- Email: [email protected]
A new operative classification of both anatomic vascular variants and physiopathologic conditions affecting transradial cardiovascular procedures
120
Letters to the Editor
A new operative classification of both anatomic vascular variants and physiopathologic conditions affecting transradial cardiovascular procedures Francesco Burzotta a,⁎, Carlo Trani a, Maria De Vita a,b, Filippo Crea a a b
Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy Cardiology Department “Morgagni-Pierantoni” Hospital, Forlì, Italy
a r t i c l e
i n f o
Article history: Received 12 June 2009 Accepted 15 June 2009 Available online 17 July 2009 Keywords: Radial approach Anatomy Classification
Transradial approach (TRA) for coronary diagnostic and interventional procedures is known to shorten hospitalization and dramatically reduce access-site complications [1,2] On such bases, TRA has been successfully adopted not only for coronary interventions and in selected patients, but also for coronary interventions in complex patients [3,4] and for peripheral interventions [5–7]. Nevertheless, the average technical failure of transradial approach (TRA) in coronary procedures is 5.8% [2] and is significantly higher than that reported in transfemoral approach. Such higher failure rate of TRA is due to a series of factors including radial artery spasm and anatomical variants of the arteries which should be navigated to reach the ascending aorta. In particular, a wide range of anatomic variants either of the brachioradial and of the axillo-subclavian-anonymous arterial axis or of the aortic arch may be present in patients undergoing TRA procedures hindering procedural success. The relevance of anatomic variants of brachioradial arterial axis has been well recognized in a series of studies on populations undergoing coronary procedures by radial access [8–12]. These angiographic studies tried to partially incorporate in their classification the definitions of anatomic variants of the upper limb arteries emerging from postmortem studies [13,14], but no homogeneous classification has been proposed. Thus, data are not easy to compare and to apply in the clinical practice. Moreover, anatomic classifications derived from postmortem studies describe many variants which do not have any influence on TRA procedures, like the anomalous course of radial and brachial arteries in relation to muscles and nerves which are not affecting TRA. Conversely, the postmortem studies do not even report radial or brachial artery tortuosities which are frequently detected by angiography and may influence the TRA procedures. Finally, both atherosclerotic disease of the arm arteries and anatomic variants of the axillary-subclavian-anonymous arterial axis and of the aortic arch, regardless of their obvious relevance for TRA procedures, are not classified and usually not reported. Since the knowledge and recognition of the different anatomic variants is the key to successfully complete transradial coronary procedures, we reviewed the most comprehensive autopsy-based classification of arterial variants in the upper limb by Rodríguez-
⁎ Corresponding author. Via Prati Fiscali 158, 00141 Rome, Italy. Tel.: +39 3494295290; fax: +39 06 3055535. E-mail address: [email protected] (F. Burzotta).
