUTHOR]

Iatrogenic coronary artery dissection is a feared complication of percutaneous coronary intervention as it can potentially lead to severe myocardial ischemia, arrhythmias, shock, and death. Bailout-stenting or less often, emergent coronary artery bypass graft surgery may be needed for restoring antegrade flow. We describe a case of inferior ST-segment elevation acute myocardial infarction with preserved antegrade coronary flow. Percutaneous coronary intervention was complicated by acute right coronary artery closure during guide catheter engagement. Attempts for re-entry into the right coronary artery true lumen failed. Attempts to obtain right femoral arterial access resulted in retroperitoneal hematoma. The patient developed refractory ventricular fibrillation and could not be defibrillated. Veno-arterial extracorporeal membrane oxygenation was started using surgical right femoral cutdown for the venous cannula and the left common femoral artery for the arterial cannula. A dissection strategy with a knuckled guidewire was used around previously placed stents followed by successful re-entry into the distal right coronary artery using the Stingray system. The venous cannula was changed to the internal jugular vein and the right common femoral artery and vein were surgically repaired. The patient was decannulated two days later and was eventually discharged from the hospital neurologically intact. [ABSTRACT FROM AUTHOR]

Background: Pre-procedural anemia is associated with increased bleeding and mortality post-percutaneous coronary intervention (PCI). The effect of trans-radial PCI (TR-PCI) in improving outcomes compared to trans-femoral PCI (TF-PCI) in anemic patients is not known.Objective: The aim of this study was to evaluate the association between arterial access site (radial versus femoral) and outcomes in anemic Veterans undergoing PCI.Methods: Patients with baseline anemia, undergoing PCI at Veterans Affairs (VA) facilities between 2009 and 2015, were divided into two groups based on primary radial or femoral access. The association between anemia and access site with in-hospital and one-year adverse outcomes was evaluated using multivariable analysis.Results: 7330 veterans were included in the analysis, with 1712 (23%) treated via radial access. Baseline anemia was independently associated with in-hospital major bleeding (OR 3.8, 95% CI 2.5-5.6 for moderate anemia, OR 18.6, 95% CI 11.6-29.7 for severe anemia), and in-hospital mortality (OR 3.2, 95% CI 1.8-5.8 for moderate anemia, OR 7.9, 95% CI 3.7-16.8 for severe anemia). Anemia was also associated with increased one-year MACE and mortality. PCI performed via radial access was not associated with different outcomes compared with femoral access in the presence of anemia. Comparable results were noted when analysis was restricted to only patients with acute coronary syndrome (ACS).Conclusions: Moderate and severe anemia were strongly associated with increased in-hospital and one-year mortality in a large healthcare system, though there was no interaction between arterial access site for PCI and clinical outcomes among patients with moderate or severe anemia. [ABSTRACT FROM AUTHOR]

Background: Although patients prefer radial over femoral approach, some develop post-procedural arm pain after transradial procedures. This complication has been poorly defined in prior studies. We evaluated the extent of non-ischemic arm pain after transradial arterial access and identify variables that may be associated with this complication.Methods: We performed a retrospective analysis of a 1706 patient database on patients who underwent transradial catheterization at three experienced radial centers. Arm pain was assessed by adult visual analogue scale (score > 4) defined as moderate to severe pain at the accessed forearm not related to hand ischemia and was evaluated at one day after the procedure. Logistic regression was used to identify the predictors of post-procedural arm pain.Results: The overall incidence of post-procedural arm pain one day after a transradial procedure was 4.5%. Covariate associated with post-procedural arm pain were hemostasis compression >4 h (odds ratio (OR) = 29.47, p < 0.001), radial artery occlusion by Doppler evaluation (OR = 3.35, p < 0.001), radial artery diameter < 2.8 mm (OR = 2.66, p = 0.01), and multiple puncture attempts (OR = 2.31, p = 0.03).Conclusion: Approximately 1 in 20 patients undergoing transradial procedure have post-procedural arm pain one day after the procedure. Predictors of this complication relate to radial hemostasis, radial artery occlusion, radial artery diameter, and number of access attempts. [ABSTRACT FROM AUTHOR]

