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Background: The use of the distal radial access for invasive coronary procedures has been rapidly adopted by the medical community, but with no evaluation of efficacy and safety outcomes of this approach. The objective was to evaluate the rate of radial artery occlusion involved in this technique, using Doppler ultrasound. Methods: This was an observational, retrospective study involving patients undergoing invasive diagnostic or therapeutic coronary procedures via distal radial access, with assessment of the radial artery patency by Doppler ultrasound. The primary outcome analyzed was the rate of radial artery occlusion. Results: Between July and December 2020, 51 patients underwent procedures via distal radial access, with assessment of the radial artery patency, out of a total of 603 patients seen during this period. Patients were aged 58±10.8 years, 68.6% were male, 26.9% had diabetes mellitus, and 68.6% were diagnosed with acute coronary syndrome. Diagnostic procedures were performed in 68.2% of sample, and 23.5% of patients had undergone a previous use of the ipsilateral proximal radial access. Doppler ultrasound was performed over a mean period of 24 hours, and no occlusion of the radial artery was observed, with mean time for sheath insertion of 1.9 minutes. There was no major vascular complication. In two patients, pain was observed at the access point; another two had a small subcutaneous hematoma, and, one patient, presented with moderate spasm. Conclusion: The use of distal radial access was associated with a low rate of hemorrhagic complications in the access route, and absence of occlusion of the radial artery by Doppler ultrasound assessment.

RESUMO Introducao Mediante a impossibilidade de utilizacao do acesso radial em procedimentos coronarios invasivos, a tecnica ulnar apresenta-se como alternativa factivel e segura. O objetivo do presente estudo foi caracterizar sua relevância na pratica diaria de um centro que adota a estrategia radial como primeira opcao. Metodos A amostra foi extraida de um registro prospectivo unicentrico, no periodo de maio de 2008 a outubro de 2018, incluindo a totalidade de pacientes submetidos a procedimentos coronarios invasivos em hospital terciario de [...]

Background Ad hoc percutaneous coronary intervention via radial access has become frequent in interventional cardiology services, with reduced bleeding rates, vascular complications and costs. There are few reports in the medical literature on radiological exposure rates (kerma area product − Kap, and incident air kerma − Iak) in these procedures, when they are performed via radial access. The objective of the study was to compare radiological variables in staged percutaneous coronary interventions with ad hoc interventions via radial access. [...]

RESUMO Introducao Recentemente descrita, a puncao distal da arteria radial esquerda atraves da tabaqueira anatomica apresenta-se como um refinamento da tecnica. Exibe como potencial beneficio maior conforto ao paciente e ao operador, alem da manutencao do fluxo sanguineo pelo arco palmar superficial, em caso de oclusao da arteria radial. Nosso objetivo foi avaliar a seguranca e a factibilidade dessa nova tecnica. Metodos Registro prospectivo envolvendo pacientes submetidos a procedimentos coronarios invasivos diagnosticos ou terapeuticos pela porcao distal da via radial [...]

Background The transition from ticagrelor to clopidogrel is not based on pharmacodynamic or clinical studies, but it is a common practice. The aim of the present study was to test, in an exploratory way, the transition to two different doses of clopidogrel at the time of hospital discharge in patients diagnosed with acute coronary syndrome submitted to percutaneous coronary intervention who were initially treated with ticagrelor. Methods Patients previously treated with ticagrelor were randomized to receive a loading dose of 300 mg clopidogrel at hospital discharge, or 75 mg without the loading dose. The primary endpoint was the incidence of cardiovascular adverse events or bleeding at 30 days. Results Of 348 selected patients, 132 were enrolled and completed the study. The incidence of ischemic and hemorrhagic events at 30 days was similar between the groups, resulting in a rate of cardiac and cerebrovascular events of 6.1% vs. 9.1% (RR: 0.787; 95% CI: 0.361-1.715; p = 0.74). Conclusions The transition to clopidogrel with a dose of 75 mg at discharge, without a loading dose, appears to be a possible strategy. Studies with greater statistical power are needed to confirm these findings.

