Advertisement
Transradial Angiography: Coming to a Consensus

Transradial Angiography: Coming to a Consensus

Research indicates that the adoption of transradial angiography increased 10-fold between 2007 and 2011 in the United States. Randomized and observational studies have suggested that radial access reduces bleeding and vascular complication risks. Other studies have shown the approach reduces costs, increases patient satisfaction, and reduces mortality in some high-risk patients. 3 Major Recommendations To provide a guide to operators who are early in their adoption of radial procedures or are contemplating adoption, the Society for Cardiovascular Angiography and Intervention (SCAI) published a consensus statement in Catheterization and Cardiovascular Interventions. The document issued three major recommendations: 1. Preserve the radial artery and utilize practices that preserve radial artery patency. 2. Minimize patient and operator radiation exposure during radial procedures. 3. Transradial primary PCI for patients with STEMI should be performed only after sufficient experience is achieved in elective cases. “To monitor for and reduce the risk of radial artery occlusion, we recommend using adequate anticoagulation, the smallest profile equipment possible to minimize trauma to the radial artery and still obtain high-quality images, and non-occlusive hemostasis at the end of the procedure,” says Sunil V. Rao, MD, FSCAI, who served as lead author of the SCAI consensus statement (Table 1). “It’s important to keep enough pressure on the radial artery to obtain hemostasis but not so much that the antegrade flow is prevented.” The consensus statement also recommends that operators monitor for radial artery occlusions immediately after a radial procedure and during follow-up. SCAI recommends using ultrasound Doppler measurements or the reverse Barbeau test to accomplish this task. Radiation: Operator Considerations SCAI has published much information on reducing patient and...
Medical Simulation in Interventional Cardiology

Medical Simulation in Interventional Cardiology

Use of medical simulation has grown considerably over the past decade because it helps physicians overcome many training challenges, such as work-hour restrictions and the pace at which technology is evolving. According to John C. Messenger, MD, FSCAI, interventional cardiology is particularly well-suited for simulation. “These procedures are often complex,” he says. “The learning curves can be steep, and complications can be life-threatening. Simulation provides a safe arena to develop and refine skills that improve overall patient care. It’s especially helpful in interventional cardiology because of the field’s ever-changing technological and procedural environment.” A Call to Action In Catheterization and Cardiovascular Interventions, the Society for Cardiovascular Angiography and Interventions (SCAI) examined the current state of medical simulation in interventional cardiology. SCAI also issued recommendations for expanding and standardizing the use of this training technology by interventional cardiologists and fellows-in-training. “We need to increase use of medical simulation and accessibility to this training for highly complex procedures, such as structural heart interventions,” says Dr. Messenger, who chairs SCAI’s Simulation Committee. “Simulation can also improve training in areas where procedural volumes are low.” A key recommendation from SCAI is to integrate formal simulation programs into annual meetings and other training programs for fellows and practicing physicians. However, one of the major issues with integrating simulation is the high cost of simulators. “The key is for clinicians and simulation vendors to collaborate and find ways to alleviate the financial burden associated with simulation,” says Dr. Messenger. “Using simulation at annual meetings and establishing regional or central simulation centers could ease this burden.”   The key is for clinicians and simulation vendors to...
The Impact of Chronic Lung Disease in MI