Background: Patients' intra and post procedural comfort, quick recovery, as well as procedure success, are key elements for choosing the right arterial access site. Radial artery access has been of increasing interest since it was first described. Advanced treatments of coronary lesions, from primary percutaneous interventions during ST elevation myocardial infarction cases to chronic total occlusion cases, have been increasingly done through the radial access. Distal left trans radial artery (dlTRA) is a new technique first described by Kiemineij. We report the first documented US experience of the left distal radial artery access for coronary angiography and interventions.Methods: dlTRA was attempted on 22 consecutive patients, consented for a cardiac catheterization. 7 patients underwent percutaneous coronary intervention. The left hand is prepped in the usual fashion, exposing the anatomical snuff box. Under ultrasound guidance, the artery is punctured and the sheath is inserted carefully. The cardiac catheterization is completed using standard diagnostic and guiding catheters, that are typically chosen for femoral artery access. Hemostasis was achieved with a radial band. Patients had the ability to use the right hand as well as bend their left wrist post procedure.Results: dlTRA was successful in all 22 patients. 7 patients underwent PCI through this approach. Two patients required a multivessel complex PCI with multiple stents and additional equipment. There were no conversions to the right radial or femoral approach. All patients had excellent hemostasis with a radial band, with no complications. Pre discharge radial pulses were intact in the wrist as well as in the anatomical snuff box.Conclusion: Distal left trans radial access is feasible and safe in patients that are carefully selected and are deemed good candidates. There is a learning curve for developing such program, as is the case with conventional radial access. [ABSTRACT FROM AUTHOR]

We describe the patient selection, intraprocedural imaging, and procedural technique for transseptal puncture through the Gore® Cardioform interatrial septal occluder. Due to new indications for PFO closure and increasing need for access to the left atrium via percutaneous approach, we expect an increasing need for utilization of a trans-septal puncture technique through these devices. [ABSTRACT FROM AUTHOR]

Background: Micropuncture technique (MPT) is being adapted nationally to reduce vascular complications (VC). We initiated a quality improvement project in our cath lab to reduce VCs utilizing MPT.Methods: We utilized MPT on all of our non-STEMI femoral artery (FA) access cases starting September 2016. As a comparator group, we collected data from April to August 2016. Anatomic localization of FA and fluoroscopic marking of femoral head was utilized in all cases. VCs were defined by BARC definitions for bleeding/hematomas, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia.Results: A total of 647 patients (Male 357, Female 290; MPT 333) were included in the analysis. MPT as compared to regular 18-gauge needle access did not demonstrate a reduction in VCs (2.4% vs. 2.2%; p = 1.0). MPT utilization did not affect the risk of VCs on univariate (OR 1.08; 95% CI 0.38-3.01; p = 0.88) or multivariate analysis (OR 0.91, 95% CI 0.28-2.93; p + 0.87). Vascular closure device (VCD) utilization as compared to manual/fem-stop hemostasis was the only factor that demonstrated a statistically significant and lower VC rate on both univariate (OR 0.28; 95% CI: 0.08-0.89; p = 0.03), and multivariate (OR 0.24; 95% CI 0.06-0.93; p = 0.039) analysis.Conclusion: Utilization of MPT in conjunction with fluoroscopic marking of the femoral head and without ultrasound guidance did not contribute to statistically significant reduction in the VC rate. The only factor found to be beneficial is utilization of VCDs. Further large randomized studies are required to demonstrate benefit of routinely utilizing MPT. [ABSTRACT FROM AUTHOR]

Objective To assess the crossover rate from primarily chosen transradial access (TRA) in a high volume transradial center. Methods All consecutive 30,848 patients, that underwent diagnostic angiography and/or intervention in the period from 2010 until 2015 were examined. Preprocedural radial artery angiography was performed in all patients since 2011. Clinical and procedure characteristics, reason for crossover and its direction were analyzed. Primary end-point of the study was the occurrence of TRA failure and need to crossover to another approach to finish the procedure. Results Procedural success of primarily chosen TRA was 94% (n = 28,988). Crossover to other access sites was 6% (n = 1860). Most common reason for crossover was inability to puncture the right radial artery in 4,1%, presence of radial artery anomalies (0,3%), high grade spasm (0,1%), or radial artery occlusion (1,2%). Crossover direction was primarily through the ipsilateral transulnar access (TUA) 3,8%, left radial access (LRA) 1,5% and in only 0,6% (n = 189) of patients to transfemoral access (TFA). Access site bleeding complications were present in 5,1% (n 1579). Conclusion Total wrist access is feasible and safe with low rate of access site complications and crossovers, especially when performed in experienced high volume transradial center. [ABSTRACT FROM AUTHOR]

