Division of Cardiology, Department of Internal Medicine, Hallym University Medical Center, 94-200, Yeongdeungpo-dong, Yeongdeungpo-gu, 150-030, Seoul, Republic of Korea. cardioguy@korea.ac.kr

Wake Heart and Vascular Associates, Wake Heart Center, 3000 New Bern Avenue, Raleigh, NC 27610, USA.

Department of Interventional Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands. G.Amoroso@olvg.nl

Centre for Coronary Artery Disease, Department of Cardiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China. yyj58@yahoo.com

Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, No.123 Ta-Pei Road, Niao-Sung Township, Kaohsiung County, 83301 Taiwan, ROC.

Cardiology Department, Sandro Pertini Hospital, Rome, Italy. stefanorigattieri@yahoo.it

Centre for Cardiovascular Science, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.

Division of Cardiology, Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University Collage of Medicine, Kaohsiung, Taiwan, R.O.C.

Department of Diagnostic Radiology, Kawasaki Medical School, Okayama, Japan. takenori@med.kawasaki-m.ac.jp

Unidad de Cardiologia Intervencionista, Medtec, Hospital Meixoeiro, Vigo, Spain.

Wake Heart and Vascular Associates, Wake Heart Center, Raleigh, North Carolina.

Wonju College of Medicine, Yonsei University, Wonju, Kangwon Province, South Korea

OBJECTIVE: We sought to evaluate the effects and optimal application time of a eutectic mixture of local anesthetic cream (EMLA-C) in relieving wrist pain during transradial coronary procedures (TRCP). METHODS: The Phase I study enrolled 147 patients to evaluate the efficacy and safety of the EMLA-C during TRCP. The Phase II study was designed to evaluate the optimal preprocedure application time frame of EMLA-C for wrist pain reduction in 400 patients. The EMLA or placebo cream was applied at the puncture site from 2 to 4 hours before the procedure in Phase I, and randomized to 5 time groups according to the time of drug application in Phase II. We evaluated wrist pain by the visual analogue scale (VAS) or verbal rating scale (VRS-4), and evaluated complications as well. RESULTS: EMLA-C demonstrated greater pain relief by VAS (control: 49+/-24, EMLA: 19+/-22; p = 0.001) and VRS-4 (control: 2.3+/-0.5, EMLA: 1.5+/-0.6; p = 0.001), and there was a negative correlation (r = -0.476; p = 0.001) between VAS and the preprocedure application time of EMLA-C. In Phase II, there was a significant difference in pain levels between the control and 1- to 2-hour groups by VAS (control: 49+/-29, EMLA1-2 hours: 32+/-24; p = 0.001) and VRS-4 (control: 2.4+/-0.6, EMLA1-2 hours: 1.9+/-0.6; p = 0.001). Drug-induced local erythema frequently occurred in the 3- to 4-hour group (6.6%) and >4 hours group (11.9%). CONCLUSIONS: EMLA-C can be effective in reducing wrist pain during TRCP without any significant drug-related complications when the application time is 1 to 3 hours before the procedure.

Department of Internal Medicine, Division of Cardiology, China Medical University Hospital, Taichung, Taiwan. joe5977@ms32.hinet.net

BACKGROUND: Dysfunctional Brescia-Cimino fistulae contribute to significant morbidity in hemodialysis patients. These fistulae normally are treated through a retrograde venous approach. There are no data regarding a transradial approach. Furthermore, measurement of pressure reduction in the radial artery appears to be useful. METHODS: We retrospectively examined 50 interventions to treat 49 patients (17 men, 32 women; mean age, 61.8 +/- 10.6 years) with Brescia-Cimino fistulae. Inclusion criteria were patients with palpable radial arteries and dysfunctional end-to-side Brescia-Cimino fistulae. Patients with infected fistulae, contrast allergy, upper-arm/synthetic graft/central-vein stenosis, and end-to-end Brescia-Cimino fistulae were excluded from the study. Radial arterial pressures before and after angioplasty were compared as a surrogate of stenosis relief. Anatomic and clinical success rates were calculated. RESULTS: Sixty-five stenoses and 4 total occlusions were treated through radial access. All radial punctures were successful, except in 1 patient. Most lesions were located in the cephalic vein (87%). Mean length of treated lesions was 4.1 +/- 2.8 cm. Mean pretreatment diameter of lesion stenoses was 76.7% +/- 12.1%. Mean posttreatment diameter stenosis was 22.6% +/- 8.2% (P < 0.001). Systolic, diastolic, and mean blood pressures recorded from the radial artery decreased from 130 +/- 40, 60 +/- 18, and 87 +/- 27 to 88 +/- 40, 43 +/- 18, and 60 +/- 26 mm Hg (P < 0.001, P < 0.001, and P < 0.001), respectively. The anatomic success rate of the transradial approach was 91.3%. The clinical success rate of the transradial approach was 96%. CONCLUSION: The transradial approach is a feasible and highly effective approach to treat dysfunctional Brescia-Cimino fistulae. Measuring blood pressure reduction through the radial artery appears promising as a hemodynamic evaluation method.

