BACKGROUND: In some randomized clinical trials, transradial access (TRA) compared with transfemoral access (TFA) was associated with lower mortality in patients with coronary artery disease undergoing invasive management. We analyzed the effects of TRA versus TFA across multicenter randomized clinical trials and whether these associations are modified by patient or procedural characteristics. METHODS: We performed an individual patient data meta-analysis of multicenter randomized clinical trials comparing TRA with TFA among patients undergoing coronary angiography with or without percutaneous coronary intervention. The primary outcome was all-cause mortality and the co-primary outcome was major bleeding at 30 days. The primary analysis was conducted by 1-stage mixed-effects models on the basis of the intention-to-treat cohort. The effect of access site on mortality and major bleeding was assessed further by multivariable analysis. The relationship among access site, bleeding, and mortality was investigated by natural effect model mediation analysis with multivariable adjustment. RESULTS: A total of 21 600 patients (10 775 TRA, 10 825 TFA) from 7 randomized clinical trials were included. The median age was 63.9 years, 31.9% were women, 95% presented with acute coronary syndrome, and 75.2% underwent percutaneous coronary intervention. All-cause mortality (1.6% versus 2.1%; hazard ratio, 0.77 [95% CI, 0.63-0.95]; P=0.012) and major bleeding (1.5% versus 2.7%; odds ratio, 0.55 [95% CI, 0.45-0.67]; P<0.001) were lower with TRA. Subgroup analyses for mortality showed consistent results, except for baseline hemoglobin level (Pinteraction=0.003), indicating that the benefit of TRA was substantial in patients with moderate or severe anemia, whereas it was not significant in patients with milder or no baseline anemia. After adjustment, TRA remained associated with 24% and 51% relative risk reduction of all-cause mortality and major bleeding, respectively. A mediation analysis showed that the benefit of TRA on mortality was only partially driven by major bleeding prevention and ancillary mechanisms are required to fully explain the causal association. CONCLUSIONS: TRA is associated with lower all-cause mortality and major bleeding at 30 days compared with TFA. The effect on mortality was driven by patients with anemia. The reduction in major bleeding only partially explains the mortality benefit. REGISTRATION: URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42018109664.
- MeSH
- arteria femoralis diagnostické zobrazování MeSH
- arteria radialis MeSH
- koronární angiografie * škodlivé účinky MeSH
- koronární angioplastika * škodlivé účinky MeSH
- krvácení etiologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- multicentrické studie jako téma MeSH
- randomizované kontrolované studie jako téma MeSH
- rizikové faktory MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
Transradial access (TRA) is increasingly used worldwide for percutaneous interventional procedures and associated with lower bleeding and vascular complications than transfemoral artery access. Radial artery occlusion (RAO) is the most frequent post-procedural complication of TRA, restricting the use of the same radial artery for future procedures and as a conduit for coronary artery bypass graft. The authors review recent advances in the prevention of RAO following percutaneous TRA diagnostic or interventional procedures. Based on the available data, the authors provide easily applicable and effective recommendations to prevent periprocedural RAO and maximize the chances of access in case of repeat catheterization or coronary artery bypass grafting surgery.