Niedenführ et al. [14] and the categories identified in the angiographic studies on TRA coronary procedures. Then, we propose a simplified “operative” classification which is not limited to the radial–brachial axis but also includes the variants of the axillary-subclavian-anonymous axis and of the aortic arch [15–17], possibly affecting TRA procedures. In this new classification we add to the anatomic variants some physiopathologic conditions, potentially altering the arterial lumen and course, like arm arteries atherosclerotic disease and the age-related aortic arch elongation which in our experience are relevant for TRA. The proposed operative classification is reported in Table 1 (left column) and compared with the postmortem anatomical classification (if available, right column) [14]. However, the incidence of such variants assessed by postmortem studies or by systematic angiography does not reflect their impact on procedures. Thus, we estimated the frequency of each variant in a series of 2680 consecutive TRA coronary procedures (by two expert operators, CT and FB, from January 2006 to April 2009) in which angiography was performed anytime difficulty was encountered during catheter or wire advancement/manipulation (338 cases, 12.6%). This simplified but comprehensive classification, incorporating all the angiographic variants which need to be overcame for successful TRA, may provide practical insights to interventional cardiologists performing transradial procedures. The authors of this manuscript certify that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [18]. References [1] Agostoni P, Biondi-Zoccai GG, de Benedictis ML, Rigattieri S, Turri M, Anselmi M, Vassanelli C, Zardini P, Louvard Y, Hamon M. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–56. [2] Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157:132–40. [3] Hildick-Smith DJ, Ludman PF, Lowe MD, Stephens NG, Harcombe AA, Walsh JT, Stone DL, Shapiro LM, Schofield PM, Petch MC. Comparison of radial versus brachial approaches for diagnostic coronary angiography when the femoral approach is contraindicated. Am J Cardiol 1998;81(6):770–2. [4] Burzotta F, Trani C, Hamon M, Amoroso G, Kiemeneij F. Transradial approach for coronary angiography and interventions in patients with coronary bypass grafts: tips and tricks. Catheter Cardiovasc Interv 2008;72:263–72. [5] C. Trani, A. Tomassino, F. Burzotta. Transradial renal stenting: why and how. Catheter Cardiovasc Interv 2009. [Electronic publication ahead of print]. [6] Trani C, Burzotta F, Tomassino A, Giammarinaro M. Transradial approach to treat superficial artery in-stent restenosis. Catheter Cardiovasc Interv 2009;74 (2):267–72. [7] Trani C, Burzotta F, Coroleu GF. Transradial carotid artery stenting with proximal embolic protection. Catheter Cardiovasc Interv 2009;74:494-498–272. [8] Yokoyama N, Takeshita S, Ochiai M, Koyama Y, Hoshino S, Isshiki T, Sato T. Anatomic variations of the radial artery in patients undergoing transradial coronary intervention. Catheter Cardiovasc Interv 2000;49:357–62. [9] Yoo BS, Yoon J, Ko JY, Kim JY, Lee SH, Hwang SO, Choe KH. Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity. Int J Cardiol 2005;101:421–7. [10] Valsecchi O, Vassileva A, Musumeci G, Rossini R, Tespili M, Guagliumi G, Mihalcsik L, Gavazzi A, Ferrazzi P. Failure of transradial approach during coronary interventions: anatomic considerations. Catheter Cardiovasc Interv 2006;67:870–8. [11] Lo TS, Nolan J, Fountzopoulos E, Behan M, Butler R, Hetherington SL, Vijayalakshmi K, Rajagopal R, Fraser D, Zaman A, Hildick-Smith D. Radial artery anomaly and its influence on transradial coronary procedural outcome. Heart 2009;95:410–5. [12] Louvard Y, Lefèvre T. Loops and transradial approach in coronary diagnosis and intervention. Catheter Cardiovasc Interv 2000;51:250–2.
Letters to the Editor
121
Table 1 Vascular anatomic variants affecting transradial approach (TRA) for percutaneous procedures: procedure-oriented angiographic classification integrated with the comprehensive classification of upper limb vascular anatomic anomalies described in postmortem studies. Procedural classification Radio-brachial arterial axis Radial artery pulse absent – Congenital absence of the artery – Acquired occlusion due to previous injury or occlusive atherosclerotic disease Significant (N 50%) radial artery atherosclerotic stenosis Radial and brachial artery tortuosities (bending N45°) Radial artery loops (360° loop in the arterial course not located at anastomotic sites) Radio-ulnar loops (360° loop at the anastomosis with brachial-ulnar artery) Brachial artery loops (360° loop in the arterial course not located at anastomotic sites) High origin of the radial artery from brachial or axillary artery
Other variants (not or marginally affecting TRA)
Anatomic classification/definition
