Transradial approach for coronary angiography and interventions in patients with coronary bypass grafts: Tips and tricks

Among patients undergoing coronary procedures, patients with coronary artery bypass grafts represent an important, high risk subgroup. Routine transradial approach may be successfully adopted in these patients to reduce access‐site complications. However, transradial cannulation of the grafts may result technically demanding. In this article we discuss the specific technical issues and we present a series of tips and tricks which may facilitate angiography and interventions on both internal mammary and aorto‐coronary grafts. © 2008 Wiley‐Liss, Inc.     

Transradial cardiac catheterization: A Review of Access Site Complications

Transradial catheterization (TRC) has been associated with a lower incidence of major access site related complications as compared to the transfemoral approach. With the increased adoption of transradial access, it is essential to understand the potential major and minor complications of TRC. The most common complication is asymptomatic radial artery occlusion, which rarely leads to clinical events, owing to the dual collateral perfusion of the hand. Adequate anticoagulation, appropriate compression techniques, and smaller sheath size can minimize the risk of radial artery occlusion. Hand ischemia with necrosis has never been reported during TRC with thorough pre‐examination of intact collateral circulation. Radial artery spasm is relatively common, and can result in access and procedural failure. It can be prevented by the use of vasodilator cocktails and hydrophilic sheaths. Radial artery perforation can lead to severe forearm hematoma and compartment syndrome if not managed promptly. Careful observation, prompt detection of the hematoma, and management with a pressure bandage dressing are critical to avoid serious complications. Pseudoaneurym and arteriovenous fistula are rare complications, which can likely be managed conservatively without surgical intervention. Nerve injury occurring during access has been reported. Close observation for improvement is necessary, although symptoms usually improve over time. In summary, to prevent access site complications, avoidance of multiple punctures, gentle catheter manipulation, use of guided compression, coupled with careful observation for adverse warning signs such as hematoma, loss of pulse, pain, are critical for safe and effective TRC. © 2011 Wiley Periodicals, Inc.     

Transradial bilateral cardiac catheterization and endomyocardial bioposy: a feasibility study.

A case series and technique of transradial cardiac catheterization with cardiac biospy are described. Transradial cardiac catheterization is perceived to be limited to arterial procedures. Using the veins of the forearm, we have converted many previous femoral arterial/venous cardiac procedures to a transradial/forearm approach. Retrospective review of patients undergoing transradial procedures with concurrent cardiac biopsies was undertaken. A convenience sample of transfemoral procedures with biopsies performed by the same operator was identified for comparison. Coronary angiography/left heart catheterization was performed using standard transradial/femoral approaches. A 7 Fr introducer sheath was placed via a large median forearm or femoral vein. Right heart catheterization was done using a 120 cm balloon-tipped catheter and endomyocardial biopsy was performed with a 7 Fr biotome. Both groups were then compared for baseline characteristics and procedural events. Transradial (n = 8) and transfemoral (n = 12) procedures were all done for postcardiac transplantation management. There was no crossover between groups. Durations of the radial procedures (median, 73 min; range, 40-95) were similar to transfemoral procedures (median, 68 min; range, 45-105). No procedural complications were reported. Endomyocardial biopsy plays an important role in the diagnosis of transplant rejection and identification of pathological processes that cause myocardial dysfunction. Transradial cardiac catheterization has some clear advantages over a transfemoral approach. Bilateral cardiac catheterization with concurrent cardiac biopsy is technically feasible using a transradial/forearm approach. This approach offers an alternative approach for selected patients in need of cardiac biopsy.     

Outpatient cardiac catheterization and coronary angiography

The cost of and hospitalization required for cardiac catheterization led us to evaluate this procedure in 308 adult outpatients. Patients were scheduled on the basis of stability of symptoms. Two hundred eighty-eight underwent left heart catheterizations and coronary arteriography. Ninety-five percent of the procedures were performed by the percutaneous technique. Fifty patients had normal studies and 30 patients had congenital or valvular disease. Two hundred twenty-eight patients had significant coronary artery disease, 85 patients had triple vessel disease, and 45 patients had left main coronary artery disease. There were six significant complications: one death; two myocardial infarctions; one air embolism, and two patients with hematomas. Three of the complications were in patients with left main disease. Only two of the complications can be ascribed to the outpatient nature of the procedure. The complication rate is comparable to that reported in the literature. Fifteen hundred subsequent cases were studied as outpatients, with a very low mortality and morbidity. It is concluded that cardiac catheterization can be performed on an outpatient basis with safety comparable to inpatient studies, and at a great economic savings.     

