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Radial artery occlusion after transradial procedures is a frequent iatrogenic thrombotic process. The impact on prognosis has not been investigated. This study sought to investigate whether radial artery occlusion is related to increased risk of major adverse cardiac and cerebrovascular events, defined as death, myocardial infarction, stroke and coronary revascularization.Eight hundred thirty-seven consecutive patients who underwent a transradial coronary procedure had patency of radial artery checked at 24 hours. Radial artery occlusion occurred in 41 over 837 patients (4.8%); 764 (91.2%) were available for planned follow-up at 1 year and were included in the analysis. Event-free survival rate between patients with and without radial artery occlusion was calculated using Kaplan-Meier estimates, and Cox proportional-hazards models were used to identify independent risk factors.At a median 370-day follow-up (IQR: 366-375 days), adverse events occurred in 37 patients (4.8%), 2 in patients with radial artery occlusion and 35 in patients without. One-year survival rate was 94.9% vs. 95% (unadjusted HR=1.026, 95% CI: 0.24 to 4.6, P=0.9). After multivariable modeling, age and coronary artery disease extension was associated with increased risk of adverse events.Age and coronary artery disease extension were independent predictors of adverse events at follow-up. RAO had no prognostic impact. (NCT02762344).

OBJECTIVES To compare incidence of forearm radial artery occlusion (RAO) and hemostasis characteristics between distal and conventional transradial approach (DRA and TRA, respectively). BACKGROUND DRA has the potential advantage of reducing RAO. DRA effectively reduces time-to-hemostasis, however its role on preserving flow in the radial artery (PF) during hemostasis and consequent impact on RAO remains speculative. METHODS Eight hundred thirty-seven patients with TRA were previously enrolled in a prospective registry investigating the relationship of residual anticoagulation and RAO. Three hundred twenty-six additional patients with DRA were added to the cohort and matched to the original cohort by propensity score. The composite end-point of RAO at forearm and distal site of puncture (dRAO) was evaluated as secondary end-point. RESULTS RAO occurred in 4.8% (41 of 837) of patients undergoing TRA and in 0% (0 of 326) of those undergoing DRA (p

OBJECTIVES To assess the independent predictors of patent and occlusive hemostasis (PH and OH, respectively) during radial hemostasis after coronary procedures. BACKGROUND Radial artery occlusion (RAO) is a thrombotic complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Sheath-vessel diameter ratio, postprocedure compression time, occlusive hemostasis, inadequate, and excessive anticoagulation are all predictors of RAO. METHODS As a part of a previously published study investigating the relationship between residual anticoagulation and risk of RAO, 837 patients undergoing transradial diagnostic coronary angiography or percutaneous coronary interventions were enrolled. Cumulative heparin dose used during the procedure and ACT measured before sheath removal were recorded. PH with reverse Barbeau test was attempted in all patients (NCT02762344). RESULTS PH was less frequently obtained for increasing cumulative heparin dose and ACT values (p

Aims In patients aged at least 80 years, atrial fibrillation is responsible for significant morbidity and mortality, with a high incidence of stroke. Four new direct oral anticoagulants (DOACs) have been introduced in Italy for the prevention of thromboembolism. Their safety and efficacy in the elderly have already been confirmed. Frailty is frequently associated with aging, but only a few studies have paid attention to interactions between frailty and anticoagulation therapy. Methods We retrospectively evaluated the effectiveness and safety of DOACs in a population aged at least 80 years. Frailty was appraised using an adaptation of the Reported Edmonton Frail Scale, considering a value at least 8 (on a scale from 0 to 18). Results The majority (644/731) of patients remained on DOACs for more than 1 year. A total of 19 patients experienced a thrombotic event while on anticoagulation (1.11 events per 100 person-years) and 26 patients a major bleeding episode (1.52 events per 100 person-years). The probability of interrupting therapy increased significantly with frailty [hazard ratio 2.91 with confidence interval (CI) 2.15-3.92 at univariate analysis, hazard ratio 2.80 with CI 2.03-3.86 at multivariate]; frailty showed a significant impact also on major bleeding (hazard ratio 3.28 with CI 1.45-7.37 at univariate analysis, hazard ratio 3.56 with CI 1.58-8.01 at multivariate). Conclusion Our study highlights how DOACs are a safe and effective option for anticoagulation, even in frail elderly people; the introduction of these drugs is leading to an increased use of anticoagulation therapy in this population. Prospective trials will be needed to reinforce these results and to consider new variables in the thrombotic and hemorrhagic risk scores underlying the prescription of DOACs.

