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Background: Aortic stenosis (AS) is the most common valvular heart disease in elderly people. Transcatheter aortic valve implantation (TAVI) has emerged as a revolutionary treatment for elderly patients with symptomatic severe aortic stenosis. The authors present the first experiences with transcatheter aortic valve implantation treatment in Macedonia and compare their findings in regard to differences between open vascular vs. minimalistic transfemoral TAVI approach., Methods: The procedure was performed in 54 patients with severe and symptomatic AS in the period from December 2014 until February 2018. All patients were deemed having high surgical risk or were denied surgery. Pre-procedural screening included detailed clinical and echocardiographic evaluation, coronary, peripheral and carotid angiography and computed tomography scan of the aortic root. A self-expandable aortic valve (Core Valve/Evolut R, Medtronic, USA) was implanted in all patients., Results: Mean patient age was 75 ± 7.2 years, 28 (52%) were female, 26 patients (48%) male. All interventions were successfully performed through right transfemoral approach with 100% implantation success. Ancillary right radial and ulnar approach was used for correct valve positioning and control. 22(40%) cases were performed under general anesthesia and open vascular access to the femoral artery. All other 32(60%) cases were performed with minimalistic approach (local anaesthesia and analgosedation of the patients, access site was closed with closure devices). Patients in the minimalistic approach group were older, with more chronic conditions as anaemia, chronic kidney disease, poor mobility and peripheral vascular disease (p<0.0001). Also 4(12.5%) patients in the minimalistic group had bicuspid valve TAVI implantation (p<0.0001). Procedural time and contrast amount spent were shorter in this group with 97± 38 vs. 121± 38.3(p<0.0001) and 287± 122 vs. 330± 115 ml, while fluoroscopy time was similar in both groups. Immediate hemodynamic improvement was obtained in all patients. Echocardiographic peak gradient decreased from 85 ± 25 to 17 ± 8 mmHg (p < 0.001) and mean pressure gradient from 49 ± 26 to 8.3 ± 4.2 mmHg, (p < 0.001). Effective valve orifice area was 1.8±0.4 cm2 after intervention. None of the patients had significant aortic regurgitation after implantation. After intervention 7(12%) patients developed a permanent heart block and required implantation of a permanent pacemaker. There was a larger Hgb drop after intervention with open vs. minimalistic approach 1,9±0.9 vs. 0.7±0,2 g/dL (p<0.0001). 3 (13% vs.0%) patients from the open vascular access group had a major bleeding complication with 2 requiring transfusion after intervention (p<0.0001). Mortality was 5.5%, 2 with open-vascular and 1 with minimalistic approach. MACCE rate that included MI, Stroke, Major bleeding and Death rate, was recorded in 5(18%) patients with open vascular approach vs. 1(3.1%) in minimalistic approach (p<0.0001). Hospital discharge was 8.7±3.1 vs. 4±3.1 days respectively (p<0.0001). All TAVI patients with minimalistic approach were discharged the following day after intervention. All discharged patients had a good neurological condition, which was assessed based on the CPC-1 (Cerebra Performance Categories Scale). After median follow up of 26 months, the survival rate was 95% with clinical improvement in all patients., Conclusion: Percutaneous aortic valve implantation can be successfully conducted with high success rate and low rate of complications in patients with severe aortic stenosis. Using a less invasive approach with local anaesthesia and analgosedation is associated with shorter length of stay and a decrease in post-procedural complication rates and MACCE.

Introduction and Aim: Transradial (TRA) instead of transfemoral (TFA) approach strategy has been presented in research literature as superior access strategy especially for acute ST elevation myocardial infarction (STEMI) primary percutaneous coronary intervention (PCI). There is a paucity of registry-based data of outcomes from default TRA strategy compared to TFA., Materials and Methods: All-comers STEMI PCI institutional Registry identified 1808 consecutive patients in time-frame of 40 months from 2007 to 2010, without making any exclusions. Moreover, we applied Propensity Score Matching (PSM) to replace randomization, address the potential confounding and selection bias. PSM derived 565 congruent pairs of patients from the groups., Results: After 30 days the primary composite endpoint of major adverse cardiovascular events (MACE) was in favor of TRA 6.5% vs. 12.4% in TFA group, simultaneously secondary endpoints of death in TRA with rate of 4.8% and with rate of 10.1% in TFA. Moreover, the rate of major access related bleeding was 1.1% in TRA vs. 8.5% in TFA, in contrast the major non-access related bleeding was 1.8% and 2.4% respectively showed no significant difference. One year Kaplan Meier survival plots were in favor of TRA., Conclusions: Default transradial access strategy is associated with improved STEMI PCI outcomes.

The transradial approach (TRA) for treatment of aortoiliac occlusive disease (AIOD) is nowdays a more common approach than several years ago. This is due to less post-procedural bleeding complications and its impact on mortality. The main reason for the growing interest in the TRA is because of the safety profile of this access. Peripheral arterial disease (PAD) is a growing phenomenon. It is a common circulatory problem in which narrowed arteries reduce blood flow to lower extremities due to atherosclerotic arterial lesions. According to the Trans Atlantic Inter-Society Consensus on the Management of Peripheral Arterial Disease (TASC II), an endovascular approach is recommended in type A and B lesions, and an open surgical approach for type C and D lesions. The aim of the study is to put the accent on the advantages of the transradial approach (TRA) versus the transfemoral approach (TFA), its safety and efficacy in treating peripheral arterial disease (PAD) even in type C and D lesions, in well and properly selected patients on whom it may be performed, and to evaluate the outcomes of transradial iliac stenting (TRAIS), attempting to increase the demand for the new devices and tools for its treatment. These improvements will exclude some disadvantages and limitations of TRA in the field of endovascular peripheral interventions (distance from the puncture site to the lesion location, bigger support, thinner devices). Despite difficult lesions, TASC C/D, the overall primary procedural and technical success rate was 100%. The ankle brachial index (ABI) significantly improved from a mean of 0.46 to 0.90 and 0.94 on the six months follow-up. Angiographic estimated residual stenosis was 0%. No minor or major complications (haematoma, distal emboli, vessel dissection, rupture, death) were documented. The primary patency rate was 100% for the iliac and for the SFA. The secondary patency rate after 6 months follow-up was also 100%. Transradial access might be recommended as the first-choice vascular access site for interventions on the iliac, and even proximal femoral territories. This technique is still limited by the lack of adequate equipment. This issue should be overcome in the future.