Comparison of arterial closure devices in antegrade and retrograde punctures.

PURPOSE: To compare the efficacy, primary failure rates, and complications for the Angio-Seal and Perclose closure devices in antegrade and retrograde common femoral artery (CFA) punctures during peripheral angioplasty procedures. METHODS: A retrospective single-center analysis was conducted between April 2002 and June 2006 of all patients who had a CFA puncture and no other intervention planned during the same admission. Patients undergoing thrombolysis were excluded. Of 215 punctures in 191 patients, 123 closures in 97 patients (82 men; mean age 69.5 +/-10.4 years, range 41-93) were eligible for analysis. Of these, 49 punctures were antegrade and 74 were retrograde. An Angio-Seal device was used in 40 closures, while 83 punctures were closed with a Perclose device. Deployment outcomes and complications were compared between devices for each puncture direction and between antegrade and retrograde punctures. RESULTS: Seventy-eight (63.4%) of the 123 closures reached the primary endpoint of complication-free progress to discharge, comprising 30 (61.2%) of the 49 antegrade closures and 48 (64.9%) of the 74 retrograde closures. There was no significant difference between the devices for the primary endpoint. Twenty-two (17.9%) attempted closures failed. Forty-one (33.3%) closures had a complication after the procedure, but none required further intervention. In antegrade closures, Angio-Seal had a significantly lower rate of primary failure (11.1% versus 38.7% for Perclose, p = 0.038). Antegrade closures had a higher rate of primary failure (p<0.01); however, this did not translate into any significant differences in postprocedural complications. No significant differences in primary failure or complication rates were found between the devices when used in retrograde punctures. CONCLUSION: Angio-Seal had a lower rate of primary failure than Perclose in antegrade puncture closures. We believe this reinforces the need for larger studies to compare closure devices in antegrade punctures.     

Retrograde recanalization of chronic total occlusions from the transradial approach; Early canadian experience

Background : Retrograde approach for chronic total occlusions (CTO) improves recanalization success rates. Eight French (Fr) catheters and the femoral approach are advocated. Objectives : Evaluate whether transradial operators can achieve similar success rates using smaller catheters. Methods : This is a single‐operator series of 42 consecutive cases performed between January and December 2010, including 13 while demonstrating CTO recanalization. Patients were referred because of complexity of the CTO or after failed attempt. Results : Most frequent indications for recanalization were CCS 3–4 angina (52%) and CCS 1–2 in 21%. Eighteen (43%) patients underwent previous failed attempts. CTO was in the right coronary in 74%, left anterior descending in 24%, and a left main in 1. Most lesions (88%) were ≥20 mm long and 52% were calcified. We used septal collateral channels (CC) in 33 (79%), epicardial CC in 8 (20%), and a saphenous vein graft in one case. Radial access was used in all patients and was bilateral in 37 (88%). Five cases required one radial and one femoral access. Six French guides were used in 91% for the retrograde side and 71% for the antegrade side. Otherwise, 7 Fr guides were used. The Corsair® was used in 38 (90%). Procedural success was achieved in 37 (88%), mostly using reverse controlled antegrade–retrograde tracking (60%) or retrograde crossing (29%). The average <24‐h Hb drop was 0.75 ± 0.84 g/dl. No in‐hospital major cardiac events occurred. Conclusion : Transradial retrograde CTO recanalization is feasible, safe, and still associated with high success rates despite the use of smaller guide catheters. © 2011 Wiley‐Liss, Inc.     