Mobile cardiac catheterization: Comparison with outpatient and inpatient catheterization at tertiary facilities

The study group included 1,553 consecutive patients from areas serviced by our mobile catheterization laboratories: 719 procedures were performed in the mobile unit at their local hospitals, 277 were performed at a tertiary hospital with less than a 24 hr hospital stay, and 557 were performed at a tertiary hospital as inpatients. The indications for mobile catheterization were predominantly atypical chest pain, angina pectoris, or positive treadmill stress test, whereas patients with less than 24 hr hospitalization at the tertiary center had their catheterization performed for additional reasons. The majority of the inpatient indications were for recent myocardial infarction or unstable angina. Using the American College of Cardiology/American Heart Association (ACC/AHA) criteria for outpatient catheterization, the mobile catheterizations were performed safely with a complication rate of only 0.7% compared to a complication rate of 3.1% for inpatients demonstrating that a low risk group of patients can be prospectively identified and catheterized safely in the mobile setting. An extremely high risk group of patients with ongoing unstable angina and recent myocardial infarction was also identified which should undergo catheterization only at a tertiary center.     

Trained and supervised physician assistants can safely perform diagnostic cardiac catheterization with coronary angiography.

Using a prospectively collected database of patients undergoing cardiac catheterization, we sought to compare the outcomes of procedures performed by supervised physician assistants (PAs) with those performed by supervised cardiology fellows-in-training. Outcome measures included procedural length, fluoroscopy use, volume of contrast media, and complications including myocardial infarction, stroke, arrhythmia requiring defibrillation or pacemaker placement, pulmonary edema requiring intubation, and vascular complications. Class 3 and 4 congestive heart failure was more common in patients who underwent procedures by fellows compared with those undergoing procedures by PAs (P = 0.001). PA cases tended to be slightly faster (P = 0.05) with less fluoroscopic time (P < 0.001). The incidence of major complications within 24 hr of the procedure was similar between the two groups (0.54% in PA cases and 0.58% in fellow cases). Under the supervision of experienced attending cardiologists, trained PAs can perform diagnostic cardiac catheterization, including coronary angiography, with complication rates similar to those of cardiology fellows-in-training.     

Cardiac perforation with tamponade during cardiac catheterization

Among 6,675 adult patients undergoing cardiac catheterization in our institution, three patients developed cardiac perforation and tamponade (incidence 0.04%). Two perforations involved the left atrium, and one the right atrium. Tamponade developed in the three patients. Hemodynamic confirmation of tamponade was available in two patients. Pericardiocentesis was performed in all three patients. Two patients required emergency surgery. All patients recovered.     

Outpatient cardiac catheterization: a report of 3,000 cases.

A total of 3000 patients have had cardiac catheterization in the Andreas Gruentzig Cardiovascular Laboratory of the Emory Clinic. The purpose of this presentation is to describe the patient population selected for this procedure and our experience with this group. The concept of catheterization as an outpatient is attractive from the standpoint of cost savings and time conservation. Safety has been questioned. We have found that this technique can be performed safely in carefully selected outpatients. Careful selection attempted to eliminate those with unstable symptoms, recent myocardial infarction, severe diabetes, and renal failure. Small catheters were used to minimize the potential for bleeding. Excellent opacification of vessels was obtained with these catheters. Despite careful screening we found 2.2% had significant left main obstruction, 10.8% had triple-vessel disease, 16.0% had double-vessel disease, and 23.5% had single-vessel disease, and a similar percentage had normal coronary arteriograms. Our patients experienced ventricular fibrillation on five occasions, there were two small cerebral emboli with reversible neurologic defects, two episodes of pulmonary edema, and two episodes of severe allergic reactions. Only three patients had significant groin bleeding at home that required compression of the site. We subsequently did angioplasty on 323 patients, performed cardiac surgery (mostly coronary bypass) on 187 patients, and admitted 18.2% of the entire group. We conclude that this procedure can be done safely in this carefully designed setting and it saves time and offers cost savings. Patient selection is very important to minimize potential emergency situations and complications. The laboratory must be carefully set up and provide a close relationship with a hospital capable of attending to any unexpected emergency.     