- MeSH
- angiografie * škodlivé účinky MeSH
- arteria femoralis * diagnostické zobrazování patofyziologie MeSH
- arteriální okluzní nemoci diagnostické zobrazování etiologie patofyziologie prevence a kontrola MeSH
- benchmarking MeSH
- hodnocení rizik MeSH
- konsensus MeSH
- lidé MeSH
- ochranné faktory MeSH
- periferní katetrizace * škodlivé účinky MeSH
- průchodnost cév MeSH
- rizikové faktory MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
- směrnice pro lékařskou praxi MeSH
Objectives: The aim of this study was to analyse the consequence of radial or femoral access during coronary interventions to radiation dose, fluorography time and a number of pseudoaneurysms following each type of intervention. Background: According to the results of many recent studies (RIVAL, RIFLE-STEACS, STEMI RADIAL), current guidelines favour radial over femoral access during coronary intervention for safety, especially in cases of acute coronary syndromes. However, several papers have referred to problems in the design of these studies and the management of antithrombotic therapy. The influence of access site on radiation dose and fluorography time is also still unclear. Methods: We retrospectively analysed 4522 patients who underwent coronary angiography in 2012 and 2016 in a single centre in the Czech Republic. We compared the access site with the average radiation dose and mean effective dose that each patient received in Gy/cm2 or mSv, respectively. We also compared average fluorography time in minutes and the incidence of pseudoaneurysms. Results: The radiation dose was a body mass index (BMI)-dependent parameter since each five points of body mass index increased radiation dose approximately by 23%. Use of femoral access resulted in lower fluorography time in all subgroups (p < .001) and decreased radiation dose in patients with coronary artery bypass grafts (CABGs) by 26% (p = .044). On the other hand, there has been 16 times lower frequency (p < .001) of post-catheterisation pseudoaneurysms after radial access than after femoral access. Conclusions: Both the radiation dose and fluorography time were lower after femoral access compared to radial access in patients with CABGs. On the other hand, radial access led to significantly fewer periprocedural pseudoaneurysms. Radial access therefore should be considered as the preferred access site during coronary intervention in patients with a high risk of pseudoaneurysm development, and femoral access should be considered for patients with a high risk of contrast-induced nephropathy.
- MeSH
- arteria femoralis * diagnostické zobrazování zranění MeSH
- arteria radialis * diagnostické zobrazování zranění MeSH
- dávka záření MeSH
- hodnocení rizik MeSH
- incidence MeSH
- koronární angiografie škodlivé účinky metody MeSH
- koronární angioplastika škodlivé účinky metody MeSH
- lidé MeSH
- nepravé aneurysma epidemiologie MeSH
- periferní katetrizace škodlivé účinky metody MeSH
- poranění cév epidemiologie MeSH
- punkce MeSH
- radiační expozice MeSH
- retrospektivní studie MeSH
- rizikové faktory MeSH
- srdeční katetrizace škodlivé účinky metody MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- srovnávací studie MeSH
- Geografické názvy
- Česká republika MeSH
The geometry of the distal anastomosis of a femoropopliteal bypass influences local hemodynamics and formation of intimal hyperplasia. We hypothesized that the distal anastomosis of an above-knee femoropopliteal bypass undergoes remodeling that results in displacement of the original course of the popliteal artery and change in the anastomosis angle. We identified 43 CT angiography examination with proximal femoropopliteal bypass and either a preserved contralateral popliteal artery or previous CTA before construction of the bypass for comparison. In these examinations, we measured the displacement distance and angle at the level of the distal anastomosis and compared these measurements with clinical and imaging data. The displacement distance was 8.8+/-4.9 mm (P<0.0001) and the displacement angle was -1° (IQR=44°). The angle between the inflow and outflow artery was 153+/-16° (P<0.0001). There was a negative association between the displacement angle and the angle between the bypass and the outflow artery (r=-0.318, P=0.037). Patients with reversed venous grafts had a greater displacement of the anastomosis (14.7+/-3.0 mm) than patients with prosthetic grafts (8.0+/-4.5 mm, P=0.0011). We conclude that construction of a distal anastomosis of proximal femoropopliteal bypass results in displacement of the original course of the popliteal artery towards the bypass and this effect is more pronounced in reversed venous grafts.