Magnetic navigation in left-sided AV reentrant tachycardias: preliminary results of a retrograde approach

Introduction: A novel magnetic navigation system allows remote guidance of floppy radiofrequency (RF) ablation catheters. We evaluated the feasibility of mapping and ablation of left-sided accessory pathways (APs) using the retrograde transaortic approach with this system. This might open the gate to retrograde ablation of left atrial arrhythmias.
Methods and Results: Twenty consecutive patients were included. A Helios II was used in five and in 15 a Celsius RMT RF catheter with higher magnetic mass and different flexibility was used. Mapping and ablation were attempted. The learning curve was analyzed. Ablation was acutely successful in 60% of the patients using the Helios II and in 80% using the Celsius RMT. Median procedure time was 158 minutes, with median patient and physician fluoroscopy times of 26 and 4 minutes. In the last 10 patients, procedure times became significantly shorter (median 122 minutes, only Celsius RMT catheters) and standard catheters had to be used only twice. No complications occurred.
Conclusions: Remote retrograde transaortic RF ablation of left-sided APs is feasible, safe, and reduces the physician's fluoroscopy exposure. There is a very steep initial learning curve, with the success rate increasing from 50% in the first 10 cases to 80% in the last 10 cases. Different catheter configurations may influence the outcome.     

Intracoronary autologous bone marrow cell transplantation beneficially modulates heart rate variability

Antegrade femoral artery access is commonly used for percutaneous transluminal revascularization of ipsilateral lower limbs in patients with critical limb ischemia. While hemostasis at the end of the procedure can be achieved by manual compression, this may lead to an increase in local vascular complications. Femoral artery closure devices, such as the Angioseal collagen plug and anchor device, have been approved and shown of benefit after retrograde femoral artery catheterization. To date, there are however no data on the use of such arteriotomy closure device after antegrade femoral access. We hereby report a case series of five patients in whom Angioseal was successfully used after antegrade femoral puncture and below-the-knee percutaneous transluminal angioplasty. In all cases the device enabled immediate and complete hemostasis without major complications, despite the intense antithrombotic regimen, including heparin, aspirin, and clopidogrel in all patients, as well as glycoprotein IIb/IIIa inhibitors (in two patients) and fibrinolytic therapy (in one).     

Dual vascular access for critical limb ischemia: Immediate and follow‐up results

Purpose : To describe a procedural technique involving a combined antegrade femoral and retrograde tibial approach for treatment of complex popliteal and infrapopliteal occlusions, and to determine the safety and efficacy of this technique. Materials and Methods : From May 2008 to March 2010, seven patients presenting with critical limb ischemia received dual vascular access intervention in this institution. Five legs were treated via the retrograde tibial approach after failure of antegrade intervention. A dual access approach was planned and adopted in another two legs. The target vessels were located at popliteal or infrapopliteal arteries. Results : We successfully gained all retrograde tibial access sites and achieved 100% procedural success and immediate hemodynamic improvement. Five legs required stent implantation to optimize the procedural results. No major complication occurred at the tibial access site. During the follow‐up period (11.3 ± 7.2, range 3–23 months), no patients required any major amputation; only one patient underwent a mid‐foot amputation. The target vessel revascularization rate at 3 and 6 months was 0 and 28.6%, respectively. Conclusion : Dual vascular access was successfully used in a small number of selected patients and this technique may hold promise in improving the success rates in the treatment of complex popliteal and infrapopliteal occlusions. © 2011 Wiley‐Liss, Inc.     

Radial approach and single wiring as first intentional strategies in chronic total occlusions of the left anterior descending coronary artery

BackgroundPercutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of the left anterior descending coronary artery (LAD) specifically is associated with improved long-term 5 years survival as compared to PCI failure. Simpler PCI techniques may be successful and safer than complex techniques which are perceived to have high failure rates and technical complexity.We aimed to describe the safety and effectiveness of first intentional single wiring and radial approach in the treatment of patients with a CTO of the native LAD coronary artery at Toulouse Rangueil university hospitals.Patients and methodsThe study was a single center prospective registry. All patients showed evidence of myocardial viability in LAD territory. The operators’ initial strategy was to start by a radial access as a first choice whenever feasible; if not, a femoral access was chosen. The initial strategy for lesion crossing in either antegrade or retrograde approaches was single wiring by lesion crossing using one guidewire (GW) as a simple technique.ResultsA total of 30 patients with 30 LAD CTO lesions (100%) were recorded. Mean age was 71.6 + 15 years, 77% were males and 23% were females. The access route was radial 66% of the time and femoral 54% of the time and with double access for contralateral injection in 40% of the patients. Sheaths and catheters sizes 6F were used in 53% of the patients, and 7F in 73% of the patients.Overall lesion success rate was 83% of lesions. Single wiring was the prevailing technique used in 97% of successful lesions (83% of total cases), while only 3% were by multiple wiring techniques. Successful single antegrade wiring represented 63% of our total study cases with a GW success rate of 92% of cases. Successful single retrograde wiring represented 13% of our cases with a GW success rate of 67%. Q-wave myocardial infarction (MI), stent thrombosis, stroke, emergency coronary artery bypass graft (CABG), major bleeding, radiation dermatitis, cardiac tamponade or clinical perforation requiring any hemostatic maneuvers did not occur. There was a post-procedural Troponin rise of 3x normal levels in 30% of patients, and contrast induced nephropathy in 7%. Intra-aortic balloon counterpulsation (IABCP) was used in 3% of patients and cardiac death occurred in 3% of patients.ConclusionSingle wiring and radial access as initial strategies in PCI for LAD-CTO lesions in either approaches antegrade or retrograde are associated with a high procedural success rate and an acceptable incidences of adverse events.     

An Alternative Treatment of Stump Occlusion of the Superficial Femoral Artery with Percutaneous Direct Puncture Followed by Antegrade Recanalization

IntroductionThe purpose of the study was to evaluate the efficacy and safety of the “percutaneous direct puncture of occluded superficial femoral artery (SFA)” technique for recanalization of SFA, after failure of antegrade recanalization in patients with limited access to retrograde popliteal and crural arteries.Material and methodsBetween April 2014 and November 2017, 10 patients with CLI (Critical limb ischemia) underwent endovascular recanalization with direct percutaneous puncture of occluded SFA after failed antegrade recanalization. All patients had a long segment (39,9 ± 2.8 cm) occluded SFA without stump causing failed antegrade recanalization with a cannulated guidewire in the SFA origin. After unsuccessful attempts with the antegrade approach, the retrograde direct puncture technique of the occluded SFA was performed and followed by antegrade recanalization. Patients were followed up clinically with Doppler ultrasonography and according to the Rutherford scale at 1, 3, 6 and 12 months after discharge.ResultsTechnical success was achieved in 8/10 patients (80%).The mean follow-up period was 25,1 ± 9,6 months. One patient underwent major amputation, resulting in 90% limb salvage rate at 12 and 24 months. Amputation-free survival estimated by Kaplan-Meier analysis was 60% at 12 and 24 months. Primary patency rates were 62.5% at 12 and 24 months and secondary patency rates were 87.5% at 12 and 24 months.ConclusionTreatment of SFA occlusions without a stump in CLI patients via the percutaneous direct puncture of occluded SFA approach improved technical success and clinical recovery, especially in cases unsuitable for conventional antegrade and retrograde approaches.     

Endovascular treatment of femoro-popliteal occlusions with retrograde tibial access after failure of the antegrade approach

Background

Despite the development in endovascular technologies and the introduction of new tools in clinical practice, the endovascular crossing of femoropopliteal occlusions is not always possible with the antegrade approach, with a failure rate that can be up to 20%. This study aims to assess the feasibility, safety, and efficacy in terms of acute outcome of the endovascular retrograde crossing of femoro-popliteal occlusions with tibial access.

Methods

This study is a single-centre, retrospective analysis of prospectively collected data of 152 consecutive patients, who had undergone, from September 2015 to September 2022, endovascular treatment of femoro-popliteal arterial occlusions with retrograde tibial access after the failure of the antegrade approach.

