80岁以上老年患者经桡动脉和股动脉途径行经皮冠状动脉介入治疗的对比研究

目的:评价80岁以上老年患者经桡动脉途径行经皮冠状动脉介入治疗(PCI)的安全性和临床疗效.方法:2003-05至2007-05进行PCI 80岁以上的高龄患者268例,男性176例,年龄80～97岁;经股动脉途径PCI组156例(股动脉组),经桡动脉途径PCI组112例(桡动脉组).对比两组的临床特点、PCI特点、住院期间主要的不良心脏事件(MACE,包括心脏性死亡、非致死性心肌梗死和靶病变再次重建率).结果:桡动脉组与股动脉组相比,PCI的成功率相似,均在95%以上;桡动脉组需要更改途径的比率显著增高(P<0.05);冠状动脉导管插入时间(P<0.01)、X线曝光时间(P<0.05)均显著延长;造影剂用量有增多趋势(P>0.05),但两组差异未达统计学意义;术后卧床时间显著缩短(P<0.01),所有原因的穿刺部位血管并发症显著降低(P<0.01),其中,局部出血发生率(P<0.01)和局部血肿发生率(P<0.01)均显著减低.经多因素回归分析显示,桡动脉途径(OR=0.25,CI=0.09～0.75)是穿刺部位血管并发症独立的阴性预测因素.结论:80岁以上高龄患者的PCI,桡动脉途径可以降低穿刺血管局部并发症,与股动脉途径相比具有同样的临床效果和成功率,但是,穿刺失败率高,穿刺时间和曝光时间较长.     

Influence of Bleeding Risk on Outcomes of Radial and Femoral Access for Percutaneous Coronary Intervention: An Analysis From the GLOBAL LEADERS Trial

BackgroundRadial artery access has been shown to reduce mortality and bleeding events, especially in patients with acute coronary syndromes. Despite this, interventional cardiologists experienced in femoral artery access still prefer that route for percutaneous coronary intervention. Little is known regarding the merits of each vascular access in patients stratified by their risk of bleeding.MethodsPatients from the Global Leaders trial were dichotomized into low or high risk of bleeding by the median of the PRECISE-DAPT score. Clinical outcomes were compared at 30 days.ResultsIn the overall population, there were no statistical differences between radial and femoral access in the rate of the primary end point, a composite of all-cause mortality, or new Q-wave myocardial infarction (MI) (hazard ratio [HR] 0.70, 95% confidence interval [CI] 0.42-1.15). Radial access was associated with a significantly lower rate of the secondary safety end point, Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding (HR 0.55, 95% CI 0.36-0.84). Compared by bleeding risk strata, in the high bleeding score population, the primary (HR 0.47, 95% CI 0.26-0.85; P = 0.012; P_interaction = 0.019) and secondary safety (HR 0.57, 95% CI 0.35-0.95; P = 0.030; P_interaction = 0.631) end points favoured radial access. In the low bleeding score population, however, the differences in the primary and secondary safety end points between radial and femoral artery access were no longer statistically significant.ConclusionsOur findings suggest that the outcomes of mortality or new Q-wave MI and BARC 3 or 5 bleeding favour radial access in patients with a high, but not those with a low, risk of bleeding. Because this was not a primary analysis, it should be considered hypothesis generating.     

Radial vs. Femoral Access for Percutaneous Coronary Artery Intervention in Patients With ST-Elevation Myocardial Infarction

BackgroundWe aimed to compare the safety and efficacy of transradial vs transfemoral access for coronary angiography and intervention in patients presenting with ST-segment elevation myocardial infarction (STEMI) without cardiogenic shock.MethodsPubMed, Embase and Cochrane Central were searched for randomized controlled trials (RCTs) comparing outcomes of STEMI patients who underwent transradial angiography (TRA) compared to transfemoral angiography (TFA). Our outcomes of interest were major adverse cardiac events (MACE), all-cause mortality, severe bleeding, access site bleeding, myocardial infarction, stroke, and major vascular complications. Summary statistics are reported as odds ratios (OR) with 95% confidence intervals (CI).ResultsIn a pooled analysis of 17 RCTs with 12,118 randomized patients, the use of transradial compared to transfemoral approach in STEMI patients without cardiogenic shock was associated with a significant reduction in MACE [OR 0.85 (95% CI 0.73–0.99; p = 0.04; NNT = 111; I² = 0%)] and all-cause mortality [OR 0.71 (95% CI 0.57–0.88; p < 0.01; NNT = 111; I² = 0%)]. Severe bleeding [OR 0.57 (95% CI 0.44–0.74; p < 0.01; NNT = 77; I² = 0%)], access-site bleeding [OR 0.39 (95% CI 0.26–0.59; p < 0.01; NNT = 67; I² = 24%)], and major vascular complications [OR of 0.31 (95% CI 0.17–0.55; p < 0.01; NNT = 125; I² = 0%)] were lower in TRA compared to TFA. There was no difference in stroke (0.6% vs 0.5%) or recurrent myocardial infarction (2.01% vs 2.02%) between the two approaches.ConclusionsFor coronary intervention in STEMI patients without cardiogenic shock, there is a clear mortality benefit with the TRA over TFA. Further studies are needed to see if this mortality benefit persists over the long-term.     

