Faculty of Medicine

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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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DISTAL TRANSRADIAL APPROACH IN HIGH-RISK PATIENT WITH STEMI AND CARDIOGENIC SHOCK – A CASE REPORT
(Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, 2022)
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Kitanoski, Darko
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Bushljetikj, Oliver
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Conventional transradial access has been considered as a recommended choice in PCI and myocardial revascularization.The vascular complications such as radial artery occlusion, perforation and spasm have led to the development of a new approach, which was proposed to overcome these limitations. This was a distal transradial approach (snuffbox approach). A 74-year-old woman presented to the emergency department with oppressive chest pain and dyspnea formore than 3 hours.On clinical examination, the patient appeared pale and diaphoretic, with weak and rapidpulsation and systolic blood pressure below 70mmHg. A 12 lead ECG lead was performed, whichshowed ST segment elevation of 4 mm in inferior lead.She was admitted to the catheterization laboratory with blood pressure 70/40mmhg andnorepinephrine vasopressor support. A 6Fr introducer sheath was placed in distal radial (anatomical snuffbox). The coronary angiography revealed RCA with acute total occlusion and high thrombotic burden TIMI 5 in proximal segment,normal LMCA, LAD and Circumflex. RCA was engaged with a guide catheter and advanced distally a floppy guidewire, then the occlusion site was predilated with a balloon and advanced stent from proximal segment with TIMI3 final flow. 2D transthoracic echocardiography was performed, and it showed heart failure with mildly reduced ejection fraction and hypokinesia of the inferior wall. Distal transradial access is a new approach which might offer several advantages over conventional radial access such as reduction of the risk of radial artery occlusion, short hemostasis andsaving the radial artery for possible future coronary artery graft.
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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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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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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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Newly Diagnosed Diabetes and Stress Glycaemia and Its' Association with Acute Coronary Syndrome
(Scientific Foundation SPIROSKI, 2015-12-15)
Kamceva, Gordana
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Kitanoski, Darko
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Diabetes is diagnosed in 10-20% of patients with acute coronary syndrome (ACS) not known to be diabetics. Elevated blood glucose is an independent risk factor for cardiac events, regardless of presence of diabetes.
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Radial artery anomalies in the Macedonian population during transradial angiography procedures
(Association of Medical Doctors "Sanamed" Novi Pazar, 2016)
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Petkoska, Danica
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Antov, Slobodan
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Vasilev, Ivan
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Jovkovski, Aleksandar
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Total wrist access for angiography and interventions: Procedural success and access site crossover in a high volume transradial center
(Elsevier BV, 2018)
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Antov, Slobodan
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