Results

The median lesion length was 25 cm and 66 patients (43.4%) had a calcium grading according to the peripheral arterial calcium scoring system of 4. Angiographically, 44.7% of the lesions were TASC II category D. In all cases, successful cannulation and sheath introduction were performed with an average cannulation time of 150.4 s. Femoropopliteal occlusions were successfully crossed with the retrograde route in 94.1% of cases; the intimal approach was performed in 114 patients (79.7%). The mean time from puncture to retrograde crossing was 20.5 min. Acute vascular access-site complications were noted in 7 (4.6%) patients. Thirty-day major adverse cardiovascular events rate and 30-day major adverse limb events rate of 3.3% and 2%, respectively, were observed.

Conclusions

The results of our study indicate that retrograde crossing of femoro-popliteal occlusions with tibial access is a feasible, effective, and safe approach in case of failed antegrade approach. The results presented represent one of the largest investigations ever published on tibial retrograde access and contribute to the small body of literature present on this topic to date.     

Access and closure of the left ventricular apex: state of play

Calcific aortic stenosis is the most frequent manifestation of valvular heart disease. The preferred treatment for patients of all age groups is surgical aortic valve replacement. Recently, transcatheter aortic valve implantation (TAVI) has become the standard of care for patients that are deemed to be at high risk for open heart surgery. The most common access route for TAVI is the retrograde transfemoral (TF) approach, followed by the antegrade transapical (TA) approach. Both access routes have distinct indications. While the TF route is least invasive and the access of choice at most centers, the apical route is used complementary in patients with poor femoral access. In addition, the TA approach holds various benefits such as a short distance from the operator to the annulus facilitating exact positioning of the valve and the possibility to accommodate larger sheaths. Furthermore, the TA approach not only provides direct access to the aortic valve but also the mitral valve allowing for a wide range of interventions. Various apical closure devices are currently being developed under the premise of increasing overall safety of the TA-TAVI approach by further standardizing the procedure, alleviating left ventricular access and minimizing the risk of complications, such as apical bleeding. The aim of this article is to give an overview of current devices for apical closure. The ideal apical closure device should be easy to put in place, leave a minimum of foreign material, provide complete hemostasis and have a minimal risk of displacement. So far the range of commercially available devices in Europe is very limited with only one CE-certified device on the market and one device that is expected to receive CE-certification soon. Off-the-shelf closure devices could help flatten the initial operator learning curve and facilitate a safe apical access, ultimately leading to an entirely percutaneous TA-TAVI approach.     

Success rate of retrograde double-balloon enteroscopy

BACKGROUND: Retrograde double-balloon enteroscopy (rDBE) is technically a different procedure from its antegrade counterpart. Its unique indications, success rate, and learning curve have not been specifically reported. OBJECTIVE: To examine technical issues specific to the rDBE approach. DESIGN: Retrospective review. SETTING: Single tertiary-care center. PATIENTS: All patients referred for rDBE. MAIN OUTCOME MEASUREMENTS: Procedure duration, technical success, learning curve, and complications related to rDBE. RESULTS: A total of 59 rDBEs were performed on 56 patients for obscure GI bleeding (46.4%), metastatic carcinoids (23.2%), Crohn's disease (14.3%), and other indications. rDBE enabled a diagnosis in 47.5% of procedures and had a 38% diagnostic rate in finding primary small-bowel lesions that were responsible for metastatic carcinoids. The mean (standard deviation) total procedure time was 111.3 +/- 39.9 minutes. Procedure failure occurred in 12 cases (21%), which is significantly more than reported with antegrade procedures (2%). Failure was more common among patients with a prior abdominal or pelvic surgery (P = .001), and the time to achieve a stable ileal intubation was prolonged in these patients (13.9 vs 38.1 minutes; P = .0006). A trend was noted toward successful small-bowel access and increased lengths of small bowel examined after 20 procedures were performed. LIMITATIONS: Small retrospective study. CONCLUSIONS: rDBE is effective for the evaluation and the treatment of lower small-intestinal lesions; however, maintaining access through the ileocecal valve may be difficult. Prior surgery may be an important factor associated with failure. A minimum of 20 rDBE procedures was needed to minimize procedure failure, examine a substantial segment of the small-bowel, and shorten procedure duration.     