Radial vs Femoral Access After Percutaneous Coronary Intervention for ST-segment Elevation Myocardial Infarction. Thirty-day and One-year Mortality Results

Introduction and objectives

Little attention has been given to the effect of vascular access site on mortality, while an increasing body of evidence is showing that radial access has much more benefit than femoral access for ST-segment elevation myocardial infarction patients. We aimed to assess the influence of vascular access site on mortality at 30 days and at 1 year in ST-segment elevation myocardial infarction patients.

Methods

We included all patients with ST-segment elevation myocardial infarction who had undergone primary angioplasty at 2 Galician hospitals between 2008 and 2010. We performed 2 multivariate regression models for each endpoint (30-day and 1-year mortality). The only difference between these models was the inclusion or not of the vascular access site (femoral vs radial). For each of the 4 models we calculated the Hosmer-Lemeshow test and the C-index. We also tested the interaction between hemodynamic instability and vascular access.

Results

We included 1461 patients with a mean age of 64. Of these patients, 86% had radial access and 7.4% had hemodynamic instability. All-cause mortality was 6.8% (100/1461) at 30 days and 9.3% (136/1461) at 1 year. Vascular access site follows hemodynamic instability and age in terms of effect on mortality risk, with an odds ratio of 5.20 (95% confidence interval, 2.80-9.66) for 30-day mortality. A similar effect occurs for 1-year mortality. The C-index slightly improves (without achieving statistical significance) with the inclusion of the vascular access site.

Conclusions

Vascular access site should be taken into account when predicting mortality after a primary percutaneous coronary intervention.     

Ultrasound- Versus Fluoroscopy-Guided Femoral Access for Percutaneous Coronary Intervention of Chronic Total Occlusions: Insights From FOUND BLOOD CTO Registry

ObjectiveTo compare vascular complications in patients undergoing percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) using ultrasound guidance (USG) versus fluoroscopy guidance (FSG) for femoral access.BackgroundIn patients undergoing PCI, using the arterial femoral access increases the risk of vascular complications compared using the radial access. USG reduces time to access, number of attempts, and vascular complications compared with FSG, but the efficacy of USG has never been tested in the setting of CTO-PCI.MethodsA total of 197 patients undergoing CTO-PCI using at least a femoral vascular access from November 2015 to September 2020 were screened. The primary outcome was a composite of local hematoma, pseudoaneurysm, retroperitoneal hemorrhage, arteriovenous fistula or hemoglobin drop ≥3 g/dL during hospitalization. The independent association between USG and the primary outcome of interest was explored.ResultsThe primary outcome occurred in 17.3% of patients. Patients in the USG group had a significantly lower incidence of vascular complications compared with patients in the FSG group (8.5% vs. 21.0%, p = 0.039), driven by a reduction of localized hematomas (3.4% vs 13.0%, p = 0.042). After adjustment for type of CTO approach and heparin dose, USG was significantly associated with a reduced relative risk of the composite primary outcome (adjusted odds ratio 0.16, 95% confidence interval 0.05 to 0.51; p = 0.002).ConclusionUSG in CTO-PCI is associated with a decreased risk of vascular complications, primarily driven by a reduction in local hematomas, especially in complex CTO-PCI where the larger use of heparin increases the risk of vascular complications.     