Absence of radial artery: 4%–13%b complete absence of the radial artery supplied by the anterior interosseous or the median arteries (reported incidence b 0.03%) Not described
0.4%
Not described
5.9%
Not described
0.3%
Brachioradial artery and superficial brachioradial artery: 0.7% the brachioradial artery and the superficial brachioradial artery merging with the brachial and/or the ulnar artery with a 360° loop Not described 0.1%
Brachioradial artery: 3.4% high origin of radial artery from brachial or axillary artery with a normal brachial artery branching into ulnar and interosseous arteries Superficial brachioradial artery: high origin of radial artery from brachial or axillary artery with a normal brachial artery branching into ulnar and interosseous arteries with an anomalous course over the brachioradialis muscle Superficial brachioulnoradial artery: superficial brachial artery branching into radial and ulnar arteries coexisting with a normal brachial artery that origins from the axillary artery and continues as the common interosseous trunk Superficial brachial artery: 0.01% anomalous course in front of the median nerve Accessory brachial artery: two brachial arteries rejoining before branching in the two normal forearm arteries Brachioulnar artery: high origin of isolated ulnar artery coexisting with a brachial artery branching into radial and interosseous arteries Superficial brachioulnar artery: high origin of isolated ulnar artery coexisting with a brachial artery branching into radial and interosseous arteries with an anomalous course over the brachioradialis muscle Brachiointerosseous artery: high origin of isolated interosseous artery coexisting with a normal brachial artery branching in radial and ulnar arteries Superficial brachiomedian artery: high origin of the isolated median artery coexisting with a normal brachial artery branching in radial and ulnar arteries with an anomalous course over the superficial flexor muscles Superficial radial artery: superficial course of the radial artery over the tendons Duplication of radial artery: normal radial artery coexisting with brachioradial artery originating from the axillary artery; the two arteries anastomosed at the elbow and than continues separately to the wrist (incidence b 0.02%) Duplication of the ulnar artery: normal ulnar artery coexisting with the brachioulnar artery originating from the axillary artery Absence of ulnar artery: complete absence of the ulnar artery supplied by the radial and intereosseous arteries
Axillary-subclavian-anonymous arterial axis Severe tortuosities (bend of more than 90° NA in the contour of the vessel) Significant (N 50%) atherosclerotic stenosis of the NA axillary-subclavian anonymous arterial axis Aortic arch Retro-esophageal right subclavian artery (RORSA or arteria lusoria) Aortic arch elongation Other anatomical abnormalities (not or marginally affecting TRA)
Incidence (angiographya)
1.7% 0.6%
Right subclavian artery arising from the distal and posterior margin of the horizontal part of the aortic 0.1% arch at its junction with the descending aorta, less frequently from the proximal descending aorta Aortic arch elongation creating distal dislodgement of the anonymous trunk and changes in the 0.1% ascending aorta anatomy, generally associated with advanced age and hypertension • Sharp angulations between the anonymous trunk and the ascending aorta 0.3% • Posterior origin of the anonymous trunk often associated with extreme angulation between this artery and the ascending aorta • Dilatation of the ascending aorta associated to distortion of its orientation (creating sharp angulation between ascending aorta and aortic arch long axes)
NA: not available. a The incidence of each item is based on 338 angiography performed in the case of difficult catheter/wire advancement during 2680 consecutive procedures performed by transradial (TRA) approach by two operators (CF and FB). b Reported rates of radial artery occlusion after transradial cardiac catheterization.
122
Letters to the Editor
[13] Mc Cormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet 1953;96:43–54. [14] Rodríguez-Niedenführ M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sañudo JR. Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study, with a review of the literature. J Anat 2001;199(Pt 5):547–66. [15] Cha KS, Kim MH, Kim HJ. Prevalence and clinical predictors of severe tortuosity of right subclavian artery in patients undergoing transradial coronary angiography. Am J Cardiol 2003;92:1220–2.
[16] Rigatelli G, Rigatelli G. Screening angiography of supraaortic vessels performed by invasive cardiologists at the time of cardiac catheterization: indications and results. Int J Cardiovasc Imaging 2005;21:179–83. [17] Abhaichand RK, Louvard Y, Gobeil JF, Loubeyre C, Lefèvre T, Morice MC. The problem of arteria lusoria in right transradial coronary angiography and angioplasty. Catheter Cardiovasc Interv 2001;54:196–201. [18] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.