- MeSH
- anastomóza chirurgická trendy MeSH
- arteria femoralis diagnostické zobrazování fyziologie chirurgie MeSH
- arteria poplitea diagnostické zobrazování fyziologie chirurgie MeSH
- CT angiografie trendy MeSH
- dolní končetina krevní zásobení diagnostické zobrazování chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- remodelace cév * fyziologie MeSH
- retrospektivní studie MeSH
- senioři MeSH
- výkony cévní chirurgie trendy MeSH
- zákroky plastické chirurgie trendy MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Úvod: Aneurysma hluboké stehenní tepny (deep femoral artery, DFA) se vyskytuje velmi vzácně. Diagnóza se vzhledem k anatomickému uložení tepny stanovuje obtížně. Obecně se aneurysma projevuje komplikacemi - kompresí a rupturou. Popis případu: Popisujeme případ 78letého muže, který byl urgentně přijat na oddělení cévní chirurgie a který si stěžoval na náhlou bolest a velkou pulsující hmotu ve femorálním trojúhelníku levého stehna. Vyšetření ultrazvukem a CT angiografie (CTA) potvrdily přítomnost prasklého aneurysmatu DFA s velkým hematomem vlevo. CTA prokázala aneurysmata i v obou iliackých, stehenních a lýtkových tepnách. Femoropopliteální segment byl průchodný na obou stranách. Vzhledem k závažnému přidruženému onemocnění byla provedena ligace proximálního krčku aneurysmatu a zašita prasklá stěna. Diskuse: Aneurysmata DFA jsou velmi vzácná - jedná se 0,5 % všech aneurysmat periferních cév. Vzhledem k jejich malému průměru fyzikální vyšetření málokdy prokáže přítomnost aneurysmatu. Mezi cenné diagnostické metody patří duplexní sonografie a CTA, přičemž druhá metoda je užitečnější, protože prokáže průchodnost a uložení DFA distálně k aneurysmatu. V našem případě nám ruptura aneurysmatu a průchodnost femoropopliteálního segmentu umožnila provést prostou ligaci krčku aneurysmatu a zašití prasklé stěny bez distální rekonstrukce. Závěr: Náš případ potvrzuje přednosti CTA ve srovnání s ultrazvukem při hodnocení postižení vícečetnými aneurysmaty. Výběr způsobu léčby - ligace - byl dán závažným přidruženým onemocněním a průchodností femoropopliteálního segmentu.
Introduction: Aneurysms of the deep femoral artery (DFA) are extremely rare. The diagnosis is difficult due to the anatomical location of the artery. Generally, the aneurysm presents itself with its complications - compression, rupture. Presentation of case: We present a case of 78-year-old man admitted in state of emergency in Vascular Surgery department, presenting with suddenly appearing pain and big pulsatile mass in the femoral triangle of the left thigh. The performed ultrasonography and CTA confirmed the presence of ruptured DFA aneurysm with big hematoma on the left side. CTA established also aneurysms of both iliac, femoral and popliteal arteries. Femoro-popliteal segment was patent at both sides. Due to the severe comorbidity, the performed procedure was ligation of the proximal neck of the aneurysm and suturing the ruptured wall. Discussion: The aneurysms of the DFA are very rare - 0.5% of all aneurysms of the peripheral vessels. Due to the small diameter physical examination rarely establishes the presence of aneurysm. Valuable methods for diagnosis are duplex ultrasonography and CTA. More important is the latter because it shows the patency and location of the DFA, distally to the aneurysm. In our case rupture of the aneurysm and patency of the femoro-popliteal segment allowed us to do simple ligation of the aneurysmal neck and suturing the ruptured wall, without distal reconstruction. Conclusion: Our case confirms the value of CTA over ultrasonography in the estimation of the multi aneurysmal disease. The choice of treatment method - ligation, was determined by the severe comorbidity and patency of the femoro-popliteal segment.
