The radial artery has been increasingly used for its favorable safety profile. However, no conclusive data are available on the optimal sheath size. In particular, it is seemingly difficult to weight both advantages and disadvantages of narrower versus larger sheaths size. Despite several studies were performed to compare the use of 6-Fr to the smaller 5-Fr sheaths, these were mostly small, single center-studies, yielding various results.We performed a comprehensive meta-analysis of all available studies comparing the use of 5-Fr versus 6-Fr sheaths in coronary procedures through the TRA.Studies comparing a 5-Fr versus a 6-Fr sheaths were searched for in PubMed, the Cochrane Library, and ISI Web of Knowledge databases.Studies were deemed eligible if they only included patients undergoing transradial cardiac catheterization with 5-Fr or 6-Fr system and reported at least one of these parameters: contrast dye volume, procedural success, procedural time, access complications, radial artery occlusion, and bleedings.Odds ratio (OR) and the mean difference (MD) were respectively used for dichotomous and continuous variables as summary measures. Both the random-effects model and the fixed effect models were used for computation of meta-analyses. Heterogeneity was assessed by means of the Cochrane Q test. Metaregression was calculated using the unrestricted maximal likelihood random effects model.The use of a 5-Fr system is associated with a significant lower contrast medium administration (MD = −22.20 [−36.43 to −7.96], P < 0.01) and significantly reduces bleedings (OR = 0.58 [0.38–0.90], P = 0.02), without compromising procedural success (OR = 0.95 [0.53–1.69], P = 0.86) or procedure length (OR = 0.55 [−2.58 to 3.69], P = 0.73), compared to the 6-Fr system. Despite no significant difference was observed between the groups (OR = 0.88 [0.50–1.56], P = 0.67), at metaregression RAO incidence in the 5-Fr group was increasingly lower as the percentage of women included into the study increased (P = 0.02).Some potentially interesting technical details, such as sheath length, hydrophilic coating, or periprocedural anticoagulation, were not homogeneously reported in individual studies.Results of the present meta-analysis confirm the excellent safety profile of transradial procedures both with 5-Fr and 6-Fr system. A 5-Fr system could be preferred in patients with a higher bleeding propensity or kidney injury.

Aims  The aim of this study was to determine the contemporary use of reperfusion therapy in the European Society of Cardiology (ESC) member and affiliated countries and adherence to ESC clinical practice guidelines in patients with ST-elevation myocardial infarction (STEMI). Methods and results  Prospective cohort (EURObservational Research Programme STEMI Registry) of hospitalized STEMI patients with symptom onset &lt;24 h in 196 centres across 29 countries. A total of 11 462 patients were enrolled, for whom primary percutaneous coronary intervention (PCI) (total cohort frequency: 72.2%, country frequency range 0–100%), fibrinolysis (18.8%; 0–100%), and no reperfusion therapy (9.0%; 0–75%) were performed. Corresponding in-hospital mortality rates from any cause were 3.1%, 4.4%, and 14.1% and overall mortality was 4.4% (country range 2.5–5.9%). Achievement of quality indicators for reperfusion was reported for 92.7% (region range 84.8–97.5%) for the performance of reperfusion therapy of all patients with STEMI &lt;12 h and 54.4% (region range 37.1–70.1%) for timely reperfusion. Conclusions  The use of reperfusion therapy for STEMI in the ESC member and affiliated countries was high. Primary PCI was the most frequently used treatment and associated total in-hospital mortality was below 5%. However, there was geographic variation in the use of primary PCI, which was associated with differences in in-hospital mortality.

Background— Ticagrelor outperforms clopidogrel in preventing cardiovascular events in acute coronary syndrome. Despite the inclusion of a loading dose in the Platelet Inhibition and Patient Outcomes (PLATO) trial for all patients randomized to ticagrelor, it may not be necessary in patients receiving ongoing clopidogrel therapy. The aim of the present study was to assess whether a ticagrelor loading dose is associated with a further platelet inhibition during the switch from clopidogrel to ticagrelor in patients with acute coronary syndrome receiving ongoing antiplatelet treatment. Methods and Results— Fifty patients with acute coronary syndrome receiving aspirin and clopidogrel treatment were randomly assigned to a starting dose of ticagrelor (group 1, 90 mg; group 2, 180 mg). Platelet aggregation was measured using multiple electrode aggregometry and standard light transmission aggregometry just before the switch and at 2, 6, 24, and 72 hours. No relevant difference in platelet aggregation was observed between the 2 study arms at baseline ( P =0.256). Residual platelet aggregation was significantly reduced in both arms 2 hours after the first administration of ticagrelor ( P <0.001 for both), with no difference in aggregation between groups (multiple electrode aggregometry, 17.6±7.2 versus 18.1±6 U; P =0.281). Similar results were observed with LTA. Conclusions— Switching from clopidogrel to ticagrelor without a reloading dose is feasible, and it does not hinder platelet aggregation inhibition in patients with acute coronary syndrome. Further prospective studies are needed to assess the clinical relevance of our findings. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01795820.