Background: Radial artery occlusion (RAO) is a thrombotic complication of transradial catheterization that can lead to permanent occlusion of the radial artery. Sheath-vessel diameter ratio, postprocedure compression time, occlusive hemostasis, and insufficient anticoagulation are all predictors of RAO. However, excessive anticoagulation can lead to longer time to achieve complete hemostasis and less patent hemostasis rate. This study was designed to assess the relationship among residual anticoagulation at the end of a percutaneous coronary procedure and the risk of RAO. Methods: Eight hundred thirty-seven patients undergoing transradial catheterization were enrolled. Activated clotting time (ACT) was measured before sheath removal. Patients were divided into 3 groups according to ACT values (ACT 250 s), patent hemostasis with reverse Barbeau test was attempted in all patients, and compression device removed as soon as possible. Within 24 hours, patency of radial artery was checked by Doppler using reverse Barbeau technique. Results: Incidence of RAO was higher for the extreme ACT values. Patent hemostasis were less frequently obtained and time to hemostasis significantly longer for increasing ACT values ( P =0.004 for trend and P =0.001) while adjusted probability for RAO confirmed U-shaped relationship with ACT values. Conclusions: The level of anticoagulation is strongly related to incidence of RAO and should be measured objectively by ACT. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02762344.

Background and Objective Late and very-late stent occlusion remains a serious complication of coronary stenting. Despite their high anti-restenotic efficacy, drug-eluting stents (DES) have been associated to more late-thrombosis as compared to bare-metal stents (BMS). The aim of this study is to analyze the clinical presentation, angiographic, and intravascular ultrasound (IVUS) findings in patients with late or very late stent thrombosis and the relationship with the antiplatelet regimen. Methods and Results Between January 2007 and December 2011, 34 consecutive patients with clinical syndromes compatible with late or very-late stent occlusion were studied with IVUS during emergency catheterization; 25 had DES and 9 had BMS. Thrombotic total occlusion was more common in DES (16 = 64%) than BMS patients (2 = 22%; P = 0.02) and ST-segment elevation myocardial infarction was the predominant clinical presentation in the former group (60% compared to 22%; P = 0.05). The time elapsed between implantation and failure was much longer in DES patients: 33 ± 22 versus 17 ± 14 months for BMS; P = 0.05. IVUS analysis showed a higher incidence of incomplete stent apposition (ISA) in the DES group compared to the BMS group (56% vs. 11%; P = 0.005) and in-stent plaque rupture was the most common finding in the BMS group (78%). In DES group, ISA was found more frequently in patients still under dual antiplatelet therapy (71%). Conclusions Very late DES failure often causes ST-elevation myocardial infarction; these very late events may not correlate with the interruption of antiplatelet therapy. Severe, late acquired ISA belongs to DES and is frequently observed in patients with very late DES thrombosis. © 2013 Wiley Periodicals, Inc.

Late and very-late stent occlusion remains a serious complication of coronary stenting. Despite their high anti-restenotic efficacy, drug-eluting stents (DES) have been associated to more late-thrombosis as compared to bare-metal stents (BMS). The aim of this study is to analyze the clinical presentation, angiographic, and intravascular ultrasound (IVUS) findings in patients with late or very late stent thrombosis and the relationship with the antiplatelet regimen.Between January 2007 and December 2011, 34 consecutive patients with clinical syndromes compatible with late or very-late stent occlusion were studied with IVUS during emergency catheterization; 25 had DES and 9 had BMS. Thrombotic total occlusion was more common in DES (16 = 64%) than BMS patients (2 = 22%; P = 0.02) and ST-segment elevation myocardial infarction was the predominant clinical presentation in the former group (60% compared to 22%; P = 0.05). The time elapsed between implantation and failure was much longer in DES patients: 33 ± 22 versus 17 ± 14 months for BMS; P = 0.05. IVUS analysis showed a higher incidence of incomplete stent apposition (ISA) in the DES group compared to the BMS group (56% vs. 11%; P = 0.005) and in-stent plaque rupture was the most common finding in the BMS group (78%). In DES group, ISA was found more frequently in patients still under dual antiplatelet therapy (71%).Very late DES failure often causes ST-elevation myocardial infarction; these very late events may not correlate with the interruption of antiplatelet therapy. Severe, late acquired ISA belongs to DES and is frequently observed in patients with very late DES thrombosis.