- MeSH
- angiografie MeSH
- arteria femoralis diagnostické zobrazování patofyziologie MeSH
- arteriální okluzní nemoci diagnostické zobrazování terapie MeSH
- balónková angioplastika MeSH
- cévy - implantace protéz metody MeSH
- lidé MeSH
- mladý dospělý MeSH
- Check Tag
- lidé MeSH
- mladý dospělý MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- kazuistiky MeSH
The descending branch of the lateral circumflex femoral artery (DBLCFA) has been suggested as an option for use in coronary artery bypass grafting (CABG). Our aim was to combine radiological examination, surgical and anatomical preparation, and histological assessment of the DBLCFA to map its variability and to assess the benefits of this conduit in cardiac surgery. The pelvic and femoral arteries were examined by CT angiography (CTA) in 100 patients (aged 68.3 ± 9.3 years) to assess the variability of the DBLCFA. Anatomical dissections were performed on 20 cadavers. In 15 patients, an autologous DBLCFA was implanted during CABG. In 35 samples, possible atherosclerotic lesions were examined histologically. The length of the potential DBLCFA conduits measured by CTA was 9.3 ± 2.9 cm, without correlating with the length of the thigh. Anatomical variations that would prevent the DBLCFA from being used in CABG were found in 27 out of 100 patients. Except for focal thickening of the intima, eccentric hypertrophy of the intima was found in three out of 35 samples. No inflammatory infiltration, foam cells, atheroma, or calcifications were found histologically. The DBLCFA is not to be used routinely or in preference to other grafts of choice. However, owing to its moderate variability, sufficient length, caliber, and rare atherosclerosis, it can be used in the absence of other suitable grafts as an alternative conduit implanted as a composite Y-graft end-to-side to the internal thoracic artery in patients without diabetic angiopathy, neuropathy or peripheral artery disease who are undergoing extensive or repeat coronary revascularization. Clin. Anat. 29:779-788, 2016. © 2016 Wiley Periodicals, Inc.
- MeSH
- arteria femoralis anatomie a histologie diagnostické zobrazování chirurgie MeSH
- CT angiografie * MeSH
- koronární bypass * MeSH
- lidé středního věku MeSH
- lidé MeSH
- referenční hodnoty MeSH
- senioři MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
OBJECTIVE: The mechanism of angioplasty is disruption of atherosclerotic plaque, which often results in dissections. Dissection after percutaneous transluminal angioplasty (PTA) remains a significant clinical problem and untreated may cause acute occlusion or later restenosis. Stents are used to manage dissections, which is often followed by in-stent restenosis and occasionally stent fracture. Tack (Intact Vascular, Wayne, Pa) implants have minimal metal and low radial force and are specifically designed for dissection repair. This study evaluated Tack implants for treatment of dissections resulting from standard balloon PTA for femoral-popliteal arterial disease. Twelve-month outcomes after Tack treatment of post-PTA dissections are described. METHODS: This prospective, single-arm study evaluated patients with ischemia (Rutherford clinical category 2-4) caused by lesions of the superficial femoral and popliteal arteries. Patients were treated with standard balloon angioplasty, and post-PTA dissections were treated with Tacks. The primary end points were core laboratory-adjudicated device technical success, defined as the ability of the Tack implants to resolve post-PTA dissection, and device safety, defined as the absence of new-onset major adverse events. Patients were followed up to 12 months after implantation. RESULTS: Tacks were used in 130 patients with post-PTA dissections (74.0% ≥ grade C). Technical success was achieved in 128 (98.5%) patients with no major adverse events at 30 days. The 12-month patency was 76.4%, and freedom from target lesion revascularization was 89.5%. Significant improvement from baseline was observed in Rutherford clinical category (82.8% with grade ≤1) and ankle-brachial index (0.68 ± 0.18 to 0.94 ± 0.15; P < .0001). CONCLUSIONS: Tack implant treatment of post-PTA dissection was safe, produced reasonable patency, and resulted in low rates of target lesion revascularization. Tack treatment represents a new, minimal metal paradigm for dissection repair that can safely improve the clinical results associated with PTA.
- MeSH
- arteria femoralis diagnostické zobrazování zranění patofyziologie MeSH
- arteria poplitea diagnostické zobrazování zranění patofyziologie MeSH
- balónková angioplastika škodlivé účinky MeSH
- časové faktory MeSH
- cévní protézy * MeSH
- cévy - implantace protéz škodlivé účinky přístrojové vybavení MeSH
- dolní končetina krevní zásobení MeSH
- endovaskulární výkony škodlivé účinky přístrojové vybavení MeSH
- kovy * MeSH
- lidé středního věku MeSH
- lidé MeSH
- onemocnění periferních arterií diagnostické zobrazování patofyziologie terapie MeSH
- opakovaná terapie MeSH
- poranění cév diagnostické zobrazování etiologie terapie MeSH
- prospektivní studie MeSH
- protézy - design MeSH
- průchodnost cév MeSH
- senioři MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- klinické zkoušky MeSH
- multicentrická studie MeSH
