Faculty of Medicine

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Microcatheter Crossing of Radial Artery Loops and Tortuosities: New Ideas in Reducing Trans Radial Approach Crossover
(Scientific Foundation Spiroski (publications), 2021-12-29)
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Spiroski, Igor M.
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Jovkovski, Aleksandar
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BACKGROUND: Transradial access is currently the default access site for percutaneous cardiovascular interventions. Radial artery (RA) anomalies present a significant challenge in radial access success. RA 360-degree loops are an uncommon, but quite challenging vascular anomaly even for the most experienced radial operators.CASE REPORT: We report on two cases of patients with complex RA loops referred for PCI through radial approach in a high-volume radial center. Pre-procedural RA angiography was performed in both cases identifying a 360-degree RA loop in the proximal part of the RA below the entrance into the brachial artery. In both cases, we present a novel “Microcatheter crossing” technique of the complex RA loop as a new strategy in overcoming even the most difficult radial adversary. After identifying the loop a hydrophilic wire 0.014 inch was used to cross the loop and extend it in the upper arm. Then a microcatheter ASAHI corsair (Asahi Intecc USA, Inc.) was advanced through the loop without difficulty. The microcatheter is advanced through the wire until middle of the upper arm. Hydrophilic wire is then exchanged with High Torque Iron man guide wire (Abbott Vascular). Again, the wire is advanced in the upper arm. Microcatheter is then removed and 5F catheter JR 4.0 or similar is advanced gently through the iron man wire with a clockwise rotation through the loop. Then, wire and catheter are pulled back to straighten the loop. The percutaneous angiography procedure was performed successfully in both cases.CONCLUSION: Both patients were discharged without registered bleeding complications from place of puncture. They both reported slight pain during the beginning of the procedure in the arm of puncture, but without additional problems after the procedure.
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Sex differences in transradial access failure in ST segment elevation myocardial infarction
(Wiley, 2024-09-30)
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Jovkovski, Aleksandar
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Taravari, Hajber
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Kitanoski, Darko
Background Transradial access (TRA) is now the default access site for PPCI, but technically is a more challenging approach mostly due to anatomic challenges connected to the RA. Aims To assess the differences according to sex in radial artery (RA) access site characteristics during primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI). Material and Methods All 5092 consecutive STEMI patients from our center in the period from March 2011 until December 2017 were examined. The right proximal radial was the “intention‐to‐treat” access in all patients. Preprocedural RA angiography was performed in all patients. Clinical and procedure characteristics, type of radial anatomy variants, need to use another arterial access sites (the primary endpoint for this study), and procedure time were analyzed by sex. Using logistic regression, we selected predictors of radial crossover. Access site bleeding complications and vascular complications were also recorded. Results The STEMI population in this period included 1326 females and 3766 male patients. Females were older (65 ± 11 years) than males (59 ± 11 years, p < 0.0001). Among standard risk factors, hypertension and diabetes mellitus were more common in women and smoking less common. RA anomalies were more frequent in the females (8.8% vs. 6.5%, p < 0.0001), with complex RA loop and tortuous RA twice as frequent in women. Failure of TRA access as the initially chosen site occurred in 4.6% (61) of females versus 2.5% (97) of male STEMI patients (p = 0.0003). The most common subsequent access site was right ulnar access in both groups (57 and 61% respectively). Access site bleeding complications were more common in women 4.4% versus 3.2%, mirrored in hematomas with EASY score III to V. Clinical RA spasm (RAS) was significantly more frequent in females (5.7% vs. 2.2%, p < 0.0001). Multiple regression analysis identified 5 independent predictors for TRA access crossover: previous TRA, anomalous RA, RAS, along with female sex and diabetes. Conclusion Female sex is a significant predictor of more complex TRA in STEMI. Understanding sex differences and predictors for TRA crossover will strengthen the use of different procedural modalities that can help in preserving a successful wrist access in female STEMI patients.
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Ipsilateral transulnar artery approach catheterizations after failure of the radial approach—Are two sheaths in the same arm safe?