RESUMO Introducao A transicao do ticagrelor para o clopidogrel nao esta fundamentada em estudos farmacodinâmicos ou clinicos, mas e uma pratica comum. O objetivo do presente estudo foi testar, de forma exploratoria, em pacientes com diagnostico de sindrome coronariana aguda submetidos a intervencao coronariana percutânea, inicialmente tratados com ticagrelor, a transicao para duas diferentes doses de clopidogrel no momento da alta hospitalar. Metodos Pacientes previamente tratados com ticagrelor foram randomizados para receber uma dose de ataque de 300 mg de clopidogrel no momento da alta hospitalar, ou 75 mg, omitindo‐se a dose de ataque. O objetivo primario foi a incidencia de eventos adversos cardiovasculares ou sangramento aos 30 dias. Resultados Dentre 348 pacientes selecionados, 132 foram incluidos e completaram o estudo. A incidencia de eventos isquemicos e hemorragicos aos 30 dias foi similar entre os grupos, traduzindo‐se em uma taxa de eventos cardiacos e cerebrovasculares de 6,1% vs. 9,1% (RR: 0,787; IC 95%: 0,361‐1,715; p = 0,74). Conclusoes A transicao para clopidogrel com a dose de 75 mg no momento da alta, omitindo‐se uma dose de ataque, aparenta ser uma estrategia possivel. Estudos com maior poder estatistico sao necessarios para confirmar estes achados.

RESUMO Introducao A valvula aortica transcateter de segunda geracao Lotus™ foi desenhada para proporcionar ao intervencionista o controle completo de sua liberacao durante o procedimento. O presente estudo apresenta a experiencia inicial e os desfechos hospitalares de pacientes tratados com essa protese no Brasil. Metodos Registro observacional, retrospectivo, que incluiu pacientes com estenose aortica grave sintomaticos, considerados de alto risco cirurgico, tratados em sete centros. Resultados Receberam o dispositivo 31 pacientes, sendo 61,3% do sexo feminino, com idade de 82,9 ± 6,9 anos e escore STS de 6,5 ± 4,1%. A area valvar aortica foi de 0,73 ± 0,18 cm2 e o gradiente medio de 51,7 ± 13,9 mmHg. Todos os procedimentos foram realizados pela via transfemoral, e a pre‐dilatacao foi necessaria em 65% dos casos. A taxa de sucesso do procedimento foi de 96,7%. Nao houve complicacao vascular com necessidade de intervencao cirurgica e nem casos de acidente vascular cerebral. O gradiente medio apos o procedimento foi de 10,5 ± 5,8 mmHg e nao foram observadas regurgitacoes aorticas de graus moderado/importante. A taxa de implante de marca‐passo definitivo foi de 38,7%, e a permanencia hospitalar de 8,5 ± 4,8 dias. Conclusoes Na experiencia inicial com o implante da valvula aortica Lotus™, os resultados hospitalares demostraram a seguranca e a eficacia do dispositivo, alem de ausencia de regurgitacao aortica relevante.

RESUMO Introducao O conhecimento dos fatores de risco relacionados as complicacoes do acesso vascular em pacientes submetidos a estrategia invasiva precoce permite adotar estrategias capazes de minimiza‐las. Metodos Realizamos subanalise do estudo ARISE, com o objetivo de identificar preditores de complicacoes vasculares em pacientes randomizados para as tecnicas radial ou femoral com emprego de dispositivo de oclusao vascular (DOV). Resultados Foram incluidos 240 pacientes, com media de idade de 63,0 ± 10,7 anos, sendo 30,8% diabeticos e, exceto pela maior prevalencia de mulheres no grupo radial, nao foram observadas diferencas clinicas entre os grupos. Intervencao coronaria percutânea foi realizada em 86,7% dos casos. A taxa de complicacoes vasculares aos 30 dias foi de 13,3% no grupo radial, a custa de hematomas > 5 cm (6,7%) e oclusao arterial assintomatica (5,8%), e de 12,5% no grupo femoral, a custa de hematomas > 5 cm, sem diferenca significativa. Foram identificados como fatores de risco para complicacoes do acesso vascular o indice de massa corporal (IMC), o acidente vascular encefalico previo, a maior duracao do procedimento e o insucesso do DOV. Pela analise estratificada, o sexo feminino e o escore CRUSADE de alto ou muito alto risco foram variaveis preditoras de complicacoes apenas para o grupo femoral. No modelo multivariado, os fatores que permaneceram significantes foram o IMC e o insucesso do DOV. Conclusoes As tecnicas radial e femoral, com o emprego de DOV, compartilharam variaveis preditoras de complicacoes. Fatores de risco, como sexo feminino e escore CRUSADE de alto risco, foram atenuados pela utilizacao da tecnica radial.