Retrograde approach for complex popliteal and tibioperoneal occlusions

Purpose: To describe the technical aspects of the retrograde approach for endovascular treatment of complex popliteal and/or tibioperoneal occlusions and determine its efficacy in minimizing failure rates. Methods: An observational registry of retrograde revascularizations was maintained at our institution over 14 months (September 2006 to December 2007). During this time frame, antegrade revascularization failed in 62 (17.8%) of 343 limbs with complex total occlusions of the popliteal and/or infrapopliteal vascular territory. Of these antegrade failures, 51 (82.2%) limbs in 51 patients (32 men; mean age 72+/-8 years) were suitable for a retrograde attempt. From this subgroup, 45 (88.2%) were treated via a percutaneous transpedal access site and 6 (11.8%) via a transcollateral intra-arterial technique. Results: The overall success rate was 86.3% (44/51); adjunctive stenting was needed in 21 (41.1%) to optimize results. Only 1 (1.9%) major complication (a pedal access site occlusion) and 4 (7.8%) minor sequelae (arterial perforation in 3 and a pedal hematoma without consequence) were documented. Conclusion: In complex popliteal to infrapopliteal occlusions, an antegrade recanalization attempt can fail in up to 20% of the cases. The additional use of a retrograde approach seems feasible and safe and can favorably modify this failure rate. This technique could be valuable for patients with critical limb ischemia due to popliteal and infrapopliteal occlusions once larger studies with follow-up confirm safety, efficacy, and clinical benefit.     

Rapid cycle change to predominantly radial access coronary angiography and percutaneous coronary intervention

Objectives : This study sought to evaluate the safety and feasibility of all operators at a single center changing from predominantly femoral to radial access for coronary percutaneous procedures. Background : The radial artery is currently regarded as a useful vascular access site for coronary angiography and percutaneous coronary intervention (PCI). The reduction in local vascular access complications is thought to be a major advantage of the radial route. Despite this, the technique is used less frequently possibly reflecting concerns by cardiologists about the feasibility of using radial access as a preferred option. Methods : A retrospective study of 1004 consecutive patients who underwent coronary angiography with or without PCI was analyzed. Procedure details and clinical outcomes were assessed according to the radial or femoral approaches. Results : The success rate for cardiac catheterization via the radial approach was 97.4% (815/837) and the femoral approach was 98.8% (165/167). The procedural failure rate for radial access was not different from the femoral route [2.6% vs. 1.2%; odds ratio (OR), 2.26; 95% confidence interval (CI), 0.53–9.71; P = 0.41]. Major access site complications occurred in 0.25% patients in the radial group compared with 4.8% patients in the femoral group [OR, 0.05 (95% CI, 0.01–0.23); P < 0.0001]. Conclusions : The radial approach has a high rate of success and is associated with fewer major local vascular access site complications than the femoral route. These results can be achieved early in the operator learning curve of low to medium volume operators. © 2011 Wiley Periodicals, Inc.     

Safety and effectiveness of sirolimus-eluting stent implantation for in-stent restenosis of the unprotected left main coronary artery

