Part 1 Introduction: non-penetrating injuries. Part 2 Anatomy: the hyoid bone the larynx the pharynx and oesophagus the carotid sheath the carotid arteries the vertabral artery and its main branches the veins of the neck the cervical vertebrae the spinal cord, meninges and other related structures. Part 3 Techniques of examination: external examination prior to dissection: dissection of the anterior structures dissection of the posterior structures examination for air embolism other techniques for detection of neck trauma. Part 4 Penetrating injuries: stabbing incised wounds and missile wounds internal structural injury from penetrating wounds. Part 5 Compressive neck injury I - signs of mechanical asphyxia: petechial haemorrhages cyanosis congestion of internal organs pulmonary oedema fluidity of blood. Part 6 Compressive neck injury II - manual strangulation: external injuries to the neck internal injuries associated injuries to other regions extent of struggle, length and force of application survivability and complications compression of the neck from neck holds. Part 7 Compressive neck injury III - ligature strangulation: external findings internal injuries. Part 8 Compressive neck injury IV - hanging: the scene of hanging the ligature mark and other external findings internal signs of hanging mechanism of death accidental hanging sexual asphyxia homicidal hanging simulated suicidal hanging to conceal homicide judicial hanging. Part 9 Internal airway obstruction: homicidal choking accidental choking suicidal choking mechanism of death in choking. Part 10 Non-compressive blunt impact injuries to the anterior compartment: hyoid bone injuries laryngeal trauma cervical trachea trauma pharyngeal and oesophageal trauma anterior neck injuries and degenerative disease of the cervical spine injuries to the carotid arteries. Part 11 Non-compressive blunt impact injuries to the posterior compartment: incidence flexion and extension injuries axial compression lateral flexion injuries rotational force injuries whiplash injuries road traffic accident injuries sports injuries injuries to the cervical spine affected by chronic degenerative conditions cervical cord trauma vertebral artery trauma. Part 12 Toxic and miscellaneous environmental causes of neck injuries: thermal burns chemical burns electrical injuries voice misuse. Part 13 Injuries resulting from therapeutic, investigative and other related actions: injuries from tracheostomy injuries resulting from intubation oesophageal injuries injuries resulting from invasive vascular techniques chiropractic manipulation of the neck neck traction injuries following resuscitation injuries from ionizing radiation.

Advances in personalized medicine and Systems Biology have introduced probabilistic models and error discovery to cardiovascular care, aiding disease prevention and procedural planning. However, clinical application faces cultural, technical, and methodological hurdles. Patient autonomy remains essential, with shared decision-making (SDM) gaining importance in managing complex cardiovascular treatment options. Effective SDM relies on collaboration between providers and patients, guided by P5 Medicine principles, which combine psycho-cognitive considerations with predictive, personalized, preventive, and participatory care. Here we propose a three-step methodological proposal for implementing SDM and enhancing consent acquisition in cardiovascular care. The approach emphasizes personalized patient engagement and the need for clear, comprehensive consent processes. It identifies and addresses significant gaps in current practices, including the complexity of consent language, information dispersion, and the specific needs of vulnerable populations. Issues of Medical Responsibility and/or Liability may raise in the case of absence of consent acquisition or invalid consent due to insufficient/incorrect information. The International Guidelines on Medico-Legal Methods of Ascertainment and Evaluation Criteria are reported. In conclusion, the paper proposes practical solutions, including the use of artificial intelligence (AI) to enhance decision-making and patient counseling, and strategies to ensure that consent processes are both thorough and legally sound and respectful to the individual's autonomy.