Background The second-generation Lotus TM transcatheter aortic valve was designed to provide the interventional cardiologist with complete control of its release during the procedure. This study presents the initial experience and in-hospital outcomes of patients treated with this prosthesis in Brazil. Methods This observational and retrospective study included patients with symptomatic severe aortic stenosis considered at high surgical risk, treated in seven centers. Results The device was used in 31 patients, 61.3% female, aged 82.9 ± 6.9 years, and with STS score of 6.5 ± 4.1%. The aortic valve area was 0.73 ± 0.18 cm 2 and the mean gradient was 51.7 ± 13.9 mmHg. All procedures were performed by the transfemoral access route, and pre-dilation was necessary in 65% of cases. The success rate of the procedure was 96.7%. There were no vascular complications requiring surgical intervention nor cases of stroke. The mean gradient after the procedure was 10.5 ± 5.8 mmHg; no cases of moderate to severe aortic regurgitation were observed. The rate of permanent pacemaker implantation was 38.7%, and mean in-hospital length of stay was 8.5 ± 4.8 days. Conclusions In the initial experience with the use of the Lotus TM aortic valve, in-hospital results demonstrated the safety and efficacy of the device; no cases of significant aortic regurgitation were observed.

Background The knowledge of risk factors related to vascular access complications in patients undergoing early invasive strategy allows the adoption of methods to minimize them. Methods We performed a subanalysis of the ARISE study, aiming to identify predictors of vascular complications in patients randomized to the radial or femoral techniques with the use of vascular closure device (VCD). Results A total of 240 patients with a mean age of 63.0 ± 10.7 years were included, with 30.8% of diabetics. Except for a higher prevalence of women in the radial group, there were no clinical differences between the groups. Percutaneous coronary intervention was performed in 86.7% of the cases. The rate of vascular complications after 30 days was 13.3% in the radial group, due to hematoma > 5 cm (6.7%) and asymptomatic artery occlusion (5.8%), and 12.5% in femoral group, due to hematoma > 5 cm, without significant difference. The following were identified as risk factors for vascular access complications: body mass index (BMI), previous stroke, longer duration of the procedure, and VCD failure. At the stratified analysis, female gender and high or very high-risk CRUSADE score were predictors of complications only for the femoral group. In the multivariate model, the factors that remained significant were BMI and VCD failure. Conclusions The radial and femoral techniques, with the use of VCD, shared variables that were predictors of complications. Risk factors, such as female gender and high-risk CRUSADE score, were attenuated by the use of the radial technique.

Background Percutaneous mitral valvuloplasty is the treatment of choice for rheumatic mitral stenosis with favorable anatomy, for its ability to prevent complications inherent to a surgical procedure, while maintaining effectiveness. It is necessary to promote comparisons between the results obtained by the procedure performed at referral centers with high patient inflow and at institutions with lower volume and fewer patients, which represents the main objective of this study. Methods Thirty-one consecutive patients undergoing percutaneous mitral valvuloplasty were analyzed from September 2006 to January 2015. Immediate procedural success and late event-free survival rates were evaluated, defined as cardiovascular death or need for a new mitral valve intervention. Results The mean age was 40.9 ± 14.2 years, with a predominance of females (96.8%). The mean Wilkins and Block score was 8.1 ± 1.2. All procedures were performed using the Inoue technique, with an immediate success rate of 90.3%. At mean follow-up of 6.8 ± 2.5 years, seven events (22.6%) were observed: two cardiovascular deaths, four surgeries for mitral valve replacement, and one mitral commissurotomy. Conclusions In a hospital with intermediate procedure volume, the results of percutaneous mitral valvuloplasty in the treatment of rheumatic mitral stenosis with favorable anatomy were comparable to those achieved by high-volume centers.