Given their suboptimal success rates, coronary chronic total occlusions (CTO) represent one of the last challenges of percutaneous coronary intervention (PCI). Among several novel techniques, the retrograde approach is one of the most promising, but it is still incompletely described. We report our 5-year experience in retrograde PCI for CTOs. We abstracted patient and procedural data on all cases with attempted retrograde approach. End-points were technical and procedural success, plus long-term major adverse cardiovascular events (MACE). The retrograde approach was used in 17 patients, with procedural success in 12 (71%), including 9 CTOs of right coronary, 2 of left circumflex, and 2 of left main arteries. Conversely, 4 cases of technical failure and 1 post-procedural myocardial infarction in an otherwise angiographically successful procedure were found. Causes of retrograde failure were: inability to deliver the balloon through the chosen collateral in 2 cases, inability to retrogradely cross the distal stump with the wire in 1 case, and interruption of the procedure due to rupture of a minor septal collateral branch during attempts at advancing the non-inflated balloon in 1 case. In all patients with retrograde failure, subsequent antegrade attempts could be carried out, with ultimate success in everybody. Follow-up at 24+/-21 months showed an overall MACE rate of 23%. In conclusion, the retrograde approach appears feasible and safe, and its application can be envisioned as a promising alternative strategy in selected patients in whom antegrade approaches fail or are deemed unsafe.     

The safety and feasibility of bilateral radial approach in chronic total occlusion percutaneous coronary intervention

Few studies have reported results for transradial (TR) percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) lesions. The purpose of this study was to evaluate the feasibility and safety of bilateral radial PCI for CTO lesions.Eighty-five consecutive patients with CTO lesions received PCI via a bilateral TR approach. A high radial artery puncture (10-15 cm above styloid process) accommodating a 7 Fr catheter (85 cm long) was used for a retrograde approach, and a 6 Fr catheter was used in the other radial artery for an antegrade approach. Retrograde wiring was conducted primarily or after failure of antegrade wiring. Mean duration of CTO was 42.8 ± 54.9 months. Vessels with occlusions attempted were the left anterior descending artery (40.0%; 34/85), right coronary artery (58.8%; 50/85), and left circumflex artery (1/85). PCI re-attempts were made in 41.2% of the cases. The overall success rate was 87.1%. Retrograde wiring was successful in 61/85 cases (71.8%), via septal collaterals followed by epicardial collaterals and saphenous vein graft. There were no major complications (30 day in-hospital death, Q wave myocardial infarction, or emergency bypass surgery), or serious access site complications.For experienced TR-PCI operators who are already doing complex TR coronary interventions, the bilateral radial approach for CTO lesions appears feasible and safe.     

Efficiency,Safety, and Long‐Term Follow‐up of Retrograde Approach for CTO Recanalization: Initial (Belgrade) Experience with International Proctorship

Background: Retrograde approach increases the success rate for percutaneous recanalization of complex chronic total occlusion (CTO) of coronary arteries. Objectives: The purpose of this study was to describe our initial experience of retrograde percutaneous coronary intervention for CTO program, focusing on its safety and feasibility, and long‐term clinical follow‐up. Methods: The study was a single center retrospective registry which included a total of 40 patients, of 590 CTO treated patients (6.7%), between January 2008 and October 2011, who underwent retrograde approach for CTO recanalization. Results: Mean occlusion duration was 37.8 ± 40.3 months. Overall success recanalization rate was 87.5% (35/40). Septal collaterals were used to access the occlusion in all cases (100%). Retrograde guidewire crossing of collateral channels was successful in 36/40 (90.0%) patients with success rate of CTO recanalization in these patients of 97.2%. Retrograde approach as the primary strategy was applied in 23/40 (57.5%) patients, retrograde approach immediately after antegrade failure attempt was performed in 8/40 (20.0%) patients, and retrograde approach as elective procedure, after previously failed antegrade attempt, was performed in 9/40 (22.5%) patients. The success rate of these strategies was: 87.0% (20/23 patients) for primary, 87.5% (7/8 patients) for retrograde immediately after antegrade failure, and 88.9% (8/9 patients) for retrograde after previous failed antegrade attempt, respectively. Total in‐hospital major adverse cardiac events (MACE) rate was 5.0% (2 non‐Q‐wave myocardial infarctions). The MACE free survival at median follow‐up of 20 months was 89% (95% CI: 78–100%). Conclusions: This study has demonstrated that adequate training and international proctorship for this complex and demanding technique is a necessity and prerequisite to achieve high overall success rates, with acceptable complication rates and excellent long‐term survival rate. (J Interven Cardiol 2012;25:540–548).     