Percutaneous translumbar cardiac catheterization and central venous line insertion: An alternative approach in children with congenital heart disease

Children with congenital heart disease present major problems with venous access, eliminating conventional routes for cardiac catheterization. Although the transhepatic approach has recently gained popularity, we describe here an alternative approach using percutaneous translumbar approach for cardiac catheterization and/or in-dwelling central line insertion in three children with congenital heart disease. Diagnostic hemodynamic studies, transcatheter delivery of an intravascular stent for left pulmonary artery (LPA) stenosis, and chronic central venous line insertion were performed using this technique. Disadvantages include interventionalist's unfamiliarity with technique, awkward patient positioning, technically more difficult than transhepatic, and potential injury to kidney and bowel. Advantages include avoidance of vascular-rich hepatic parenchyma, thus reducing risk of hemorrhage; providing an alternative where transhepatic entry may be contraindicated; avoidance of bile duct, portal vein, and hepatic artery injury; and providing another alternative for not only transvenous, but also transarterial access that may be required for intravascular aortic stent delivery. The interventional radiologist should be utilized as a valuable resource to the cardiologist to help teach and supervise this technique in selected infants and children with limited vascular access. Cathet. Cardiovasc. Intervent. 46:187–192, 1999. © 1999 Wiley-Liss, Inc.     

A comparison of arterial versus venous-activated clotting time in patients with congenital heart disease undergoing cardiac catheterization

Studies in adult patients undergoing percutaneous coronary angioplasty have demonstrated differences in measured activated clotting time (ACT) in venous vs. arterial blood samples. Ninety-two patients with congenital heart disease undergoing cardiac catheterization were prospectively evaluated to compare venous vs. arterial ACT values in monitoring heparin effect in this population. Simultaneous venous and arterial ACT samples were drawn at baseline, 10 min, 60 min, and every 30 min thereafter until each case was finished. ACT values were determined simultaneously with a dual-chambered Hemochron 801 instrument. At baseline and throughout the study up to 90 min, venous and arterial ACT values were not significantly different. They were also no different in the subgroup of cyanotic patients. Therefore, venous and arterial ACT values can be safely used alternatively to guide heparin dosing during cardiac catheterization in patients with congenital heart disease without the risk of undercoagulation. Cathet. Cardiovasc. Intervent. 46:194–196, 1999. © 1999 Wiley-Liss, Inc.     

Permanent pacemaker implantation in the cardiac catheterization laboratory: The subclavian vein approach

During a 36-month period, 171 permanent pacemaker procedures were performed in the cardiac catheterization laboratory by invasive cardiologists. This included 111 initial pacemaker system implants, via the percutaneous subclavian vein approach, 45 pulse generator changes, and 15 miscellaneous procedures. In no case did subclavian vein puncture result in pneumothorax, hemothorax, or brachial plexus injury. In patients undergoing initial lead placement, the dislodgment rate was 0.8% over a 16-month follow-up period. The reoperation rate for causes other than premature battery depletion was 5.4% during the first 12 months. The implantation of permanent pacemakers can be safely and effectively accomplished by experienced invasive cardiologists in the cardiac catheterization laboratory. In our series not only was continuity of patient care improved, but also medical costs were reduced.     

Splenic infarction: a complication of cardiac catheterization.

Patients with extensive atherosclerosis are at increased risk of developing embolic complications during cardiac catheterization. We describe a 51-year-old man with unstable angina and bilateral leg claudication who developed fever and right upper abdominal pain shortly after cardiac catheterization. Liver-spleen scintigraphy demonstrated a wedge-shaped filling defect compatible with splenic infarction, and serial scans performed over a period of five months showed resolution of this finding. Splenic infarction tends to be under-diagnosed, and physicians should be aware of this potentially serious complication of cardiac catheterization.     