0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.06.025
Measuring the adherence to medication of elderly patients with heart failure: Is there a gold standard? Helen Smith a,⁎, Matthew Hankins a, Andrew Hodson a , Charles George b a b
Division of Public Health & Primary Care, Brighton & Sussex Medical School, Brighton, United Kingdom School of Medicine, Southampton University, United Kingdom
a r t i c l e
i n f o
Article history: Received 11 June 2009 Accepted 15 June 2009 Available online 16 July 2009 Keywords: Heart failure Adherence Compliance
The overall prevalence of heart failure in the UK has been estimated to be 1%, rising to 5–12% of those aged over 75 years [1]. First choice treatments are angiotensin converting enzyme inhibitors (ACE-I) [2–5] and loop diuretics [6]. Loop diuretics have a short duration of action [7] and the pharmacological effects of ACE-I require at least 80% inhibition of that enzyme [7]. Consequently it is important for patients to take their medicines regularly to derive maximum benefit. A recent review [8] estimated that the medication adherence of patients with heart failure ranged from 10% to 99% depending on the measurement method employed. Electronic monitoring is often considered the ‘gold standard’ but, whilst technologically sophisticated, it monitors only the opening of the medication container, not the ingestion. Pill counts [9] are similarly regarded as objective though there is no guarantee that medication absent at the count has been taken as prescribed. Patients' self-reported adherence depends on accurate recall and patients may exaggerate their adherence to please their clinician [10]. Self-report has been validated against ‘objective’ methods of measurement in elderly populations (e.g. hypertension [11], Parkinson's [12]) but it is likely that each method varies in performance depending on the population studied and the medications taken. The ⁎ Corresponding author. Brighton & Sussex Medical School, Room 319 Mayfield House, Village Way, Falmer, Brighton, BN1 9PH, United Kingdom. Tel.: +44 1273 644192; fax: +44 1273 644440. E-mail address: [email protected] (H. Smith).
aim of this report was therefore to assess the concordance of three methods of measuring adherence (electronic monitoring, pill count and self-report) in a sample of elderly patients with heart failure. Participants were recruited from three general practices in Romsey, UK. Eligibility criteria were diagnosis or signs indicative of heart failure, aged 65+ years and receiving ACE inhibitors with diuretics. Fifty-two patients were eligible (35 male, 17 female). Mean age was 76 years (SD 6 years). All were Caucasian. The median number of medications taken was 6 (maximum 11). Eleven participants were asymptomatic, 33 mild and 8 moderate in severity (NYHA classification). The eDEM monitor (Aardex Ltd., Switzerland) is a medication container that electronically records each opening. Patients were given their medications pre-packaged in the eDEM device which was retrieved by the research nurse after 6 weeks at the study end. At the same time pill counts and self-report measures were also obtained. Self-reported adherence was assessed using a 6-item questionnaire. Adherences to ACE-I and diuretic were assessed separately. Patients were classified ‘adherent’ by two criteria (90% adherent and 100% adherent) applied to all three methods. Phi coefficients were used to assess the association between each method. Table 1 shows the adherence estimates for ACE-I and diuretic by the three methods. Using the 100% adherence threshold, 81% of patients were classified adherent by self-report for ACE-I, compared to 79% for pill count and 20% for electronic monitoring. For diuretics, 55% of patients
Table 1 Number (%) of adherent participants by the three methods with 100% and 90% thresholds (N = 52). Self-report
Pill count
Electronic monitoring
ACE-I 100% adherent 90% adherent Missing data
42 (81) 50 (96) 0
41 (79) 47 (96) 3
10 (20) 26 (53) 3
Diuretic 100% adherent 90% adherent Missing data
28 (55) 44 (85) 1
30 (63) 40 (83) 4
5 (11) 18 (38) 5
Letters to the Editor
A new operative classification of both anatomic vascular variants and physiopathologic conditions affecting transradial cardiovascular procedures Francesco Burzotta a,⁎, Carlo Trani a, Maria De Vita a,b, Filippo Crea a a b
Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy Cardiology Department “Morgagni-Pierantoni” Hospital, Forlì, Italy
a r t i c l e
i n f o
Article history: Received 12 June 2009 Accepted 15 June 2009 Available online 17 July 2009 Keywords: Radial approach Anatomy Classification
Transradial approach (TRA) for coronary diagnostic and interventional procedures is known to shorten hospitalization and dramatically reduce access-site complications [1,2] On such bases, TRA has been successfully adopted not only for coronary interventions and in selected patients, but also for coronary interventions in complex patients [3,4] and for peripheral interventions [5–7]. Nevertheless, the average technical failure of transradial approach (TRA) in coronary procedures is 5.8% [2] and is significantly higher than that reported in transfemoral approach. Such higher failure rate of TRA is due to a series of factors including radial artery spasm and anatomical variants of the arteries which should be navigated to reach the ascending aorta. In particular, a wide range of anatomic variants either of the brachioradial and of the axillo-subclavian-anonymous arterial axis or of the aortic arch may be present in patients undergoing TRA procedures hindering procedural success. The relevance of anatomic variants of brachioradial arterial axis has been well recognized in a series of studies on populations undergoing coronary procedures by radial access [8–12]. These angiographic studies tried to partially incorporate in their classification the definitions of anatomic variants of the upper limb arteries emerging from postmortem studies [13,14], but no homogeneous classification has been proposed. Thus, data are not easy to compare and to apply in the clinical practice. Moreover, anatomic classifications derived from postmortem studies describe many variants which do not have any influence on TRA procedures, like the anomalous course of radial and brachial arteries in relation to muscles and nerves which are not affecting TRA. Conversely, the postmortem studies do not even report radial or brachial artery tortuosities which are frequently detected by angiography and may influence the TRA procedures. Finally, both atherosclerotic disease of the arm arteries and anatomic variants of the axillary-subclavian-anonymous arterial axis and of the aortic arch, regardless of their obvious relevance for TRA procedures, are not classified and usually not reported. Since the knowledge and recognition of the different anatomic variants is the key to successfully complete transradial coronary procedures, we reviewed the most comprehensive autopsy-based classification of arterial variants in the upper limb by Rodríguez-
⁎ Corresponding author. Via Prati Fiscali 158, 00141 Rome, Italy. Tel.: +39 3494295290; fax: +39 06 3055535. E-mail address: [email protected] (F. Burzotta).
Niedenführ et al. [14] and the categories identified in the angiographic studies on TRA coronary procedures. Then, we propose a simplified “operative” classification which is not limited to the radial–brachial axis but also includes the variants of the axillary-subclavian-anonymous axis and of the aortic arch [15–17], possibly affecting TRA procedures. In this new classification we add to the anatomic variants some physiopathologic conditions, potentially altering the arterial lumen and course, like arm arteries atherosclerotic disease and the age-related aortic arch elongation which in our experience are relevant for TRA. The proposed operative classification is reported in Table 1 (left column) and compared with the postmortem anatomical classification (if available, right column) [14]. However, the incidence of such variants assessed by postmortem studies or by systematic angiography does not reflect their impact on procedures. Thus, we estimated the frequency of each variant in a series of 2680 consecutive TRA coronary procedures (by two expert operators, CT and FB, from January 2006 to April 2009) in which angiography was performed anytime difficulty was encountered during catheter or wire advancement/manipulation (338 cases, 12.6%). This simplified but comprehensive classification, incorporating all the angiographic variants which need to be overcame for successful TRA, may provide practical insights to interventional cardiologists performing transradial procedures. The authors of this manuscript certify that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [18]. References [1] Agostoni P, Biondi-Zoccai GG, de Benedictis ML, Rigattieri S, Turri M, Anselmi M, Vassanelli C, Zardini P, Louvard Y, Hamon M. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349–56. [2] Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157:132–40. [3] Hildick-Smith DJ, Ludman PF, Lowe MD, Stephens NG, Harcombe AA, Walsh JT, Stone DL, Shapiro LM, Schofield PM, Petch MC. Comparison of radial versus brachial approaches for diagnostic coronary angiography when the femoral approach is contraindicated. Am J Cardiol 1998;81(6):770–2. [4] Burzotta F, Trani C, Hamon M, Amoroso G, Kiemeneij F. Transradial approach for coronary angiography and interventions in patients with coronary bypass grafts: tips and tricks. Catheter Cardiovasc Interv 2008;72:263–72. [5] C. Trani, A. Tomassino, F. Burzotta. Transradial renal stenting: why and how. Catheter Cardiovasc Interv 2009. [Electronic publication ahead of print]. [6] Trani C, Burzotta F, Tomassino A, Giammarinaro M. Transradial approach to treat superficial artery in-stent restenosis. Catheter Cardiovasc Interv 2009;74 (2):267–72. [7] Trani C, Burzotta F, Coroleu GF. Transradial carotid artery stenting with proximal embolic protection. Catheter Cardiovasc Interv 2009;74:494-498–272. [8] Yokoyama N, Takeshita S, Ochiai M, Koyama Y, Hoshino S, Isshiki T, Sato T. Anatomic variations of the radial artery in patients undergoing transradial coronary intervention. Catheter Cardiovasc Interv 2000;49:357–62. [9] Yoo BS, Yoon J, Ko JY, Kim JY, Lee SH, Hwang SO, Choe KH. Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity. Int J Cardiol 2005;101:421–7. [10] Valsecchi O, Vassileva A, Musumeci G, Rossini R, Tespili M, Guagliumi G, Mihalcsik L, Gavazzi A, Ferrazzi P. Failure of transradial approach during coronary interventions: anatomic considerations. Catheter Cardiovasc Interv 2006;67:870–8. [11] Lo TS, Nolan J, Fountzopoulos E, Behan M, Butler R, Hetherington SL, Vijayalakshmi K, Rajagopal R, Fraser D, Zaman A, Hildick-Smith D. Radial artery anomaly and its influence on transradial coronary procedural outcome. Heart 2009;95:410–5. [12] Louvard Y, Lefèvre T. Loops and transradial approach in coronary diagnosis and intervention. Catheter Cardiovasc Interv 2000;51:250–2.
Letters to the Editor
121
Table 1 Vascular anatomic variants affecting transradial approach (TRA) for percutaneous procedures: procedure-oriented angiographic classification integrated with the comprehensive classification of upper limb vascular anatomic anomalies described in postmortem studies. Procedural classification Radio-brachial arterial axis Radial artery pulse absent – Congenital absence of the artery – Acquired occlusion due to previous injury or occlusive atherosclerotic disease Significant (N 50%) radial artery atherosclerotic stenosis Radial and brachial artery tortuosities (bending N45°) Radial artery loops (360° loop in the arterial course not located at anastomotic sites) Radio-ulnar loops (360° loop at the anastomosis with brachial-ulnar artery) Brachial artery loops (360° loop in the arterial course not located at anastomotic sites) High origin of the radial artery from brachial or axillary artery
Other variants (not or marginally affecting TRA)
Anatomic classification/definition
Absence of radial artery: 4%–13%b complete absence of the radial artery supplied by the anterior interosseous or the median arteries (reported incidence b 0.03%) Not described
0.4%
Not described
5.9%
Not described
0.3%
Brachioradial artery and superficial brachioradial artery: 0.7% the brachioradial artery and the superficial brachioradial artery merging with the brachial and/or the ulnar artery with a 360° loop Not described 0.1%