Complications with femoral access in cardiac cathetization. Impact of previous systematic femoral angiography and hemostasis with VasoSeal-ES collagen plug

INTRODUCTION AND OBJECTIVES: Most cardiac catheterizations are performed via femoral artery access, and hemostatic devices are commonly used. We evaluate the relationship between the strategy used for femoral arteriography and the use of VasoSeal-ES, and local vascular complications. PATIENTS AND METHOD: Prospective study of 540 consecutive catheterizations with systematic femoral artery and sheath angiography. VasoSeal-ES was used in 427 patients. Predictors of local vascular complications such as patient-related factors, anatomy and hemostasis were analyzed. Variables related to failure of the collagen plug were also studied. RESULTS: Punctures of the common femoral artery occurred in 35.9% of all patients (16% in the deep femoral artery and its ostium). Spasm was evident in 18% (ranging from 58.1% in the deep femoral artery to 5.2% in the common femoral artery). Puncture at the site of ramification was seen in 11.3%. Angiographically significant atheroma was seen in 17.8%. The femoral head was a valid landmark for the common femoral artery in only 63.9% of the pateints. Risk factors for local vascular complications were punctures of the common femoral artery, female sex and failure of VasoSeal-ES to achieve hemostasis (15.8% in the first two months of use, 5.2% in the last months of the study). Complications involving superficial and deep femoral arteries occurred in 6.7% and 1.2% of the patients, respectively, in contrast to 0.6% involving the common femoral artery. Variables related to collagen plug failure were patient-related factors, weight less than 55 kg, operator-related factors and the learning curve. CONCLUSIONS: Systematic femoral angiography provides data that aids the choice of the best hemostasis procedure to reduce local vascular complications. Punctures of the common femoral artery were more frequent than expected, and were associated with a higher complication rate. VasoSeal-ES is a safe and useful method of hemostasis, and its infrequent failures were associated with high complication rates that were substantially reduced with experience.     

Combined radial‐tibial access strategy and radial‐tibial reverse CART in a patient with aortobifemoral graft and complex superficial femoral artery occlusion

We present the case of a patient with a history of aortobifemoral grafting who presented with left lower extremity ischemic rest pain. Aortofemoral angiography was performed through a left radial access and showed a long, calcified total occlusion of the left superficial femoral artery (SFA) and a subtotal popliteal occlusion. The popliteal artery and SFA were crossed retrogradely through a 4‐Fr anterior tibial access; the retrograde devices went subintimally and did not reenter at the common femoral level. Subsequently, the radial access was used for antegrade subintimal crossing and dilatation of the SFA, which allowed reentry of the retrograde devices (radial‐tibial reverse controlled antegrade‐retrograde tracking [CART]). The SFA was then successfully treated retrogradely with orbital atherectomy and drug‐coated balloon angioplasty, through a 4‐Fr equivalent tibial sheath. © 2017 Wiley Periodicals, Inc.     

Predictors of complications and learning curve using the Angio-Seal closure device following interventional and diagnostic catheterization.

A retrospective study was conducted to determine the frequency and nature of groin complications when the Angio-Seal device was used on 252 occasions by one operator immediately following interventional (66%) and diagnostic (34%) procedures. Sixty-nine percent of the 238 successfully deployed cases received ticlopidine or clopidogrel, 16% received abciximab, and 15% received heparin postprocedure. Complications included vascular surgery for collagen plug perforation into the femoral artery (0.8%), failure to deploy (5.6%), pseudoaneurysm (0.4%), brisk, visible bleeding (9%), persistent ooze (14%), hematoma > 6 cm (0.8%), hematoma 1 cm(2) (10%). Multivariate analysis identified diagnostic cases (6 Fr sheaths) to be associated with a reduced risk of complications [odds ratio (OR) 0.1] while interventional procedures (8 Fr sheaths), postprocedure heparin, and body mass index (BMI) < 28 (OR 10.1, 3.2, and 2.8, respectively) were associated with increased risk. Gender, age, ticlopidine, clopidogrel, and abciximab were not independent predictors of complications. A learning curve for device deployment was observed in the first 50 cases (14% nondeployment vs. 3.5% for the subsequent 202 procedures, P = 0.009) and failure to deploy was independent of sheath size used. Angio-Seal can be used with reasonable safety and efficacy immediately after diagnostic and interventional procedures. Cathet. Cardiovasc. Intervent. 48:162-166, 1999.     

