Transcaval access (TCA) is a novel alternative to the traditional transfemoral arterial approach for patients requiring large catheter-based percutaneous procedures such as transcatheter aortic valve implantation (TAVI), left ventricular assist device (LVAD) and thoracic endovascular aortic repair (

Objective. We performed a systematic review with meta-analysis to compare the accuracy of fluoroscopic-guided glenohumeral injections with that of ultrasound-guided glenohumeral injections as reported in prior studies.Methods. We reviewed the databases of MEDLINE, PubMed, and Google Scholar using combinations of the keywords "ultrasound," "fluoroscopy," "injection," and "shoulder" for articles reporting the injection accuracy, confirmed by imaging, of the first attempt under either fluoroscopic or ultrasound guidance. A meta-analysis was performed to assess the accuracy of fluoroscopic-guided glenohumeral injections versus ultrasound-guided glenohumeral injections.Results. Five of 42 pertinent studies met our inclusion criteria for a total of 406 glenohumeral injections, of which 115 were fluoroscopy-guided and 291 were ultrasound-guided. The meta-effect estimates for the proportion of joints successfully injected with ultrasound and fluoroscopic guidance were 93% (95% CI, 86% to 98%) and 80% (95% CI, 63% to 93%), respectively, which did not reach statistical significance (Q[df] = 2.55 [1], p = 0.11).Conclusions. Our meta-analysis indicates that glenohumeral injections guided by ultrasound are more accurate than injections guided by fluoroscopy but this difference did not reach statistical significance. As the use of ultrasound does not expose the patient or practitioner to radiation, its similar accuracy may make it the preferred modality for image-guided glenohumeral joint injections. Limitations to our analysis include the retrospective nature, limited number of studies included, and the potential generalizability of our findings to regions outside of those included in our study. (C) 2014 Wiley Periodicals, Inc.

ObjectiveTo determine the impact of suture‐mediated vascular closure devices (VCDs) on net adverse clinical events (NACEs) after balloon aortic valvuloplasty (BAV).BackgroundIschemic and bleeding complications are common following transfemoral BAV; however, previous studies have been single center and limited by varying definitions of major bleeding.MethodsThe Effect of Bivalirudin on Aortic Valve Intervention Outcomes (BRAVOs) study was a retrospective observational study conducted at two high‐volume academic centers over a 6‐year period designed to compare the effect of bivalirudin versus unfractionated heparin. This is a subanalysis of 428 consecutive patients who underwent BAV (with 10–13 French sheaths) to compare the effect of hemostasis with VCDs versus manual compression utilizing standardized definitions. NACE was defined as the composite of major bleeding and major adverse clinical events (MACEs). All events were adjudicated by an independent clinical events committee who were blinded to antithrombin use.ResultsPreclosure was performed in 269 (62.8%) of patients. While bivalirudin was used more frequently in those with pre‐closure (60.6% vs. 37.7%, P < 0.001), a history of prior BAV (11.1% vs. 3.6%, P = 0.04) and peripheral vascular disease (30.7% vs. 19.7%, P = 0.01) was more common in those not undergoing preclosure (n = 159, 37%). Other clinical and demographic features were well balanced between groups. Vascular closure was associated with a significant reduction in NACE (24.5% vs. 10.0% P < 0.001). Results remained significant after adjusting for baseline differences and bivalirudin use (OR 0.38, 95% CI: 0.21–0.68; P = 0.001).ConclusionsOur study suggests that suture‐mediated vascular closure is associated with a substantial reduction in NACE after transfemoral BAV. Large randomized clinical trials should be conducted to confirm our results.© 2013 Wiley Periodicals, Inc.

Background Balloon aortic valvuloplasty (BAV) is a palliative treatment for severe aortic stenosis that is increasingly performed as a bridge to transcatheter aortic valve replacement. While chronic kidney disease (CKD) is a frequent comorbidity in elderly patients with aortic stenosis undergoing BAV, its impact on in-hospital outcomes has not yet been determined. Methods We conducted a retrospective analysis of 421 consecutive patients who underwent non-emergent BAV at two high-volume centers. We analyzed baseline and procedural characteristics as well as in-hospital outcomes according to the presence or absence of CKD, defined as a glomerular filtration rate of <60 mL/min/1.73m 2 . All adverse events were adjudicated by a blinded, independent clinical events committee. Results Of the 421 patients who underwent BAV, 251 (59.2%) had CKD. Patients with CKD had significantly higher rates of mortality (8.0% vs. 2.4%, p=0.02) and major bleeding (14.3% vs. 7.6%, p=0.04) as well as net adverse clinical events (18.7% vs. 11.2%, p=0.04) compared to patients without CKD. A secondary analysis stratifying the groups by type of antithrombotic used revealed an almost 3-fold decrease in major bleeding events in CKD patients treated with bivalirudin compared to those receiving heparin (5.8% vs. 14.9%, p=0.01). After multivariate analysis controlling for multiple confounders, CKD remained associated with an increased risk for bleeding (OR 1.99; 95%CI [0.83, 4.78]; p=0.12) and death (OR 2.12; 95%CI [0.61, 7.33]; p=0.24), without statistical significance. Conclusions CKD is associated with an increased risk of in-hospital mortality and bleeding complications post-BAV. Further research is warranted to determine whether adverse outcomes in CKD patients can be reduced through selective use of novel devices or alternative pharmacological approaches.

Bleeding is an important safety outcome, and has been defined historically in cardiovascular trials using multiple, heterogeneous definitions. The Bleeding Academic Research Consortium (BARC) standardized bleeding definition was developed to address this. However, a formal comparison of these