Brachioradial artery: 3.4% high origin of radial artery from brachial or axillary artery with a normal brachial artery branching into ulnar and interosseous arteries Superficial brachioradial artery: high origin of radial artery from brachial or axillary artery with a normal brachial artery branching into ulnar and interosseous arteries with an anomalous course over the brachioradialis muscle Superficial brachioulnoradial artery: superficial brachial artery branching into radial and ulnar arteries coexisting with a normal brachial artery that origins from the axillary artery and continues as the common interosseous trunk Superficial brachial artery: 0.01% anomalous course in front of the median nerve Accessory brachial artery: two brachial arteries rejoining before branching in the two normal forearm arteries Brachioulnar artery: high origin of isolated ulnar artery coexisting with a brachial artery branching into radial and interosseous arteries Superficial brachioulnar artery: high origin of isolated ulnar artery coexisting with a brachial artery branching into radial and interosseous arteries with an anomalous course over the brachioradialis muscle Brachiointerosseous artery: high origin of isolated interosseous artery coexisting with a normal brachial artery branching in radial and ulnar arteries Superficial brachiomedian artery: high origin of the isolated median artery coexisting with a normal brachial artery branching in radial and ulnar arteries with an anomalous course over the superficial flexor muscles Superficial radial artery: superficial course of the radial artery over the tendons Duplication of radial artery: normal radial artery coexisting with brachioradial artery originating from the axillary artery; the two arteries anastomosed at the elbow and than continues separately to the wrist (incidence b 0.02%) Duplication of the ulnar artery: normal ulnar artery coexisting with the brachioulnar artery originating from the axillary artery Absence of ulnar artery: complete absence of the ulnar artery supplied by the radial and intereosseous arteries
Axillary-subclavian-anonymous arterial axis Severe tortuosities (bend of more than 90° NA in the contour of the vessel) Significant (N 50%) atherosclerotic stenosis of the NA axillary-subclavian anonymous arterial axis Aortic arch Retro-esophageal right subclavian artery (RORSA or arteria lusoria) Aortic arch elongation Other anatomical abnormalities (not or marginally affecting TRA)
Incidence (angiographya)
1.7% 0.6%
Right subclavian artery arising from the distal and posterior margin of the horizontal part of the aortic 0.1% arch at its junction with the descending aorta, less frequently from the proximal descending aorta Aortic arch elongation creating distal dislodgement of the anonymous trunk and changes in the 0.1% ascending aorta anatomy, generally associated with advanced age and hypertension • Sharp angulations between the anonymous trunk and the ascending aorta 0.3% • Posterior origin of the anonymous trunk often associated with extreme angulation between this artery and the ascending aorta • Dilatation of the ascending aorta associated to distortion of its orientation (creating sharp angulation between ascending aorta and aortic arch long axes)
NA: not available. a The incidence of each item is based on 338 angiography performed in the case of difficult catheter/wire advancement during 2680 consecutive procedures performed by transradial (TRA) approach by two operators (CF and FB). b Reported rates of radial artery occlusion after transradial cardiac catheterization.
122
Letters to the Editor
[13] Mc Cormack LJ, Cauldwell EW, Anson BJ. Brachial and antebrachial arterial patterns; a study of 750 extremities. Surg Gynecol Obstet 1953;96:43–54. [14] Rodríguez-Niedenführ M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sañudo JR. Variations of the arterial pattern in the upper limb revisited: a morphological and statistical study, with a review of the literature. J Anat 2001;199(Pt 5):547–66. [15] Cha KS, Kim MH, Kim HJ. Prevalence and clinical predictors of severe tortuosity of right subclavian artery in patients undergoing transradial coronary angiography. Am J Cardiol 2003;92:1220–2.
[16] Rigatelli G, Rigatelli G. Screening angiography of supraaortic vessels performed by invasive cardiologists at the time of cardiac catheterization: indications and results. Int J Cardiovasc Imaging 2005;21:179–83. [17] Abhaichand RK, Louvard Y, Gobeil JF, Loubeyre C, Lefèvre T, Morice MC. The problem of arteria lusoria in right transradial coronary angiography and angioplasty. Catheter Cardiovasc Interv 2001;54:196–201. [18] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131:149–50.