ResumoIntroduçãoProcedimentos coronários invasivos são comuns em pacientes com revascularização miocárdica cirúrgica prévia. Dados acerca do real papel e das possíveis limitações do acesso radial nesse subgrupo de pacientes são infrequentes. O objetivo deste estudo foi avaliar a factibilidade e a segurança do acesso radial em pacientes revascularizados cirurgicamente e que foram submetidos a procedimentos coronários invasivos diagnósticos ou terapêuticos subsequentes, comparando‐o ao acesso femoral.MétodosEntre maio de 2008 e novembro de 2014, foram analisados 959 procedimentos, sendo 539 realizados pelo acesso radial e 420 pelo femoral. Todos os operadores estavam familiarizados com ambos os acessos vasculares, cabendo a eles a decisão final sobre a via a ser utilizada.ResultadosA prevalência de insucesso foi de 6,1% vs. 0,5% (p < 0,0001), favorecendo a técnica femoral. As taxas de eventos cardíacos adversos graves (0,4% vs. 0,7%) e de complicações vasculares (1,5% vs. 1,9%) foram baixas, sem diferença entre os grupos. A opção pela técnica radial implicou em maior tempo de f luoroscopia e necessidade de cruzamento entre vias de acesso, principalmente em procedimentos diagnósticos.ConclusõesO acesso radial representou uma opção segura e eficaz para a realização de procedimentos coronários invasivos em pacientes cirurgicamente revascularizados, notadamente para os procedimentos terapêuticos.AbstractBackgroundInvasive coronary procedures are common in patients with previous coronary artery bypass graft surgery. Data on the actual role and possible limitations of the radial approach in this subgroup of patients are sparse. The objective of this study was to evaluate the feasibility and safety of radial access in patients surgically revascularized and who underwent subsequent invasive diagnostic or therapeutic coronary procedures, comparing it to the femoral access.MethodsBetween May 2008 and November 2014, 959 procedures were included; 539 performed by radial access and 420 by femoral access. All operators were familiar with both vascular accesses, and the final decision on the route to be used was left to the operators discretion.ResultsThe failure rate was 6.1% vs. 0.5% (p < 0.0001), favoring the femoral approach. Major adverse cardiac events (0.4% vs. 0.7%) and vascular complications (1.5% vs. 1.9%) rates were low, with no difference between groups. The choice of the radial approach resulted in greater fluoroscopy time and crossover rate between access routes, especially in diagnostic procedures.ConclusionsThe radial approach was a safe and effective option for invasive coronary procedures in postcoronary artery bypass graft patients, especially for therapeutic procedures.

RESUMO O implante percutâneo de bioprotese aortica e a terapia estabelecida em pacientes com estenose aortica grave. Houve um progressivo aperfeicoamento na tecnologia dos dispositivos que, associada a maior experiencia dos operadores, resultou em procedimentos mais seguros e com melhores resultados. O primeiro dispositivo de segunda geracao aprovado no Brasil, o sistema de valvula Lotus™ (Boston Scientific Corporation, Natick, EUA), incorpora varias dessas novas caracteristicas. Descrevemos aqui os dois primeiros casos realizados no pais, conduzidos sob anestesia local e sedacao consciente, ambos com sucesso.

Transcatheter aortic valve implantation is a well-established therapy in patients with severe aortic stenosis. There has been a progressive improvement in device technology associated with increased experience of the interventionists, resulting in safer procedures with better outcomes. The first second-generation device approved in Brazil, Lotus™ Valve System (Boston Scientific Corporation, Natick, USA), incorporates several of these new characteristics. This report describes the first two cases, both successfully performed in the country, carried out under local anesthesia and conscious sedation.