Introduction Intravascular lithotripsy (IVL) [Shockwave Medical Inc] is a relatively novel method of treating complex, calcified coronary lesions and is becoming a fundamental staple of the coronary calcium modulation algorithm. When compared to rotational atherectomy (RA) [Boston Scientific], it has lower procedural complication rates.Objective: To compare the real-world costs and utilisation of resources, procedural and 30 days complications, radiation exposure and contrast volume use between IVL and RA at the Trent Cardiac Centre (TCC), Nottingham University Hospitals NHS Trusts - a tertiary UK cardiac centre. Method Consecutive patients undergoing percutaneous coronary intervention (PCI) where IVL was utilised (n=12) were compared to consecutive patients where RA was utilised (n=12) in 2021/22 at TCC. Patients' data were electronically retrieved from the hospital's cardiovascular electronic system TOMCAT [Philips]. Patients' demographics and risk factors, periprocedural events, procedural time, contrast volume and radiation doses were analysed and compared in both groups. Incidence of major adverse cardiovascular events (MACE) and hospital re-admissions over the following 30 days were recorded. Cost data was calculated using the NHS Patient Level Information and Costing System (PLICS). Continuous data are expressed as a mean ± 2 standard deviations and p-values calculated using one-tailed Student's t-test. Results The mean age was 74.8 ± 8.8 years in the IVL groups vs. 77.2 ± 9 years in the RA group, p=0.26. Numerically, the proportion of females was higher in IVL group as well as the presence of vascular risk factors such as hypertension, hyperlipidaemia, and smoking history. In the RA group, two procedural complications were reported (side branch occlusion and coronary dissection) whereas only one complication (femoral site access haematoma) was recorded in IVL group (p<0.07). No MACE events at 30 days were recorded in either group. There were no significant differences in procedural time (mean difference 15 mins, IVL = 128 ± 29 mins vs. RA = 113 ± 27 mins, p=0.22), contrast volume use (mean difference 34 ml, IVL = 210 ± 48 ml vs. RA = 176 ± 47 ml, p=0.16) or Dose Area Product (DAP) radiation exposure (mean difference 956 Gycm2, IVL = 4803 ± 1,604Gycm2 vs. RA =5,759 ± 3,326Gycm2, p=0.29). The cost of the IVL balloon was identical in cost to the RotaLink™ plus in our institution, at around £1440. There was no statistical difference in the procedural costs between the two groups (procedural costs mean difference £368, IVL = £3759 ± 867 vs. RA = £4128 ± 901, p<0.26), but the overall costs, which included inpatient and outpatient costs, pathology, radiology and staff costs projected out to 1 year, were significantly lower with PCI with IVL vs. PCI with RA (overall costs mean difference £3,120, IVL = £10,626 ± 2,876 vs. RA = £13,746 ± 2,536, p<0.04) (Figure1). Conclusion There were no significant differences in levels of radiation exposure, contrast volume used or length of the procedure comparing IVL with RA. There was significant overall cost reduction with the use of IVL in complex PCI procedures with cost effectiveness being predicted over the following year. Future randomised trials of new PCI technologies should include a formal health economic analysis. Conflict of Interest None

Late, repetitive or chronic remote ischaemic conditioning (CRIC) is a potential cardioprotective strategy against adverse remodelling following ST-segment elevation myocardial infarction (STEMI). In the randomised Daily Remote Ischaemic Conditioning Following Acute Myocardial Infarction (DREAM) trial, CRIC following primary percutaneous coronary intervention (P-PCI) did not improve global left ventricular (LV) systolic function. A post-hoc analysis was performed to determine whether CRIC improved regional strain. All 73 patients completing the original trial were studied (38 receiving 4 weeks’ daily CRIC, 35 controls receiving sham conditioning). Patients underwent cardiovascular magnetic resonance at baseline (5–7 days post-STEMI) and after 4 months, with assessment of LV systolic function, infarct size and strain (longitudinal/circumferential, in infarct-related and remote territories). At both timepoints, there were no significant between-group differences in global indices (LV ejection fraction, infarct size, longitudinal/circumferential strain). However, regional analysis revealed a significant improvement in longitudinal strain in the infarcted segments of the CRIC group (from − 16.2 ± 5.2 at baseline to − 18.7 ± 6.3 at follow up, p = 0.0006) but not in corresponding segments of the control group (from − 15.5 ± 4.0 to − 15.2 ± 4.7, p = 0.81; for change: − 2.5 ± 3.6 versus + 0.3 ± 5.6, respectively, p = 0.027). In remote territories, there was a lower increment in subendocardial circumferential strain in the CRIC group than in controls (− 1.2 ± 4.4 versus − 2.5 ± 4.0, p = 0.038). In summary, CRIC following P-PCI for STEMI is associated with improved longitudinal strain in infarct-related segments, and an attenuated increase in circumferential strain in remote segments. Further work is needed to establish whether these changes may translate into a reduced incidence of adverse remodelling and clinical events. Clinical Trial Registration: http://clinicaltrials.gov/show/NCT01664611 .