0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.06.025
Measuring the adherence to medication of elderly patients with heart failure: Is there a gold standard? Helen Smith a,⁎, Matthew Hankins a, Andrew Hodson a , Charles George b a b
Division of Public Health & Primary Care, Brighton & Sussex Medical School, Brighton, United Kingdom School of Medicine, Southampton University, United Kingdom
a r t i c l e
i n f o
Article history: Received 11 June 2009 Accepted 15 June 2009 Available online 16 July 2009 Keywords: Heart failure Adherence Compliance
The overall prevalence of heart failure in the UK has been estimated to be 1%, rising to 5–12% of those aged over 75 years [1]. First choice treatments are angiotensin converting enzyme inhibitors (ACE-I) [2–5] and loop diuretics [6]. Loop diuretics have a short duration of action [7] and the pharmacological effects of ACE-I require at least 80% inhibition of that enzyme [7]. Consequently it is important for patients to take their medicines regularly to derive maximum benefit. A recent review [8] estimated that the medication adherence of patients with heart failure ranged from 10% to 99% depending on the measurement method employed. Electronic monitoring is often considered the ‘gold standard’ but, whilst technologically sophisticated, it monitors only the opening of the medication container, not the ingestion. Pill counts [9] are similarly regarded as objective though there is no guarantee that medication absent at the count has been taken as prescribed. Patients' self-reported adherence depends on accurate recall and patients may exaggerate their adherence to please their clinician [10]. Self-report has been validated against ‘objective’ methods of measurement in elderly populations (e.g. hypertension [11], Parkinson's [12]) but it is likely that each method varies in performance depending on the population studied and the medications taken. The ⁎ Corresponding author. Brighton & Sussex Medical School, Room 319 Mayfield House, Village Way, Falmer, Brighton, BN1 9PH, United Kingdom. Tel.: +44 1273 644192; fax: +44 1273 644440. E-mail address: [email protected] (H. Smith).
aim of this report was therefore to assess the concordance of three methods of measuring adherence (electronic monitoring, pill count and self-report) in a sample of elderly patients with heart failure. Participants were recruited from three general practices in Romsey, UK. Eligibility criteria were diagnosis or signs indicative of heart failure, aged 65+ years and receiving ACE inhibitors with diuretics. Fifty-two patients were eligible (35 male, 17 female). Mean age was 76 years (SD 6 years). All were Caucasian. The median number of medications taken was 6 (maximum 11). Eleven participants were asymptomatic, 33 mild and 8 moderate in severity (NYHA classification). The eDEM monitor (Aardex Ltd., Switzerland) is a medication container that electronically records each opening. Patients were given their medications pre-packaged in the eDEM device which was retrieved by the research nurse after 6 weeks at the study end. At the same time pill counts and self-report measures were also obtained. Self-reported adherence was assessed using a 6-item questionnaire. Adherences to ACE-I and diuretic were assessed separately. Patients were classified ‘adherent’ by two criteria (90% adherent and 100% adherent) applied to all three methods. Phi coefficients were used to assess the association between each method. Table 1 shows the adherence estimates for ACE-I and diuretic by the three methods. Using the 100% adherence threshold, 81% of patients were classified adherent by self-report for ACE-I, compared to 79% for pill count and 20% for electronic monitoring. For diuretics, 55% of patients
Table 1 Number (%) of adherent participants by the three methods with 100% and 90% thresholds (N = 52). Self-report
Pill count
Electronic monitoring
ACE-I 100% adherent 90% adherent Missing data
42 (81) 50 (96) 0
41 (79) 47 (96) 3
10 (20) 26 (53) 3
Diuretic 100% adherent 90% adherent Missing data
28 (55) 44 (85) 1
30 (63) 40 (83) 4
5 (11) 18 (38) 5