RESUMO A via radial e amplamente utilizada para a realizacao de cateterismo cardiaco e angioplastia, com vantagens como a diminuicao do risco de sangramento e de complicacoes vasculares. O presente caso relata uma complicacao rara durante o cateterismo cardiaco por via radial: a avulsao de tecido endotelial da arteria radial pelo cateter e sua embolizacao para a arteria descendente anterior, a qual foi resolvida pela aspiracao manual do fragmento embolizado. Tal complicacao pode ter relacao com as caracteristicas anatomicas especificas da arteria radial do paciente.

Em alguns pacientes a utilizacao dos meios de contraste iodados e contraindicada pela possibilidade de desencadearem efeitos colaterais graves ameacadores da vida. Nesses casos, existem relatos em que o gadolinio (gadobutrol), comumente empregado na ressonância nuclear magnetica, pode ser usado como meio de contraste para coronariografia. Relatamos dois casos com antecedente de alergia grave ao contraste iodado, que realizaram coronariografia com gadolinio. Os procedimentos foram bem tolerados, a quantidade de contraste nao excedeu 0,3-0,4 ml/kg e as imagens obtidas foram de qualidade aceitavel para efeitos de diagnostico.

Correspondencia: George Cesar Ximenes Meireles • Rua Sena Madureira, 1265/102, Vila Clementino, CEP 04021-051, Sao Paulo, SP – Brasil E-mail: gcxm@cardiol.br, george.ximenes@terra.com.br Artigo recebido em 17/09/12, revisado em 21/12/12, aceito em 08/01/13. Palavras-chave Arterias Coronarias, Disseccao, Angioplastia Coronaria com Balao, Stents. Introducao A disseccao acidental do tronco da arteria coronaria esquerda (TCE) e uma das complicacoes mais temidas pelo cardiologista intervencionista, cuja ocorrencia pode ter consequencia grave se nao diagnosticada e tratada prontamente com a revascularizacao miocardica. A incidencia da disseccao ocasionada pelo cateter e menor que 0,1%, elevando-se para 1,05% em pacientes com lesao obstrutiva do TCE1-4. A realizacao de intervencao percutânea imediata com implante de stent parece ser a medida apropriada para tratamento de disseccao acidental do TCE de moderada/ grande extensao, como demonstrado no presente caso.

knowing the risk factors and clinical manifestations of coronary artery disease (CAD) allows us to intervene more effectively with a particular population.to identify clinical and angiographic profiles of patients undergoing cardiac catheterization, treated at a tertiary hospital and treated by percutaneous coronary interventions (PCI).the study of 1,282 patients who underwent 1,410 cardiac catheterizations, selected from March/2007 to May/2008 from a database in a general hospital for diagnosis of coronary artery disease (CAD). Risk factors, indication for examination, technical details of PCI and in-hospital outcomes were prospectively collected.there were 688 (54.0%) males, mean age 65.4 ± 10.9 years and 20.0% above 75 years age. The most frequent clinical condition was acute coronary syndrome (ACS) without ST-segment elevation (STS) (38.7%). The multi artery CAD occurred in 46.4%, PCI was indicated in 464 patients, 547 target lesions were treated (type B2 or C, 86.0%), and of these, 14.0% treated with drug eluting stents. Among those with AMI with STS, primary PCI was performed in 19.0% of the patients, from these, 77.0% were transferred from the origin hospitals late (late PCI) and had not received prior thrombolytic, and 4.0% had PCI rescue. Angiographic success was achieved in 94.2% of PCIs. Death occurred in 5.6% of patients, with average age of 75.2 ± 10.2 years.the prevalence of elderly (20.1% being75 years) and male was observed. From the risk factors for CAD, the most common were systemic hypertension and dyslipidemia. There was a predominance of ACS. Age75 years old, multiarterial CAD and chronic renal failure were predictors of in-hospital deaths.