Sahlgrenska Academy at Goteborg University, Goteborg, Sweden.

The purpose of this study was to describe patients' experience during and after coronary angiography and percutaneous coronary intervention. Data were collected by interviews with 14 patients. A qualitative content analysis approach was used. Four main categories were identified that describe patients' experience of the hours during and following intervention: emotional thoughts, bodily sensations, nursing intervention of importance, and personal strategies. All patients made a comment on staff conduct and pointed out that even minor nursing actions may be of great importance. Patients were most positive toward the transradial approach. Even though the approach via arteria radialis will increase, many patients will still have their procedure done via arteria femoralis. In spite of all research and technical developments, the patients' experience from intervention via arteria femoralis is pretty much the same as it was 1997.

Division of Cardiology, Yonsei University, Wonju College of Medicine, 162 Ilsan-dong, Wonju 220-701, Korea.

We evaluated the feasibility of the transradial coronary intervention (TRCI) in 85 consecutive patients with chronic total occlusion (CTO). Clinical, angiographic and procedural factors were compared between the success and failure groups. An overall success rate of 65.5% (57 of 87 lesions) was achieved with TRCI, and the most common cause of failure was an inability to pass the lesion with a guidewire. A multivariate analysis demonstrated that the most significant predictor of failure was the duration of occlusion (OR 1.064 per month, 95% CI 1.005 to 1.126, p = 0.03). The procedural success rate improved with use of new-generation hydrophilic guidewires. The 6 Fr guiding catheters were used in the majority of the 70 cases (81%). Five cases were crossed over to a femoral artery approach due to engagement failure of the guiding catheter into the coronary ostium because of severe subclavian tortuosity and stenosis in two cases, radial artery looping in one case, and poor guiding support in two cases. There were no major entry site complications. In conclusion, the radial artery might be a feasible vascular route in coronary interventions for CTO, with comparable procedural success and no access site complications

Department of Cardiology, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, China.

OBJECTIVE: We previously showed that factorial score of somatization, which was obtained by the examination of symptom checklist-90 (SCL-90), was higher in patients received transfemoral coronary catheterization than norm. The aim of the present study was to compare the patient's psychologic status between transradial approach and transfemoral approach percutaneous coronary catheterizations. METHODS: A total of 198 inpatients (105 transfemoral, 93 transradial) underwent scheduled first time coronary catheterizations were enrolled. All patients were studied by symptom SCL-90 on present psychologic status 24 hours before and 24-48 hours after coronary catheterizations. RESULTS: Age, sex, weight, smokers, employment, educational background, marriage status, family relations, family history of cardiovascular disease, income and medical insurance status were similar between the two groups. There was also no difference in diabetes, hypertension history as well as coronary heart disease confirmed by coronary catheterization between the 2 groups. Compared with the status before the procedure, factorial scores of somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, global severity index and total positive symptoms were significantly reduced after percutaneous coronary catheterizations (1.50 +/- 0.51 vs. 1.64 +/- 0.53, 1.50 +/- 0.48 vs. 1.67 +/- 0.55, 1.28 +/- 0.41 vs. 1.38 +/- 0.49, 1.42 +/- 0.43 vs. 1.55 +/- 0.53, 1.38 +/- 0.41 vs. 1.58 +/- 0.54, 1.32 +/- 0.35 vs. 1.44 +/- 0.41, 1.38 +/- 0.34 vs. 1.49 +/- 0.42, and 23.08 +/- 17.30 vs. 27.72 +/- 18.79, respectively, P all < 0.05). Scores on somatization, depression and positive symptom severity index were significantly lower in patients received transradial coronary catheterizations than those received transfermoral coronary catheterization approach (1.52 +/- 0.51 vs. 1.62 +/- 0.53, 1.43 +/- 0.54 vs. 1.54 +/- 0.43 and 2.36 +/- 0.66 vs. 2.50 +/- 0.43, respectively, P all < 0.05). CONCLUSION: Patients' psychologic status improved significantly after percutaneous coronary catheterizations. Improvement on psychologic status is significantly better in patients underwent transradial coronary catheterizations than that underwent transfemoral coronary catheterizations.