Pathology of Sharp Force Trauma illustrates and details sharp force trauma as seen in forensic pathology case work as well as in the clinical setting, outlining how one informs the other in interpreting such trauma for medico-legal purposes. For the purposes of discussion, the author defines sharp force trauma as: "The application of force to produce an injury which results in a clear division or separation of the skin and underlying tissues". Sharp force trauma may be caused by all manner of implements with a sharp edge and/or pointed end, whether or not they have been produced for use as a weapon, and includes knives, broken glass, scissors and many others, to name but a few. Certain tools, such as axes or machetes, combine a sharp edge with heavy weight and produce injuries with both sharp and blunt impact elements. In many countries, with the exception of those where firearms are readily available, sharp force trauma—particularly the use of knives—is the most common method of homicide and a frequent source of morbidity seen in emergency departments. Also, there has recently been an alarming upsurge in the use of knives in gang-related assaults and in terrorist incidents. As such, the book takes a comprehensive approach in explaining the different aspects of such trauma, most importantly the manner in which the victim has died. This includes cases of homicide, suicide or accident, indicating the type of weapon responsible, explaining how it was used, and presenting other such information to the investigation of such cases. Features: • Includes over 400 full-color graphic and illustrative images throughout • Addresses all aspects of the investigation including trauma, crime scene findings, post-mortem examination, characteristics of injuries and categorization into homicide, suicide or accident • Covers the biomechanics of knife trauma and tool mark examination techniques to identify implements used • Illustrates penetrating injuries caused by pointed implements which have linear components, such as arrows, nails, spears, stakes and others • Details cutting, penetrating, and other sharp force injuries resulting from medical intervention in a healthcare environment, such as might occur during surgical procedures • Examines sharp injuries caused by domesticated and wild animals • Written by one of the premier forensic pathologists in the world with over 40 years of first-hand case experience Pathology of Sharp Force Trauma is the first substantive book published in English to look exclusively at this subject. Although primarily intended for pathologists and clinicians who are involved in the examination of such injuries in the post-mortem room or in a hospital environment, it will also be of interest to medical examiners, police and criminal investigators, attorneys and legal professionals, personnel in other forensic disciplines, and all doctors and medical students with an interested in trauma and its management.

Conversion therapy is a set of practices that aim to change or alter an individual’s sexual orientation or gender identity. It is premised on a belief that an individual’s sexual orientation or gender identity can be changed and that doing so is a desirable outcome for the individual, family, or community. Other terms used to describe this practice include sexual orientation change effort (SOCE), reparative therapy, reintegrative therapy, reorientation therapy, ex-gay therapy, and gay cure. Conversion therapy is practiced in every region of the world. We have identified sources confirming or indicating that conversion therapy is performed in over 60 countries.1 In those countries where it is performed, a wide and variable range of practices are believed to create change in an individual’s sexual orientation or gender identity. Some examples of these include: talk therapy or psychotherapy (e.g., exploring life events to identify the cause); group therapy; medication (including anti-psychotics, anti- depressants, anti-anxiety, and psychoactive drugs, and hormone injections); Eye Movement Desensitization and Reprocessing (where an individual focuses on a traumatic memory while simultaneously experiencing bilateral stimulation); electroshock or electroconvulsive therapy (ECT) (where electrodes are attached to the head and electric current is passed between them to induce seizure); aversive treatments (including electric shock to the hands and/or genitals or nausea-inducing medication administered with presentation of homoerotic stimuli); exorcism or ritual cleansing (e.g., beating the individual with a broomstick while reading holy verses or burning the individual’s head, back, and palms); force-feeding or food deprivation; forced nudity; behavioural conditioning (e.g., being forced to dress or walk in a particular