Introduction Radial access is a standard approach for coronary interventions. However, it carries some risk of local or long-term complications such as hematoma or radial artery occlusion. Aim To assess the feasibility of a very distal left and right transradial approach (VITRO) for coronary interventions. Material and methods Three hundred and twenty consecutive patients were submitted to diagnostic or therapeutic coronary interventions. In 102 patients the distal radial artery was not palpable or the pulse was too weak. In 218 selected patients (142 male, 76 female, age: 69 ±11 years) we decided to perform a distal transradial approach. Results The VITRO access was suitable in 195 patients with a success rate of 89.4%. In 9 patients arterial puncture failed, while in 14 others despite successful arterial puncture the wire could not be advanced towards the forearm part of the radial artery. Not only elective diagnostic angiographies were performed with VITRO but also urgent ad hoc coronary interventions in subjects with unstable angina or NSTEMI (48 subjects; 24.3%). Moreover, this very distal approach allowed 11 rotablations and 11 FFR/iFR examinations to be performed in 22 patients. No major bleeding, requiring prolonged hospital stay, surgery or transfusion occurred. One patient on oral anticoagulation with DAPT had conservatively managed minor forearm bleeding. Conclusions Very distal radial artery access is feasible, safe and comfortable in 60% of patients referred for elective or urgent coronary arteries angiography, or coronary interventions.
Despite ongoing significant improvements in the management of pulmonary embolism (PE), the mortality rate in high-risk and intermediate-high-risk groups of patients remains high, mostly due to underuse of thrombolysis resulting from increased bleeding risk. Noteworthy progress in interventional cardiology has made percutaneous catheter-directed thrombectomy (CDT) a real alternative to surgical embolectomy in acute PE. CDT is proposed as an integrated part of PE treatment recommended by the pulmonary embolism response team (PERT), mostly dedicated to the management of haemodynamically unstable acute PE and patients with contraindication to thrombolysis. Currently, we report the first experience of Indigo System's Continuous Aspiration Mechanical Thrombectomy (Indigo CAT8 XTORQ, Penumbra, Alameda, CA, USA) in the treatment of intermediate-high-risk PE with relative contraindication to thrombolysis. A 27-year-old obese woman, after left knee arthroscopy seven days prior to hospitalisation, with a history of hormonal contraception therapy, was admitted to the intensive care unit after syncope. Urgent computed tomography angiography showed bilateral thromboembolism obstructing both main lobar pulmonary arteries. Early mortality risk was assessed as intermediate-high because of echocardiographic signs of right ventricular (RV) dysfunction (tricuspid annular plane systolic excursion was 12 mm, right to left ventricular ratio > 1) and elevated levels of cardiac troponin T (0.1 pg/mL, reference range 0-0.014 pg/mL) and N-terminal pro-B-type natriuretic peptide (NT-proBNP; 4447 pg/mL, reference range 0-300 pg/mL). Despite treatment with full-dose low-molecular-weight heparin, progressive clinical deterioration was observed, with persistent sinus tachycardia > 120 bpm, systemic blood pressure < 110 mmHg, signs of RV dysfunction, and hypoxemia with SpO 2 < 90%, indicating increased risk of PE-related in-hospital complications. Due to relative contraindications to systemic fibrinolysis (significant haematoma of the left knee after recent surgery) our local PERT decided to perform CDT using the Indigo system with a CAT8 thrombectomy catheter. Pulmonary angiography performed from the right jugular vein with a 6-F pigtail catheter revealed massive bilateral PE (Fig. 1A, B). Aspiration pulmonary thrombectomy with a separator wire was performed. The separator wire was advanced and retracted through the aspiration catheter at the proximal margin of the primary occlusion to facilitate clearing and removal of the thrombus from the catheter tip (Fig. 1C, D). A large thrombus obstructing the left lower and left main lobar arteries was fragmented and removed through the 8-F catheter with subsequent blood flow improvement in the left pulmonary artery (Fig. 1E, F). Following aspiration thrombectomy, the patient's clinical status gradually improved, and she was transferred to the cardiac intensive care unit. CTD duration, from the decision of PERT to the return of the patient to the intensive care unit was less than 120 min. After the proc...
A 43-year-old man was admitted to the Endocrinology Department because of hypocalcaemia and hypomagnesaemia developed after surgical treatment of hyperparathyroidism. There was no history of coronary heart disease and hypercholesterolemia before admission, only moderate hypertension. At about 2 pm the patient experienced sudden chest pain radiating to the jaw and upper limbs. Electrocardiogram revealed temporary horizontal ST-segment elevation in II, III and aVF leads (Fig. 1). The patient was referred to the Cardiology Department and coroangiography was performed. There were neither atherosclerotic changes nor contraction of coronary arteries during angiography (Fig. 2A-C). Laboratory test made shortly after the onset of pain revealed severe ionised hypocalcaemia -0.69 mmol/L (1.13-1.29 mmol/L) and hypomagnesaemia -0.52 mmol/L (0.7-1.0 mmol/L). Troponin I level was within the normal range -0.039 ng/mL (0.0-0.056 ng/mL) but a slight elevation of creatine kinase-MB mass was present -4.6 ng/mL (0.0-3.6 ng/mL). The chest pain ceased following intravenous administration of calcium and magnesium. Two-dimensional transthoracic echocardiography showed normal left ventricular size and function with ejection fraction of 57%, mild left ventricular hypertrophy and mild mitral and tricuspid regurgitation (Fig. 3). Although coronary spasm secondary to hypocalcaemia is a very rare facet of angina, failing to consider it in differential diagnoses in all cases of variant angina might pose a grave threat to the patient's life.
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