Dextrocardia (DC) is a rare cardiac condition in which the cardiac location, as well as apex, is rightwardly displaced. As the incidence of atherosclerotic disease is similar to that of the general population, there have been few reports of percutaneous coronary interventions (PCIs) in these patients. Proposed technical strategies for successful angiography and PCI in DC include counter-directional torquing of the catheter, as well as right-left mirror-image inversion angiographic views. All previous reports of DC PCIs have been via transfemoral access.We present a case of successful repeat transradial PCI in a patient with DC. This is first report of transradial coronary angiography, PCI, or repeat PCI in a DC patient. A literature review of technical considerations, including our own recommendations for guide catheter selection, are discussed. We also review the anatomic variations and epidemiology of DC. Although access complications for transradial PCI is known to be lower than that of the transfemoral approach, challenges in technique and concern of repeat access have limited the popularity of the former. Our report demonstrates the safety and feasibility of transradial angiography, PCI, and even repeat PCI, in the rare patient with DC. (c) 2006 Wiley-Liss, Inc.

Hopital Laval, Institut Universitaire de Cardiologie et de Pneumologie, affilie a l'Universite Laval, 2725 Chemin Ste Foy, Quebec, Canada G1V 4G5. Olivier.Bertrand@crhl.ulaval.ca

BACKGROUND: Systematic use of coronary stents and optimized platelet aggregation inhibition has greatly improved the short-term results of percutaneous coronary interventions. Transradial percutaneous coronary interventions have been associated with a low risk of bleeding complications. It is unknown whether moderate- and high-risk patients can be discharged safely the same day after uncomplicated transradial percutaneous coronary interventions. METHODS AND RESULTS: We randomized 1005 patients after a bolus of abciximab and uncomplicated transradial percutaneous coronary stent implantation either to same-day home discharge and no infusion of abciximab (group 1, n=504) or to overnight hospitalization and a standard 12-hour infusion of abciximab (group 2, n=501). The primary composite end point of the study was the 30-day incidence of any of the following events: death, myocardial infarction, urgent revascularization, major bleeding, repeat hospitalization, access site complications, and severe thrombocytopenia. The noninferiority of same-day home discharge and bolus of abciximab only compared with overnight hospitalization and abciximab bolus and infusion was evaluated. Two thirds of patients presented with unstable angina and approximately 20% presented with high-risk acute coronary syndrome prior to the procedure. The incidence of the primary end point was 20.4% in group 1 and 18.2% in group 2 (P=0.017 for noninferiority) with a troponin T-based definition of myocardial infarction; the incidence of the primary end point was 11.1% in group 1 and 9.6% in group 2 (P=0.0004 for noninferiority) with a creatinine kinase myocardial band-based definition of myocardial infarction. No death occurred. Rate of major bleeding in both groups was extremely low at 0.8% and 0.2%, respectively. From 504 patients randomized in group 1, 88% were discharged home the same day. CONCLUSIONS: Our data suggest that same-day home discharge after uncomplicated transradial coronary stenting and bolus only of abciximab is not clinically inferior, in a wide spectrum of patients, to the standard overnight hospitalization and a bolus followed by a 12-hour infusion. This novel approach offers a safe strategy for same-day home discharge after uncomplicated coronary intervention.

Department of Cardiology, Baskent University School of Medicine, Ankara, Turkey. yigitfatma2000@yahoo.com

OBJECTIVE: The radial approach has been increasingly used as an alternative to femoral access. The purpose of the present study was to assess the feasibility, success, and safety of the transradial approach (TRA) for diagnostic coronary angiography, and to describe the difficulties associated with the technique as compared with transfemoral approach (TRF). METHODS: A series of 180 consecutive patients were divided to TRA or TFA groups by two operators. We compared the groups regarding procedural time, access time, fluoroscopy time, procedural failure, complications, contrast volume, length of hospital stay, and number of used coronary catheters. RESULTS: The number of used coronary catheters was not different between the two groups (p = 0.6). Total hospital length of stay was significantly shorter in the radial group (p <0.0001) than in femoral one. We found differences between the radial and femoral groups in the success rate (p<0.0001), contrast volume (p = 0.012), procedural time (p<0.0001), access time (p<0.0001), and fluoroscopy time (p<0.0001). We did not find any major complication in the radial group. There was a major bleeding in the femoral group. CONCLUSION: The TRA is a safe alternative to femoral catheterization although with lesser procedural success, longer procedural access, and radiation time, and more contrast volume.