Cardiac surgery and catheterization in patients with Haemophilia

The present study summarizes the results of 12 cardiac surgical procedures performed in a carrier of Haemophilia B and in six patients with Haemophilia A at a single centre from 1979 to 1998. The median age of the patients at the time of intervention was 56 years ranging from 18 years to 73 years. The six patients with Haemophilia A ranged in severity from moderately to mildly affected. Three patients were hepatitis C antibody positive. No patients were HIV antibody or hepatitis B surface antigen positive. The cardiac procedures included cardiac catheterization (n=4), coronary artery bypass surgery (n=2), percutaneous transluminal coronary angioplasty (n=1), cardiac valve replacement (AVR n=1 and AVR/MVR n=2), and closure of an atrial septal defect and subsequent drainage of a pericardial effusion (n=1). No patients had demonstrable inhibitors at the time of surgery. Haemostasis was achieved with AHF in 10/11 procedures and high purity factor IX (Immunine) in one procedure. The initial procedures involved intermittent bolus factor therapy while more recently, AHF was administered by continuous intravenous infusion. All patients demonstrated excellent intra- and post-operative haemostasis. These results, although from a small and varied group of patients, demonstrate that cardiac surgical procedures can be performed safely in patients with Haemophilia.     

Transradial cardiac catheterization in elderly patients.

The safety and efficacy of transradial cardiac catheterization in elderly patients is unknown. This study examines procedure success rates for transradial catheterization in appropriately selected patients < 70 (n = 195) and >/= 70 (n = 83) years old. Elderly patients were less likely to be selected for the transradial approach (46% vs. 61%; P = 0.05). Although patients >/= 70 years old were more often female (39.7% vs. 24.1%; P = 0.008) and had a smaller body surface area (1.89 +/- 0.18 vs. 2.01 +/- 0.24 m2; P = 0. 001), procedure success rates did not differ (95.1% vs. 94.8%; P = NS). Procedure-related variables including procedure time (15.4 +/- 12.6 vs. 16.1 +/- 11.6 min; P = NS), amount of radiographic contrast (90.1 +/- 31.9 vs. 86.4 +/- 29.8 cc; P = NS), and number of catheters used (1.5 +/- 0.9 vs. 1.5 +/- 0.7; P = NS) were similar between groups. We conclude that transradial catheterization can be safely and effectively performed in selected elderly patients. Cathet. Cardiovasc. Intervent. 51:287-290, 2000.     

Utility of cardiac catheterization in pediatric cardiac patients on ECMO

Cardiac catheterization has been utilized rarely in children on extracorporeal membrane oxygenation (ECMO). We performed a retrospective review of 15 children with congenital heart disease who had undergone catheterization while on ECMO from December 1990–December 1995. The procedures, including four interventions, were successful in all patients with adequate evaluation of clinical questions. Unexpected diagnostic information of clinical importance was obtained in 40%, and clinical management of patients was significantly altered in 73%. All patients tolerated the procedure and transport well. The only significant complication was a retroperitoneal hemorrhage in one patient after approximately 12 hr. Although no patients died at catheterization, overall survival was poor, with 50% weaning from ECMO, 29% surviving to discharge, and 14% surviving at follow-up. We conclude that diagnostic and interventional catheterization may be performed in patients on ECMO with acceptable morbidity and mortality; however, long-term survival in this population is poor. Cathet. Cardiovasc. Intervent. 46:62–67, 1999. © 1999 Wiley-Liss, Inc.     

Radiation exposure to patients undergoing diagnostic and interventional cardiac catheterization procedures

There has been a recent wave of concern over radiation exposure to patients during cardiac catheterization. Accordingly, we measured the area-exposure product (AEP) to patients undergoing diagnostic and interventional cardiac catheterization procedures. Fluoroscopic and cinefluorographic exposures were determined for 510 patients using an AEP meter. The total AEP was higher in interventional than diagnostic cases (16,289 R·cm² vs. 10,873 R·cm², P < 0.00001); multi-lesion than single lesion interventions (20,311 R·cm² vs. 15,919 R·cm² P < 0.0001); and in patients with previous coronary bypass surgery (20,403 R·cm² vs. 14,298 R·cm², P < 0.00001). The highest AEPs were observed in patients with a prior history of bypass surgery who underwent diagnostic catheterization and multilesion intervention during the same procedure. Cathet. Cardiovasc. Diagn. 42:121–125, 1997. © 1997 Wiley-Liss, Inc.     