Endothelial dysfunction, wall thickening and plaque are progressive manifestations of atherosclerosis. Delayed or absent brachial artery dilation after ischemic stimulus has been associated with severity of extracoronary and coronary atherosclerosis. In the current study, we aimed to verify if delayed or absent dilation associates with critical coronary stenosis. We also evaluated the association between coronary stenosis, carotid artery wall thickness and peripheral artery disease. Endothelial function was investigated by flow-mediated dilation of the brachial artery up to 3 min after ischemia, and patients classified as early, late or no dilators. Coronary angiography was performed through transradial or femoral artery approach. Computerized quantitative angiography was used to obtain percent stenosis of all lesions, while the Gensini score was used to evaluate the severity of coronary atherosclerosis. Seventy-four patients were enrolled. Carotid wall thickness and plaque, and peripheral artery disease were detected by ultrasound. Subjects with critical coronary stenosis showed a higher prevalence of delayed or absent dilation (coronary stenosis ≥70 per cent: late dilators 50 per cent, no dilators 35 per cent; coronary stenosis ≤70 per cent : late dilators 27 per cent, no dilators 6 per cent). The Gensini score was progressively higher in late dilators and no dilators compared with early dilators (early: 4.5±13.5; late 17.5±27.1; no 39.7±55.0; P<0.02). Carotid atherosclerosis and peripheral artery disease were more prevalent in subjects with critical coronary stenosis. Delayed or absent dilation associates with coronary stenosis and different degree of coronary atherosclerosis. The kinetic of arterial dilation seems to be relevant as the magnitude of dilation.

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient’s survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

BackgroundAdequate expansion is critical to achieve optimal Bioresorbable Vascular Scaffolds (BVS) apposition to the vessel wall. However, compared to metallic stents, BVS present different mechanical properties. Hence, slow deployment and maintenance of balloon inflation for at least 30” is recommended for BVS implantation. However, since no evidences are available demonstrating the superiority of a longer balloon dilatation time, the implantation technique is highly variable among different centers.MethodsA total of 24 BVS-treated lesions were included in the present analysis. After BVS deployment at 12 atmosphere (ATM) the balloon was rapidly deflated and scaffold expansion was documented with an angiogram. The same balloon was then inflated again and kept at 12 ATM for 30”. Finally, a further angiogram was obtained to evaluate BVS expansion. Quantitative coronary angiography (QCA) was performed at each step.ResultsA significant increase of minimal luminal diameter (MLD)-to-reference scaffold diameter (RSD) ratio (MLD to RSD Ration, MR-Ratio) from 0.70 ± 0.10 after initial stent deployment to 0.79 ± 0.10 after the 30”-long balloon dilation was observed (p < 0.001). Of note, this result was consistent across all sub-segments, as well as across almost all lesion subgroups. A substantial reduction in the prevalence of residual stenosis from 29 % to 17 % was registered after the 30”-long dilation.ConclusionsOur results strongly support the maintenance of balloon inflation for at least 30” during BVS deployment to achieve optimal scaffold expansion and minimize the occurrence of residual stenosis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-015-0163-5) contains supplementary material, which is available to authorized users.

Atherosclerosis is the most common cause of peripheral arterial disease (PAD). Interventional procedures are the first treatments proposed for most PAD patients. Balloon angioplasty alone may offer good immediate results; however, has it been proposed that the addition of stents improves the procedural success of angioplasty and extends its application to more types of lesions. Isolated aortic lesions are relatively rare, and the indications for stent placement have not been established. Percutaneous transluminal recanalization of chronic iliac occlusions remains controversial. However, results of recent studies have been encouraging, with initial technical success rates greater than 90%, low complication rates, and good long-term results. About the use of stent in atherosclerotic lesions involving iliac arteries and upper region of femoral arteries, we think that it is feasible. Differently, for the lower region of the femoral artery and for the popliteal artery, the results on the use of stents are controversial. More difficult is the therapy of infrapopliteal arteries disease in which perhaps the best option is medical therapy. The Transatlantic Inter-Society Consensus Group summarized the results of femoropopliteal stenting as follows: in a comparison of 11 trials involving femoropopliteal artery stenting in 585 patients, the primary patency rate was 58% at 36 months. For percutaneous transluminal angioplasty, the patency rates were 51% at 36 months. Although the results are satisfactory in femoral lesions, especially in stenoses shorter than 10 cm, they are less favorable both in longer femoral lesions than in the popliteal artery, where the results were worst. Large clinical series after angioplasty of lower limb arteries have confirmed the clinical and economical impact of restenosis: its rate varies in a range between 30% and 50%. The restenosis after stent deployment is the result of neointima formation; therefore, the interest of investigators turned towards an agent to suppress neointimal growth and restenosis after stent deployment, as Sirolimus and/or Taxolo. The first multicenter, randomized study, evaluating the 6-month outcomes of drug-eluting stent implantation in long-segment obstructions of the superficial femoral artery, was SMART trial, published in 2002. This is the first trial to show that controlled drug release is also feasible using a self-expandable nitinol stent platform. The results at 6 months demonstrate inhibition of in-stent neointimal proliferation, reflecting a trend toward a reduction in late loss.

Head-to-head comparison of contrastenhanced magnetic resonance imaging and electroanatomical voltage mapping to assess post-infarct scar characteristics in patients with ventricular tachycardias: real-time image integration and reversed registration.