Feasibility of complex coronary and peripheral interventions by trans‐radial approach using large sheaths

Background : Trans‐radial approach (TRA) reduces vascular access‐site complications but has some technical limitations. Usually, TRA procedures are performed using 5 Fr or 6 Fr sheaths, whereas complex interventions requiring larger sheaths are approached by trans‐femoral access. Methods : During 4 years, at two Institutions with high TRA use, we have attempted to perform selected complex coronary or peripheral interventions by TRA using sheaths larger than 6 Fr. Clinical and procedural data were prospectively collected. Attempt to place a 7 Fr or 8 Fr sheath (according to the planned strategy of the procedure) was performed after 5–6 Fr sheath insertion, administration of intra‐arterial nitrates and radial artery angiography. Late (>3 months) patency of the radial artery was checked (by angiography in the case of repeated procedures or by palpation + reverse Allen test). Results : We collected 60 patients in which TRA large sheath insertion was attempted. The large sheath (87% 7 Fr, 13% 8 Fr) was successfully placed in all cases. Most of the procedures were complex coronary interventions (bifurcated or highly thrombotic or calcific chronic total occlusive lesions), whereas 8.3% were carotid interventions. Procedural success rate was 98.3% (1 failure to reopen a chronic total occlusion). No access‐site related complication occurred. In 57 (95%) patients, late radial artery patency was assessed and showed patency in 90% of the cases, the remaining patients having asymptomatic collateralized occlusion. Conclusions : In selected patients, complex percutaneous interventions requiring 7–8 Fr sheaths can be successfully performed by RA approach without access‐site clinical consequences. © 2011 Wiley Periodicals, Inc.     

Corsair microcatheter for retrograde coronary chronic total occlusion recanalization: Early experience outside the realm of dedicated recanalization specialists

ObjectiveTo determine the extent to which use of the Corsair microcatheter (CM, Asahi Intecc Co., Japan) improves procedural outcomes when an experienced operator who is not a dedicated recanalization specialist attempts retrograde chronic total occlusion (CTO) recanalization through collateral channels during percutaneous coronary intervention.BackgroundThe recently introduced CM has improved success rates of retrograde CTO recanalization to nearly 100% in the hands of dedicated coronary recanalization specialists; however, the impact the CM has on the results of non-specialist operators attempting retrograde CTO recanalization is not known.MethodsA non-specialist operator attempted CM-assisted recanalization in seven consecutive CTO cases requiring retrograde recanalization. The results obtained were compared with those achieved by the same operator in eleven consecutive retrograde CTO recanalization procedures during the last 2 years before the CM became available.ResultsCM-assisted retrograde CTO recanalization was successful in 6 of 7 cases (86%), but failed in one case attempted through a tortuous epicardial collateral; there were no complications. In contrast, during the 2 years before the CM became available, retrograde CTO recanalization was successful in only 3 of 11 attempted cases (27%), and was associated with significant morbidity. Lesions in the two groups were comparable in terms of technical difficulty and procedural risk.ConclusionsThe non-specialist operator's retrograde CTO recanalization results improve significantly when using the CM. Given the effectiveness and safety of CM-assisted retrograde CTO recanalization, operators should be less aggressive with anterograde recanalization attempts, and should switch to the retrograde approach earlier and more often.