Transradial approach for transcatheter arterial chemoembolization in patients with hepatocellular carcinoma: comparison with conventional transfemoral approach

We evaluated the clinical usefulness and safety of transradial approach for transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) compared with that of conventional transfemoral approach. The two groups (radial group, n = 177; femoral group, n = 150) of cases were retrospectively compared with regard to the successful rate of angiography or TACE, time required for catheterizaiton and complications. Hepatic angiography and TACE were completed in 174 (98.3%) of 177 cases in the radial group. There was no intergroup difference of time required for catheterization. Minor complications (dull pain, numbness) occurred in 8 (4.6%) patients in the radial group, and there were lower complications in the radial group compared to the femoral group. TACE by our new transradial approach was found to have therapeutic efficacy with lower complications comparable to that of the conventional transfemoral approach.     

Percutaneous transfemoral catheterization in aortic stenosis with a USCI sones catheter curve a type 1 (7540)

We report our experience with the use of a USCI Sones catheter curve A type 1 (7540) to cross the aortic valves of 45 patients with clinically signficant aortic stenosis. The technique was successful in all our patients with a fluoroscopic time of less than 3 min. A gradient of up to 200 mmHg across the aortic valve area was recorded, and the smallest valve area calculated was less than 0.2 cm². The method obviated the need for a guidewire and satisfactory left ventriculograms were obtained. No major complication was observed. We conclude that the technique is a simple, rapid, and safe means of obtaining left ventricular hemodynamic and angiographic information in patients with aortic stenosis of various degrees of severity.     

Propensity score analysis of vascular complications after diagnostic cardiac catheterization and percutaneous coronary intervention 1998-2003.

OBJECTIVES: To evaluate the adjusted risk of vascular complications after manual compression and vascular closure devices for femoral artery access site management in a large contemporary cohort, using propensity score analysis. BACKGROUND: Vascular closure devices (VCD) allow early ambulation after cardiac procedures involving femoral artery access, but whether the benefit of use of vascular closure devices (VCD) is offset by reduced safety in contemporary practice remains uncertain. Methods: Twenty one thousand eight hundred and forty one consecutive diagnostic cardiac catheterization (n = 13,124) and percutaneous coronary intervention procedures (n = 8,717) performed via a femoral access at a single site (WFUBMC) between 1998 and 2003 were evaluated. VCD's were used based on operator preference. Propensity to receive a vascular closure device (VCD) was calculated. The relative incidence of vascular complications was evaluated by logistic regression models, using the propensity score as a covariate. RESULTS: Overall, the unadjusted incidence of any vascular complication was 1.3% for VCD use and 1.4% for manual compression, p = NS. The propensity score-adjusted odds ratio for any vascular complication comparing VCD (n = 8,707) to manual compression (n = 13,034) was 0.86 (0.67-1.11) for all procedures, 0.80 (0.53-1.21) for diagnostic procedure, and 0.90 (0.65-1.26) for interventional procedures. CONCLUSIONS: In this large single-center, contemporary observational study, the risk-adjusted occurrence of vascular complications following VCD use for femoral artery access management is not increased by VCD use. Thus, in the current era, the benefit of VCD use is not offset by reduced safety.     

Incidence of new focal pulmonary emboli after routine cardiac catheterization comparing the brachial to the femoral approach

The incidence of pulmonary perfusion defects after routine cardiac catheterization was assessed in 56 patients by comparing ventilation–perfusion (V/Q) lung scans obtained before and 1 day after catheterization. Patients were prospectively randomized in two groups, one in which the brachial approach was performed using an antecubital cutdown procedure, and one in which the percutaneous femoral approach was used. None of the patients with the brachial approach had any ventilation–perfusion mismatch on the V/Q scan; however, three patients (8.3%) with the femoral approach did. These two groups did not differ significantly in clinical characteristics, duration of catheterization, and hemodynamic variables. The data suggest that pulmonary emboli postcardiac catheterization is more frequent in the femoral than the brachial approach. Furthermore, since those pulmonary emboli are mostly asymptomatic, their clinical recognition would be underestimated.