way); isolation (sometimes for long periods of time, which may include solitary confinement or being kept from interacting with the outside world); verbal abuse; humiliation; hypnosis; hospital confinement; beatings; and “corrective” rape. Conversion therapy appears to be performed widely by health professionals, including medical doctors, psychiatrists, psychologists, sexologists, and therapists. It is also conducted by spiritual leaders, religious practitioners, traditional healers, and community or family members. Conversion therapy is undertaken both in contexts under state control, e.g., hospitals, schools, and juvenile detention facilities, as well as in private settings like homes, religious institutions, or youth camps and retreats. In some countries, conversion therapy is imposed by the order or instructions of public officials, judges, or the police. The practice is undertaken with both adults and minors who may be lesbian, gay, bisexual, trans, or gender diverse. Parents are also known to send their children back to their country of origin to receive it. The practice supports the belief that non-heterosexual orientations are deviations from the norm, reflecting a disease, disorder, or sin. The practitioner conveys the message that heterosexuality is the normal and healthy sexual orientation and gender identity. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly2 or without their consent. This medico-legal statement also addresses the responsibility of states in regulating this practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to this practice. Definitions of conversion therapy vary. Some include any attempt to change, suppress, or divert an individual’s sexual orientation, gender identity, or gender expression. This medico-legal statement only addresses those practices that practitioners believe can effect a genuine change in an individual’s sexual orientation or gender identity. Acts of physical and psychological violence or discrimination that aim solely to inflict pain and suffering or punish individuals due to their sexual orientation or gender identity, are not addressed, but are wholly condemned. This medico-legal statement follows along the lines of our previous publications on Anal Examinations in Cases of Alleged Homosexuality1 and on Forced Virginity Testing.2 In those statements, we opposed attempts to minimise the severity of physical and psychological pain and suffering caused by these examinations by qualifying them as medical in nature. There is no medical justification for inflicting on individuals torture or other cruel, inhuman, or degrading treatment or punishment. In addition, these statements reaffirmed that health professionals should take no role in attempting to control sexuality and knowingly or unknowingly supporting state-sponsored policing and punishing of individuals based on their sexual orientation or gender identity.

Conversion therapy is a set of practices that aim to change or alter an individual's sexual orientation or gender identity. It is practiced in every region of the world by health professionals, religious practitioners, and community or family members often by or with the support of the state. Conversion therapy is performed despite evidence that it is ineffective and likely to cause individuals significant or severe physical and mental pain and suffering with long-term harmful effects. The purpose of this medico-legal statement is to provide legal experts, adjudicators, health care professionals, and policy makers, among others, with an understanding of: 1) the lack of medical and scientific validity of conversion therapy; 2) the likely physical and psychological consequences of undergoing conversion therapy; and 3) whether, based on these effects, conversion therapy constitutes cruel, inhuman, or degrading treatment or torture when individuals are subjected to it forcibly or without their consent. This medico-legal statement also addresses the responsibility of states in regulating the practice, the ethical implications of offering or performing it, and the role that health professionals and medical and mental health organisations should play with regards to it.