(Wiley, 2021-05-28)
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Jovkovski, Aleksandar
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Taravari, Hajber
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Kitanoski, Darko
Aims To assess the safety and feasibility of ipsilateral transulnar access (TUA) after failure of radial access (TRA), with two sheaths placed in the radial and ulnar arteries (RA and UA) in the same arm. Materials and Methods All consecutive patients with TUA due to inability to cross from ipsilateral TRA in the period from March 2011 until September 2020 were included in the study. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and failure mode of initial TRA. Patients were assessed by duplex ultrasound post‐procedure (at an average of 56 ± 31 months) and followed clinically (functional and pain assessment). Results In this period, out of 51,866 patients 112 (0.2%) had a transulnar artery approach due to inability to cross from ipsilateral radial approach. Mean age of patients was 65 ± 11 years with 44% females. Cause for crossover to ipsilateral TUA was inability to cross a RA anomaly in 107 (95%) patients, mostly due to the presence of a “360°” RA loop in 88 patients. Type 3 and 4 EASY Score hematoma was present in 3 patients (2.6%). Six (5.3%) of the patients had new ipsilateral radial artery occlusion noted on duplex on follow up. There were no ulnar artery occlusions detected. There were no clinical or ischemic hand complications seen during a median 4.3 years of follow up. Conclusion Ipsilateral transulnar artery access following failed radial artery access crossing is safe and successful for coronary angiography and intervention with low rates of complications.
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Comparison of distal radial with conventional radial access in patients with ST-segment elevation myocardial infarction, undergoing primary percutaneous coronary intervention.
(MDPI (Multidisciplinary Digital Publishing Institute), 2021-12)
Kitanoski, Darko
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Postadzhiyan, Arman
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Velchev, Vasil
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Stoyanov, Nikolay
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Background: There is limited data available regarding the technique of dTRA, and its potential benefit in patients with STEMI. This study investigated the feasibility, safety, and potential benefit of dTRA in patients with STEMI, compared to conventional TR approach. Methods: This was a prospective single center study that included 292 patients referred for STEMI. 152 (52%) patients had primary PCI through distal transradial access, and 140 (48%) had PPCI through conventional radial access. Exclusion criteria was absence of radial artery pulse and previous RAO. We compared clinical and procedure characteristics, access site bleeding complications, rate of Radial Artery Occlusion (RAO) and failure of primary chosen access site between two groups of STEMI patients. Results: The success rate of the puncture for dTRA was 98.7% (150/152), and for conventional TRA 99.3% (139/140). Successful primary PCI via dTRA and conventional TRA was performed in all patients in both groups. dTRA was associated with lower rate of study clinical outcomes as rate of radial artery occlusion (dTRA: 0%, TRA 5.7%, p=0.0028) and local hematoma according to EASY score (dTRA Grade I: 15.13%, Grade II: 0%, Grade III: 0%, Grade IV: 0%, TRA: Grade I 22.9%, Grade II: 7.1%; Grade III: 0.7%, Grade IV: 0%, p=0.0009). There was no difference recorded in radial artery spasm between two access sites (dTRA: Grade I: 7.2%, Grade II: 2.7%, Grade III: 1.3%, Grade IV: 0%, TRA: Grade I 7.1%, Grade II: 2.1%, Grade III: 0.7%, Grade IV: 0%) and there was no statistically significant difference in access site crossover (dTRA: 2 patients, TRA: 1 patient). dTRA was associated with a longer access time (dTRA 38.6 sec, TRA: 36.3 sec, p=0.0077). Time of hemostasis was significantly shorter with dTRA (dTRA 30-60 min, TRA 120-150 min, p<0.0001). Conclusion: dTRA is safe and successful in STEMI patients, when performed by experienced radial operators, with previous experience with dTRA. It is associated with lower rate of access site complications and early haemostasis in comparison with TRA.