Vascular closure devices (VCDs) are widely used as an alternative to manual compression of femoral puncture sites. In this report, we present a 73-year-old man who developed symptomatic venous stenosis related to VCD after pulmonary vein isolation. We performed percutaneous treatment with balloon angioplasty. This case suggests that balloon angioplasty with proper safety measures can be an option for treating venous stenosis related to VCDs. [ABSTRACT FROM AUTHOR]

The use of "Kissing Watchman" technique has been reported for left atrial appendage closure in particular case (i.e. large ostia). This case highlighted the feasibility of adapting this technique as bailout strategy in case of migration of a first device inside the LAA, due to a partial recapture of device. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to evaluate the efficacy and safety of distal radial (DR) versus traditional radial (TR) approach during coronary angiography.Methods: Two hundred patients scheduled to undergo transradial coronary angiography were randomized between the two approaches. Primary endpoint of the study was switching to another access site due to inability of successful target artery cannulation. Secondary endpoints were time to cannulation, total procedure duration, number of attempts, number of skin punctures and duration of manual hemostasis. Secondary safety endpoints were the rate of moderate or severe spasm, arm hematoma EASY class III or more and radial artery occlusion at discharge. Quality of life endpoint was the patient's preference of cannulation method at 30 days.Results: The primary endpoint was met in 30 patients (30%) from the DR group and 2 patients (2%) from the TR group (p < 0.001). The time of cannulation was longer in the DR group compared to the TR group (269 ± 251 s vs 140 ± 161 s, p < 0.001), but this did not affect the total procedural duration (925 ± 896 s vs 831 ± 424 s, p = 0.494). The number of attempts and the number of skin punctures were more in the DR group compared to the TR group (6.8 ± 6.2 vs 3.4 ± 4.5, p < 0.001 and 2.4 ± 1.7 vs 1.6 ± 1.2, p < 0.001, respectively). However, DR treated patients had faster manual hemostasis time compared to TR treated patients (568 ± 462 s vs 841 ± 574 s, p = 0.002). There were no differences recorded in the safety endpoints of moderate or severe spasm, EASY grade III or more radial hematomas or the incidence of radial artery occlusion after the procedure. Patients' preference to the randomized puncture sites was the same (79% vs 85%, p = 0.358).Conclusion: Distal radial approach is associated with lower successful cannulation rates and shorter manual hemostasis time compared to the traditional radial approach. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy and safety of “Direct Stent Puncture” technique for intraluminal stent recanalization in the femoro-popliteal segments. Methods and Materials: A cohort of diabetics who had symptomatic in-stent occlusion of the superficial femoral or popliteal arteries underwent endovascular recanalization. After antegrade failure, direct stent puncture technique was performed. The primary end-point was to efficacy assessment, intended as technical success and clinical improvement. The secondary end-point was safety assessment, intended as free of complication rate. Results: Fifty-four patients (37 men; 73.6±8.5years) underwent direct stent puncture technique, after several unsuccessful antegrade attempts to cross the occluded stent. Technical success for intraluminal stent recanalization was achieved in 53/54 (98.2%) of cases and failed in 1/54 (1.8%). Clinical improvement was obtained in 51/54 (94.4%) of cases, with regression of the clinical symptoms and improvement of the TcPO2, from 3±18mmHg to 43±11mmHg after 15days (p <0.001). Free of complications rate was 92.5%. In 2/54 (3.7%) of cases distal embolization occurred, in 1/54 (1.9%) case a sudden vessel thrombosis was diagnosed after 12hours and in 1/54 (1.9%) case hematoma at the stent puncture site was observed. Conclusions: Direct Stent Puncture technique is an efficacy and safety option for intraluminal stent recanalization in the femoro-popliteal segment in-stent occlusion. [ABSTRACT FROM AUTHOR]