Intermittent ischaemia and reperfusion cycles, or ischaemic conditioning, has been viewed as a promising potential cardioprotective technique since its first description by Murry and colleagues in 1986.1Murry CE Jennings RB Reimer KA Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium.Circulation. 1986; 74: 1124-1136Crossref PubMed Scopus (7016) Google Scholar The most encouraging iteration of this technique to emerge over the past three decades has been the application of a modified blood pressure cuff placed on the upper arm to induce cycles of remote, transient ischaemia that relay protection to the heart via predominantly neurohormonal mechanisms.2Davidson SM Arjun S Basalay MV et al.The 10th Biennial Hatter Cardiovascular Institute workshop: cellular protection-evaluating new directions in the setting of myocardial infarction, ischaemic stroke, and cardio-oncology.Basic Res Cardiol. 2018; 113: 43Crossref PubMed Scopus (65) Google Scholar Remote ischaemic conditioning showed early potential in reducing infarct size after myocardial infarction in animal models.3Kerendi F Kin H Halkos ME et al.Remote postconditioning. Brief renal ischemia and reperfusion applied before coronary artery reperfusion reduces myocardial infarct size via endogenous activation of adenosine receptors.Basic Res Cardiol. 2005; 100: 404-412Crossref PubMed Scopus (261) Google Scholar, 4Andreka G Vertesaljai M Szantho G et al.Remote ischaemic postconditioning protects the heart during acute myocardial infarction in pigs.Heart. 2007; 93: 749-752Crossref PubMed Scopus (170) Google Scholar The initial CONDI-1 trial, although small (n=333), suggested that remote ischaemic conditions used as an adjunct to the gold standard therapy of primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) improved the myocardial salvage index5Bøtker HE Kharbanda R Schmidt MR et al.Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial.Lancet. 2010; 375: 727-734Summary Full Text Full Text PDF PubMed Scopus (810) Google Scholar as well as left ventricular systolic function at 30 days in patients at risk of large infarcts.6Munk K Andersen NH Schmidt MR et al.Remote ischemic conditioning in patients with myocardial infarction treated with primary angioplasty: impact on left ventricular function assessed by comprehensive echocardiography and gated single-photon emission CT.Circ Cardiovasc Imaging. 2010; 3: 656-662Crossref PubMed Scopus (106) Google Scholar The results of the RIC-STEMI trial (n=258) echoed those of CONDI-1, with remote ischaemic conditioning showing additional benefits in reducing cardiac deaths and hospitalisations and increasing the overall mean improvement of ejection fraction after 1 year.7Gaspar A Lourenço AP Pereira MÁ et al.Randomized controlled trial of remote ischaemic conditioning in ST-elevation myocardial infarction as adjuvant to primary angioplasty (RIC-STEMI).Basic Res Cardiol. 2018; 113: 14Crossref PubMed Scopus (109) Google Scholar Medium-term follow-up data (at a median 3·6 years) from the LIPSIA CONDITIONING study (n=696) showed that remote ischaemic conditioning combined with post-conditioning reduced new heart failure diagnoses compared with remote ischaemic conditioning alone.8Eitel I Stiermaier T Rommel KP et al.Cardioprotection by combined intrahospital remote ischaemic perconditioning and postconditioning in ST-elevation myocardial infarction: the randomized LIPSIA CONDITIONING trial.Eur Heart J. 2015; 36: 3049-3057Crossref PubMed Scopus (170) Google Scholar None of these trials showed a reduction in infarct size when remote ischaemic conditioning was applied; however, cardiac MRI data suggest the ability of remote ischaemic conditioning to induce positive ventricular remodelling in the absence of absolute infarct size reduction.9Traverse JH Swingen CM Henry TD et al.NHLBI-sponsored randomized trial of postconditioning during primary percutaneous coronary intervention for ST-elevation myocardial infarction.Circ Res. 2019; 124: 769-778Crossref PubMed Scopus (28) Google Scholar In The Lancet, Derek Hausenloy and colleagues10Hausenloy DJ Kharbanda RK Møller UK et al.Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.Lancet. 2019; (published online Sept 6.)http://dx.doi.org/10.1016/S0140-6736(19)32039-2Summary Full Text Full Text PDF PubMed Scopus (173) Google Scholar report the findings of the combined CONDI-2/ERIC-PPCI trial, a large and appropriately powered randomised controlled trial to address whether remote ischaemic conditioning as an adjunct to PPCI can improve the clinical outcomes of patients with STEMI when compared with PPCI alone. The trial was a pragmatic combination of two very similar protocol designs. Between 2013 and 2018, 5401 patients undergoing PPCI for STEMI across four European countries were randomly allocated (1:1) to PPCI alone (mean age 63·1 years [SD 12·2], 576 [22·4%] women) or PPCI plus remote ischaemic conditioning (63·9 years [12·1], 611 [24·0%] women). Remote ischaemic conditioning was administered either in the ambulance en route to the hospital or in the hospital, before or during the PPCI procedure. The combined primary endpoint, cardiac death or hospitalisation for heart failure within 1 year, did not differ between groups, occurring in 220 (8·6%) patients in the control group and 239 (9·4%) in the remote ischaemic conditioning group (hazard ratio [HR] 1·10 [95% CI 0·91–1·32], p=0·32). This finding was