Background: Silent cerebral embolization,detected at transcranial Doppler (TCD) monitoring as microembolic signals (MES), is common during diagnostic coronary angiography (DCA). MES rate depends on degree of intravascular catheter manipulation. When using Judkins catheters, right transradial approach (RTA) showed higher rate of MES compared to left transradial and transfemoral, as a consequence of higher rate of catheter exchanges due to difficult navigation and manipulation through tortuous innominate arteries. Microembolization is more common in the right cerebral emisphere, according to origin of right common carotid artery from innominate artery. A single catheter fitting both coronaries (Optitorque Tiger, Terumo,Japan) is available and could reduce the embolization rate. Our aim was to compare cerebral embolization of single (SC) vs double catheters (DC) strategy during DCA performed through RTA. Methods: 19 patients with suspected coronary artery disease were submitted to DCA via RTA after randomization to single (Optitorque Tiger,n 9) or double (Judkins Left and Right,n 10) catheter strategy, with contemporaneous bilateral TCD monitoring to detect a 50% reduction of MES. Results: Less catheters were employed in SC compared to DC group (1.1 / 0.3 vs 2.1 / 0.3,p 0.0001) with similar procedural success rate (88% vs 90%,p 0.9). MES were detected in all patients, with a significant lower rate in SC group (median 30, interquartile range (IQR) 16-45, vs 57,IQR 54-69,p 0.0001), especially during catheters exchange (19,IQR 11-25 vs 41,IQR 27-49,p 0.003), whereas no difference was detected during contrast injections (5,IQR 1-13 vs 9,IQR 5-17,p 0.24) and coronary ostia engagement (2,IQR 1-6 vs 8,IQR 1-11,p 0.15). A strong negative correlation exists among number of MES and SC strategy (Spearman’s 0.78, p 0.0001); at multivariate linear regression analysis the use of a single catheter reduced incidence of MES of 50% (B 30,std error 7,beta 0.7,t 4,95% IC 46/ 15, p 0.001, costant 61). Conclusions: RIsk of silent brain injury during DCA is strongly related to number of catheters employed. A specifically designed diagnostic catheter for both coronary arteries via RTA reduced dramatically this embolic risk.

Objectives To assess the incidence of silent cerebral embolization when using the transradial approach for diagnostic coronary angiography (DCA). Background Compared to other vascular access sites, the right transradial approach (RTA) could reduce the amount of brain emboli by avoiding mechanical trauma to the aortic wall caused by catheters and wire, whereas it increases manipulation of catheters in the ascending aorta and has a higher risk of direct embolization into the right common carotid artery. A recent study showed an increased incidence of microembolic signals (MES) in RTA compared to femoral. However, left transradial approach (LTA) has never been assessed. Methods 40 patients with suspected coronary artery disease were randomized to DCA via RTA (n=20) or LTA (n=20) with contemporaneous bilateral transcranial Doppler monitoring. Results MES were detected in all patients, with a significantly higher rate in the RTA group (median 61, interquartile range (IQR) 47–105, vs 48, IQR 31–60, p=0.035). MES generated during procedures needing >2 catheters (n=8), are higher than those detected during procedures performed with 2 catheters (n=32, 102, IQR 70–108, vs 48, IQR 33–60, p=0.001). At multivariate analysis increasing number of catheters was the only independent predictor of high incidence of MES (OR 16.4, 95% CI 1.23–219.9, p=0.034, −2LL=26.7). Conclusions LTA has a lower risk of brain embolization because of the lower number of catheter exchange maneuvers. Since the degree of brain embolism depends on the magnitude of mechanical manipulation, catheter changes should be minimized to reduce the risk of cerebral embolization.

We report a case of myocardial infarction at a young age in a person with a medical history of repeated thrombophlebitis, who was heterozygous for the prothrombin G20210A mutation and homozygous for factor V Leiden mutation. A coronary angiography revealed the presence of a moderate atherosclerotic plaque (60%) in the left anterior descending coronary artery, which gave rise to suspicion of a relationship between prothrombotic gene mutations and atherosclerosis. Genetic screening for inherited thrombophilia, especially in the presence of a strong familiarity or previous venous thrombosis, and the evaluation of atherosclerotic risk factors, may be critical information for primary prevention of arterial thrombosis.