The Impact of Chronic Lung Disease in MI

Chronic lung disease (CLD)—including COPD, chronic bronchitis, and emphysema—is common, presenting in approximately one in seven patients presenting with myocardial infarction (MI). Patients with CLD are more likely to die or be hospitalized from cardiovascular disease than from any other disease. Despite this knowledge, few studies have explored the influence of CLD on patient management and outcomes following MI. Gaining a better understanding of this relationship could lead to opportunities for improving quality of care and outcomes for CLD patients. Treatments & Mortality for Chronic Lung Disease In a study published in the American Heart Journal, my colleagues and I utilized the National Cardiovascular Data Registry to determine the association of CLD with treatments and adverse events after MI. Our results showed that CLD patients presenting with non-STEMI had a 20% increased risk for in-hospital death when compared with those who did not have CLD. No such link, however, was found among CLD patients with STEMI. In addition, CLD patients with non-STEMI were markedly less likely to receive invasive procedures, such as cardiac catheterization, PCI, or CABG surgery. They were also slightly less likely to receive evidence-based medical therapies, including thienopyridines, β-blockers, and statins. Conversely, differences in treatment of STEMI patients with CLD were not clinically significant, according to findings in our investigation. Taking a Closer Look at Bleeding Risks This is also the first study to our knowledge indicating that, independent of other factors, CLD patients had a 20% to 25% higher risk of bleeding when compared with those without CLD. Major bleeding is one of the most common in-hospital complications following acute coronary syndromes and is associated...

Revised Guidelines for Evidence-Based PCI

Over the last decade, significant advances and innovations have rapidly evolved in the use of PCI for patients with coronary artery disease (CAD). The American College of Cardiology (ACC)/American Heart Association (AHA), together with the Society for Cardiovascular Angiography and Interventions (SCAI), released a revised clinical guideline for the management of CAD patients undergoing PCI. Published in the December 6, 2011 Journal of the American College of Cardiology, the update emphasizes careful selection of CAD treatment and includes the most extensive section to date on revascularization. The Heart Team Concept for PCI and CABG “The heart team includes an interventional cardiologist and a cardiac surgeon who review patient history and anatomy, discuss whether PCI and/or CABG are appropriate, and explain these options in detail with patients before a treatment option is chosen,” says Glenn N. Levine, MD, who chaired the ACC/AHA/SCAI guideline writing committee. The guidelines include a Class I recommendation for utilizing a heart team approach in patients with unprotected left main CAD and/or complex CAD in cases where the optimal revascularization strategy is not straightforward. New Section on CAD Revascularization For the first time ever, the CAD revascularization section was developed through a collaboration that involved experts from the ACC, AHA, and SCAI on both PCI and CABG. According to the guidelines, CABG is recommended for improving survival in patients with significant left main coronary artery stenosis, as well as those with significant stenoses in three major coronary arteries or in the proximal left anterior descending artery and one other major coronary artery. CABG or PCI is recommended for survivors of sudden cardiac death with presumed ischemia-mediated...

Keys to Transradial Access for Percutaneous Revascularization

Although the adoption of radial coronary angiography and radial PCI in the United States lags behind that of other countries, particularly those in Europe and Asia, transradial coronary intervention has seen an 8% to 10% increased utilization in the U.S., a trend that is expected to continue. The Society for Cardiovascular Angiography and Interventions (SCAI) published an executive summary on transradial access (TRA) for coronary and peripheral procedures in the November 2011 issue of Catheterization and Cardiovascular Interventions. The overview examined utility, utilization, and training aspects to consider when performing angioplasty via the radial artery. “Historically, the traditional route to access blocked coronary arteries has been through the larger femoral artery,” says Ronald P. Caputo, MD, FACC, FSCAI, lead author of the SCAI paper. “TRA is advantageous to transfemoral access because it’s less invasive and has been shown to decrease the risk of access site complications and bleeding.” TRA also is preferred by the vast majority of patients because, unlike the transfemoral approach, it causes less discomfort and allows them to stand up and ambulate immediately following the procedure. In addition, some patients undergoing TRA procedures can be discharged the same day. “These advantages ultimately can decrease length of stay and reduce hospitalization costs while still improving clinical outcomes,” adds Dr. Caputo. Avoiding Complications in Transradial Access Appropriate patient selection for TRA is the first important step in a successful procedure, says Dr. Caputo. Ideal patients for TRA include those with a palpably large radial artery with a strong pulse and a normal Allen’s test with no history of an ipsilateral brachial procedure. Contraindications include abnormal Allen’s test, a...
[ HIDE/SHOW ]