Distal Versus Conventional Radial Access for Coronary Angiography and Intervention: The DISCO RADIAL Trial

BackgroundCurrently, transradial access (TRA) is the recommended access for coronary procedures because of increased safety, with radial artery occlusion (RAO) being its most frequent complication, which will increasingly affect patients undergoing multiple procedures during their lifetimes. Recently, distal radial access (DRA) has emerged as a promising alternative access to minimize RAO risk. A large-scale, international, randomized trial comparing RAO with TRA and DRA is lacking.ObjectivesThe aim of this study was to assess the superiority of DRA compared with conventional TRA with respect to forearm RAO.MethodsDISCO RADIAL (Distal vs Conventional Radial Access) was an international, multicenter, randomized controlled trial in which patients with indications for percutaneous coronary procedure using a 6-F Slender sheath were randomized to DRA or TRA with systematic implementation of best practices to reduce RAO. The primary endpoint was the incidence of forearm RAO assessed by vascular ultrasound at discharge. Secondary endpoints include crossover, hemostasis time, and access site–related complications.ResultsOverall, 657 patients underwent TRA, and 650 patients underwent DRA. Forearm RAO did not differ between groups (0.91% vs 0.31%; P = 0.29). Patent hemostasis was achieved in 94.4% of TRA patients. Crossover rates were higher with DRA (3.5% vs 7.4%; P = 0.002), and median hemostasis time was shorter (180 vs 153 minutes; P < 0.001). Radial artery spasm occurred more with DRA (2.7% vs 5.4%; P = 0.015). Overall bleeding events and vascular complications did not differ between groups.ConclusionsWith the implementation of a rigorous hemostasis protocol, DRA and TRA have equally low RAO rates. DRA is associated with a higher crossover rate but a shorter hemostasis time.     

Primary and Secondary Vascular Access Site Complications Associated With Percutaneous Coronary Intervention: Insights From the BMC2 Registry

ObjectivesThis study sought to describe the association between trends in primary and secondary vascular access sites and vascular access site complications (VASCs) among patients who underwent percutaneous coronary intervention (PCI) in Michigan.BackgroundThe frequency of transradial PCI has increased. As a result, there is concern that operators may lose femoral-access proficiency resulting in a paradoxical increase in PCI complications. Anecdotally, an increase in secondary access use during PCI has also been observed.MethodsData from the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry was queried to evaluate the use of transradial and transfemoral PCI and their associated VASCs.ResultsFrom 2013 to 2017, transradial PCI increased from 25.9% to 45.2% and the overall use of secondary vascular access increased from 4.9% to 8.7% with minimal change in overall VASCs (1.2% to 1.4%). The use of secondary vascular access was associated with increased VASCs (odds ratio [OR]: 5.82; 95% confidence interval [CI]: 5.26 to 6.43). Although, patients treated by operators in the highest tertile of radial use were more likely to experience femoral VASCs (adjusted OR: 1.51; 95% CI: 1.08 to 2.13), treatment by these operators was associated with an overall reduction in all VASCs (adjusted OR: 0.62; 95% CI: 0.46 to 0.83).ConclusionsDespite increased use of transradial PCI, there has been no significant decrease in VASCs. This is in part attributable to an increased incidence of femoral VASCs and increasing use of secondary vascular access. An overall reduction in VASCs was observed in the highest radial use operators. Further strategies are needed to reduce VASCs in the transradial era.     

Bleeding Complications in Acute Coronary Syndromes and Percutaneous Coronary Intervention: Predictors,Prognostic Significance,and Paradigms for Reducing Risk

In clinical trials up to 30% of patients with acute coronary syndromes (ACS) or undergoing percutaneous coronary intervention (PCI) experience bleeding complications, and even higher rates have been reported in contemporary practice. A growing body of data suggests a strong correlation between bleeding and both short‐ and long‐term adverse outcomes, including mortality, which is independent of baseline characteristics and remains evident in most trials, despite variations in the definition of major bleeding. Although the value of antithrombin and antiplatelet therapy in reducing the risk of ischemic events is well established, the mechanisms of action that confer the benefits of these therapies have an inherent tendency to increase the risk of bleeding complications. As a result, characterization of baseline hemorrhagic risk is critical and must be accomplished before selecting an antithrombotic therapy. Risk factors for bleeding may be divided into two categories: nonmodifiable (including age, gender, race, weight, renal insufficiency, anemia, and acuity of presentation) and modifiable (including choice of antithrombotic therapy and PCI procedural characteristics). Of these predictive factors, the choice, dosage, and duration of the antithrombin and/or antiplatelet regimen are perhaps the most readily modifiable, especially in patients with an increased risk of bleeding. This review explores the nature of the association between bleeding and adverse outcomes, including mortality; evaluates risk factors for bleeding; and examines mechanisms for reducing bleeding complications through the selection of appropriate antithrombotic therapy. Copyright © 2007 Wiley Periodicals, Inc.     