consistent in prespecified subgroup analyses by age, presence of diabetes, pre-PPCI TIMI flow, ischaemia time, or infarct location. Furthermore, the 12-month incidence of major adverse cardiac and cerebrovascular events (a composite of all-cause death, reinfarction, unplanned revascularisation, and stroke) did not differ significantly between the groups (HR 1·09 [95% CI 0·90–1·32], p=0·38). Hausenloy and colleagues should be praised for their robust and clinically relevant trial to assess the role of remote ischaemic conditioning in the current landscape of STEMI management. The findings show clearly that the use of remote ischaemic conditioning around the time of PPCI for STEMI adds no clinical benefit for outcomes assessed within 1 year of the procedure.10Hausenloy DJ Kharbanda RK Møller UK et al.Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trial.Lancet. 2019; (published online Sept 6.)http://dx.doi.org/10.1016/S0140-6736(19)32039-2Summary Full Text Full Text PDF PubMed Scopus (173) Google Scholar A cautionary note pertains to the follow-up time of only 1 year: our current understanding of cardiac remodelling post-STEMI is that the clinical benefits derived from cardioprotective interventions might not manifest until after 2 years, or perhaps longer,11Hassell ME Vlastra W Robbers L et al.Long-term left ventricular remodelling after revascularisation for ST-segment elevation myocardial infarction as assessed by cardiac magnetic resonance imaging.Open Heart. 2017; 4e000569Crossref PubMed Scopus (14) Google Scholar and as such the trial could have benefited from a longer follow-up time. The authors also acknowledge that the remote ischaemic conditioning protocol used (four 5-min cycles of upper arm cuff inflations and deflations applied before PPCI) might have been insufficient to induce an adequate neurohormonal response in some patients, although this protocol has been shown to be the most efficacious one in animal and subsequent clinical studies.12Johnsen J Pryds K Salman R Løfgren B Kristiansen SB Bøtker HE The remote ischemic preconditioning algorithm: effect of number of cycles, cycle duration and effector organ mass on efficacy of protection.Basic Res Cardiol. 2016; 111: 10Crossref PubMed Scopus (101) Google Scholar The role of remote ischaemic conditioning in improving the lives of patients with STEMI has been thrown sharply into question. Despite the early promise of a number of preclinical and smaller proof-of-principle clinical trials, this large and adequately powered trial points to a lack of clinical efficacy for remote ischaemic conditioning in this setting. As such, it might be time to abandon this form of cardioprotection in favour of more effective therapies to extend and improve the lives of these patients. I declare no competing interests. Effect of remote ischaemic conditioning on clinical outcomes in patients with acute myocardial infarction (CONDI-2/ERIC-PPCI): a single-blind randomised controlled trialRemote ischaemic conditioning does not improve clinical outcomes (cardiac death or hospitalisation for heart failure) at 12 months in patients with STEMI undergoing PPCI. Full-Text PDF Open Access

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) using the hybrid algorithm has traditionally been performed femorally using 8 Fr sheaths. Antegrade dissection and re-entry (ADR) has facilitated procedures using 6 and 7 Fr guides via the radial artery. Radial artery dysfunction and occlusion is a recognized complication preventing future radial procedures, but is significantly less common with 5 Fr sheaths. Five Fr contralateral radial access (48% left, 52% right) was used in 33 consecutive patients undergoing elective CTO-PCI in a single United Kingdom (UK) center over a 2-year period. Procedural data were recorded in the UK Hybrid CTO registry. Antegrade access was via contralateral radial in 26 cases and via femoral access in 5 cases. Single 5 Fr access was used in 2 cases treated by antegrade wire escalation. The mean J-CTO score was 2.1 ± 1.2, with an overall success rate of 91%. A retrograde approach was used in 9 cases and ADR was used in 9 cases. The mean fluoroscopy and procedure times were 45.2 ± 30.6 min and 172.5 ± 118.1 min, respectively, and the mean volume of contrast use was 218.5 ± 83.0 mL. There was 1 radial artery complication, 1 case of periprocedural myocardial infarction, and 1 case of tamponade. In this series, 5 Fr contralateral access provided adequate visualization in all cases. A 5 Fr guide provided adequate support in all retrograde cases to cross with a microcatheter after wire passage. Down-sizing contralateral access to 5 Fr routinely is feasible and may lead to a reduction in radial artery dysfunction and occlusion, as well as a reduction in the volume of contrast used.