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Sex differences in transradial access failure in ST segment elevation myocardial infarction
(Wiley, 2024-11)
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Jovkovski, Aleksandar
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Vasilev, Ivan
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Taravari, Hajber
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Kitanoski, Darko
Background Transradial access (TRA) is now the default access site for PPCI, but technically is a more challenging approach mostly due to anatomic challenges connected to the RA. Aims To assess the differences according to sex in radial artery (RA) access site characteristics during primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI). Material and Methods All 5092 consecutive STEMI patients from our center in the period from March 2011 until December 2017 were examined. The right proximal radial was the “intention-to-treat” access in all patients. Preprocedural RA angiography was performed in all patients. Clinical and procedure characteristics, type of radial anatomy variants, need to use another arterial access sites (the primary endpoint for this study), and procedure time were analyzed by sex. Using logistic regression, we selected predictors of radial crossover. Access site bleeding complications and vascular complications were also recorded. Results The STEMI population in this period included 1326 females and 3766 male patients. Females were older (65 ± 11 years) than males (59 ± 11 years, p < 0.0001). Among standard risk factors, hypertension and diabetes mellitus were more common in women and smoking less common. RA anomalies were more frequent in the females (8.8% vs. 6.5%, p < 0.0001), with complex RA loop and tortuous RA twice as frequent in women. Failure of TRA access as the initially chosen site occurred in 4.6% (61) of females versus 2.5% (97) of male STEMI patients (p = 0.0003). The most common subsequent access site was right ulnar access in both groups (57 and 61% respectively). Access site bleeding complications were more common in women 4.4% versus 3.2%, mirrored in hematomas with EASY score III to V. Clinical RA spasm (RAS) was significantly more frequent in females (5.7% vs. 2.2%, p < 0.0001). Multiple regression analysis identified 5 independent predictors for TRA access crossover: previous TRA, anomalous RA, RAS, along with female sex and diabetes. Conclusion Female sex is a significant predictor of more complex TRA in STEMI. Understanding sex differences and predictors for TRA crossover will strengthen the use of different procedural modalities that can help in preserving a successful wrist access in female STEMI patients.
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SUCCESSFUL TREATMENT OF ENDOCARDITIS WITH NONSPECIFIC PRESENTATION IN A KIDNEY TRANSPLANTPATIENT-CASE REPORT
(Macedonian Association of Anatomists, 2023-11)
Uspcov, Julijana
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Kabova Karanfilovikj, Angela
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Spasovska, Adrijana
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Infective endocarditis (IE) is a serious complication in patients with transplanted kidney, leading to graft loss and a high mortality rate. We present a case of native valve endocarditis in a 51-year-old male with transplanted kidney that had atypical clinical course. The patient experienced prolonged subfebrile temperature with paroxysmal arrhythmia and development of cardio-pulmonary insufficiency. Transthoracic echocardiography (TTE) set the diagnosis of aortic valve vegetation with severe aortic regurgitation and pulmonary edema. We failed to isolate a microbiological agent, but all blood cultures were taken under antibiotic therapy. The patient was treated with surgical replacement of the native aortic valve with mechanical heart valve with significant clinical improvement. Ten days after the intervention, he was discharged with reduced markers of inflammation and proper function of the kidney graft. Immunosuppressive therapy was gradually reinstated. One year later, the patient was clinically stable and with proper graft function. Early diagnostic and therapeutic intervention, particularly intensive antibiotic therapy and surgical management can preserve the patient and the kidney allograft.