G. Kuppuswamy Naidu Hospital, Cardiology Department, Coimbatore, India.

OBJECTIVE: To study the suitability of the aberrant radial artery (ARA) as an access site for coronary angiography and angioplasty. BACKGROUND: In certain situations, the radial artery operator finds that the right radial artery in its usual location is unsuitable for a transradial procedure (TRP). In such cases, the ARA should be considered as an alternate access site. METHODS: Between January 2002 and December 2004, all patients considered suitable for a TRP with a clinically absent radial artery, or a small radial artery and a palpable ARA, underwent a TRP using this vessel as an access site. We describe the technical aspects and the differences that this approach entails, in comparison to the standard radial artery approach to TRPs. RESULTS: Of the 3,610 patients considered suitable for a TRP, 22 patients underwent 29 procedures using the ARA as an access site [22 angiograms and 7 percutaneous transluminal coronary angioplasty procedures (PTCAs)]. The median age of the patients was 55 years, with 19 males and 3 females. All procedures using the aberrant radial artery were successful. None of the patients developed spasm or an access site complication. The mean fluoroscopy time for angiography in the right radial artery group was 4.6 minutes, and 4.8 minutes for the ARA group. The procedure timed were 24 minutes and 32 minutes, respectively. CONCLUSION: The aberrant radial artery can be used as a safe alternate access site for coronary angiography and angioplasty when the right radial artery at the usual site is not suitable.

Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan

The native radiocephalic (Brescia-Cimino) fistula is usually constructed with an anastomosis of the cephalic vein and radial artery. Catheter interventions for native fistula failure have until now been performed via the transcephalic or transbrachial approach. Transradial intervention for native fistula failure was prospectively evaluated for a selected consecutive 11 patients. Six patients had a single lesion and 5 patients had double lesions. Twelve lesions were stenotic and 4 were occlusive with thrombus. Balloon angioplasty alone was successful in 10 lesions. In thrombosed fistulas, 2 lesions underwent manual catheter-directed thrombo-aspiration and 2 further lesions underwent a combination of catheter-directed thrombo-aspiration and mechanical thrombectomy. Cutting Balloon angioplasty was performed for 3 resistant venous stenoses and for 1 radial artery stenosis. Technical and clinical success were achieved in all patients. No vessel rupture or perforation was observed in this study, nor was distal embolization in the radial artery or symptomatic pulmonary embolism. No radial artery occlusion or fistula infection was seen during the follow-up. The primary patency rates were 82% at 3 months and 64% at 6 months. Transradial intervention for native fistula failure is considered safe and feasible in a selected population; yet requires further validation.

Blackpool Victoria Hospital, Blackpool, Lancashire, England, United Kingdom.

We examined the safety and feasibility of elective outpatient transradial coronary angioplasty (PCI). Four hundred and forty two patients underwent procedures over a 4-year period. Over 95% had an excellent angiographic result and 85% were discharged the same day. Radial access was successful in 417 (94%) patients. There were no major vascular complications. One patient died of a subacute stent thrombosis. Outpatient transradial PCI is safe and feasible for the majority of elective PCI cases.

Aims: Radial artery spasm remains the major limitation of transradial approach for percutaneous coronary interventions. The aim of our study was to evaluate the efficacy of vasodilators in the prevention of radial artery spasm during percutaneous coronary interventions. Methods and results: 1,219 patients were consecutively randomized to receive placebo (n = 198), molsidomine 1 mg (n = 203), verapamil 2.5 mg (n = 409), 5 mg (n = 203) or verapamil 2.5 mg and molsidomine 1 mg (n = 206). All drugs were administered through the arterial sheath. The primary end point was the occurrence of a radial artery spasm defined by the operator as severe limitation of the catheter movement, with or without angiographic confirmation. Main characteristics including age, sex, wrist and arterial sheath diameters and procedure duration were identical across the groups. The rate of radial artery spasm was lowest in patients receiving verapamil and molsidomine (4.9%), compared to verapamil 2.5 mg or 5 mg (8.3 and 7.9%), or molsidomine 1 mg (13.3%); and placebo (22.2%) (P < 0.0001). Conclusion: Radial artery spasm during transradial percutaneous interventions was effectively prevented by the administration of vasodilators. The combination of verapamil 2.5 mg and molsidomine 1 mg provided the strongest relative risk reduction of spasm compared to placebo and should therefore be recommended during percutaneous coronary interventions through the radial approach.