Sex Differences in Acute Bleeding and Vascular Complications Following Percutaneous Coronary Intervention Between 2003 and 2016: Trends From the Dartmouth Dynamic Registry

BackgroundWomen 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.MethodsWe 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.ResultsWe 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.ConclusionsThe 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.     

Cerebral Infarcts After Coronary Angiography and Percutaneous Coronary Intervention: A Prospective Propensity-Score-Adjusted Comparison of Right Radial,Left Radial,and Femoral Approaches

BackgroundNew cerebral infarcts (CIs) detected at magnetic resonance imaging (MRI) are reported after cardiac procedures. Clinical and procedural aspects are implicated as potential causal factors. The aim of this study was to evaluate the incidence of new CIs after coronary angiography and percutaneous coronary intervention according to the arterial access site.Methods180 patients undergoing elective coronary angiography were studied with cerebral MRI the day before and the day after the procedure. Unadjusted and propensity score (PS) analyses were performed comparing the occurrence of CIs in right radial (RR), left radial (LR) and transfemoral (TF) access groups.ResultsNew CIs were observed in 14 patients (7.8% of the total sample, one with neurological sequelae). CIs were detected in 15.5% vs 4.9% vs 3.3% of RR, LR and TF groups, respectively (p = .026). In PS adjusted analyses, the RR approach was associated with more CIs compared with the TF approach (odds ratio [OR] estimate from logistic regression adjusted by PS quartiles: 0.158; 95% confidence interval: 0.031 to 0.814; p = .027) and the LR approach (OR: 0.266; 95% confidence interval: 0.066 to 1.080; p = .064). In a secondary analysis, a comparison of RR vs non-RR approach (TF + LR) was performed, showing that post-procedural CIs were more frequent in the RR group (OR: 0.170; 95% confidence interval: 0.050 to 0.574; p = .004).ConclusionsOur study suggests that the RR approach may be associated with a higher rate of new CIs after coronary angiography compared with LR and TF approaches.     

Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery Stenosis: A Systematic Review and Meta-Analysis

IntroductionPCI of ULMS is frequently performed through TFA because of technical complexity and safety concern. Studies have shown comparable efficacy and safety of TRA versus TFA, however, these studies are few in number. We intended to compare the clinical outcomes between transradial access (TRA) and transfemoral access (TFA) in patients undergoing percutaneous coronary intervention (PCI) for unprotected left main coronary artery stenosis (ULMS) by performing a meta-analysis.MethodA systematic search of database, including, PubMed, Web of Science, Google scholar and Cochrane Database were performed by two independent reviewers. Studies were included comparing “TRA” versus “TFA” in patients undergoing PCI in ULMS. The primary outcome was a procedural success rate. Secondary outcomes were major bleeding, access site complications, in-hospital and long term: major adverse cardiac events (MACE), myocardial infarction (MI) and cardiovascular mortality.ResultsEight studies were included in the analysis. The procedural success rate was 97.3% and there was no statistically significant difference between TRA and TFA groups (OR, 1.41 [CI 0.64, 3.12], I² = 26%). The rates of access site complications (OR, 0.17 [CI 0.07, 0.41], I² = 16%), major bleeding (OR, 0.39 [CI 0.17, 0.86], I² = 0%) and all-cause mortality (OR, 0.28 [CI 0.12, 0.64], I² = 0%) were lower in the TRA group. There were no significant differences in in-hospital and long term cardiovascular mortality, MI and MACE between the two groups.ConclusionIn contrast to TFA, TRA is associated with reduced bleeding and access site complications, with similar procedural success rate in patients undergoing PCI of ULMS.     

经皮冠状动脉介入治疗术后出血的预防策略

对于急性冠状动脉综合征(ACS)或接受经皮冠状动脉介入治疗(PCI)的患者,出血问题备受关注。但目前临床医生往往重缺血、轻出血,出血的定义和标准也不统一,为此,美国和欧洲的学术组织、美国食品药品监督管理局(FDA)和出血学术研究会(BARC)共同推荐使用BARC出血标准定义[1]。此后,欧美几乎同时发表共识,重申应关注ACS或PCI患者出血问题[2]。这几份声明均强调了临床应重视出血风险,尽可能避免出血,包括对穿刺部位的管理和用药问题。