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Safety and Feasibility of Retrograde Recanalization of Radial Artery Occlusion in Patients with Need for Repeated Wrist Procedures
(Scientific Foundation SPIROSKI, 2022-11-25)
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AIM: The purpose of the study was to present a new technique of retrograde recanalization of radial artery (RA) occlusion (RAO) in patients with need for repeated wrist access percutaneous angiographic procedures. MATERIALS AND METHODS: During a 10-year period from March 2011–May 2021, 53 000 patients were referred for percutaneous coronary intervention (PCI) in a high-volume transradial center. RAO on angiography was documented in 1165 patients. Retrograde recanalization of RAO was attempted in 70 patients. The selected patients were with multiple previous bilateral wrist interventions (n = 3–9). Ipsilateral ulnar artery was usually rudimented or occluded and contralateral wrist approach could not be used. We examined clinical and procedure characteristics, access site bleeding and ischemic complications and procedural success of retrograde recanalization of RAO. Visual analog scale (VAS) score forearm pain assessment was performed after procedure. Technique: All patients had palpable pulse distal of previous puncture site due to collaterals from ipsilateral ulnar and interosseous artery. The RA was punctured with an inner metallic needle with a plastic cannula. Using retrograde radial angiography performed by injecting contrast through the plastic cannula, the occluded segment was visualized and crossed with different types of hydrophilic chronic total occlusion guide wires. After sheath insertion, balloon dilatation of the occluded RA segment, successful catheterization, and/or percutaneous coronary intervention was performed. Final RA angiography was performed on all patients. RESULTS: Successful retrograde opening of RAO was achieved in 65 out of 70 patients (92%). PCI was performed in 56% of patients through the opened RAO and 5 patients underwent CAS. Procedural success through opened RA was achieved in all 65 patients. Forearm pain during procedure was present in all cases (VAS score 3 ± 2.1). Access site bleeding EASY score 3 and 4 occurred in 6 patients (8.5%). One patient had discharge of embolic material up the arm without clinical consequences. In one patient, we observed dissection of the interosseous artery. Clinical and duplex long-term follow-up with a median of 4.1 years showed patent RA in only 20 patients. There were no registered cases of hand ischemia. About 61% of patients underwent subsequent PCIs, through other alternative access sites. CONCLUSION: Retrograde recanalization of RAO is successful and safe in patients with need of repeated coronary angiography procedures and inability to use other wrist access sites. Puncturing the collateral and performing retrograde radial angiography through the cannula is a key factor in successful opening of the RAO.
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Microcatheter Crossing of Radial Artery Loops and Tortuosities: New Ideas in Reducing Trans Radial Approach Crossover
(Scientific Foundation SPIROSKI, 2021-12-29)
Vasilev, Ivan
;
;
;
;
Jovkovski, Aleksandar
<jats:p>BACKGROUND: Transradial access is currently the default access site for percutaneous cardiovascular interventions. Radial artery (RA) anomalies present a significant challenge in radial access success. RA 360-degree loops are an uncommon, but quite challenging vascular anomaly even for the most experienced radial operators. CASE REPORT: We report on two cases of patients with complex RA loops referred for PCI through radial approach in a high-volume radial center. Pre-procedural RA angiography was performed in both cases identifying a 360-degree RA loop in the proximal part of the RA below the entrance into the brachial artery. In both cases, we present a novel “Microcatheter crossing” technique of the complex RA loop as a new strategy in overcoming even the most difficult radial adversary. After identifying the loop a hydrophilic wire 0.014 inch was used to cross the loop and extend it in the upper arm. Then a microcatheter ASAHI corsair (Asahi Intecc USA, Inc.) was advanced through the loop without difficulty. The microcatheter is advanced through the wire until middle of the upper arm. Hydrophilic wire is then exchanged with High Torque Iron man guide wire (Abbott Vascular). Again, the wire is advanced in the upper arm. Microcatheter is then removed and 5F catheter JR 4.0 or similar is advanced gently through the iron man wire with a clockwise rotation through the loop. Then, wire and catheter are pulled back to straighten the loop. The percutaneous angiography procedure was performed successfully in both cases. CONCLUSION: Both patients were discharged without registered bleeding complications from place of puncture. They both reported slight pain during the beginning of the procedure in the arm of puncture, but without additional problems after the procedure.</jats:p>
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Ipsilateral transulnar artery approach catheterizations after failure of the radial approach-Are two sheaths in the same arm safe?
(Wiley, 2021-05-28)
;
Jovkovski, Aleksandar
;
Vasilev, Ivan
;
Taravari, Hajber
;
Kitanoski, Darko
To assess the safety and feasibility of ipsilateral transulnar access (TUA) after failure of radial access (TRA), with two sheaths placed in the radial and ulnar arteries (RA and UA) in the same arm.
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Single Center Registry of Percutaneous Ulnar Artery Approach for Coronary Intervention as an Alternative to TRA
(American College of Cardiology, 2011)
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Antov, Slobodan
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