TRA and CABG vs. non-CABG populations.
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Transradial access (TRA) is now well established as the safest route for percutaneous coronary intervention (PCI) and must be attempted at first whenever possible. In real world, too many cases today are still performed though transfemoral access (TFA). In a case-to-case confrontation, “believers” in the radial way [1] would easily refute common arguments still actually developed by TFA proponents to skip the TRA attempt (or to dash the attempt off): planned intervention better managed/proceeded through femoral access (angiography for a patient with previous coronary artery bypass graft (CABG) surgery being a frequent one), planned interventions requiring large materials/catheters, anticipated lack of support during intervention (a true but often hidden fear for several operators), poor/small/not palpable radial artery, previous attempt failure(s), lack of time (“urgency”), “fast” intervention required for a frailty patient, negative Allen test (it is the most hilarious reason for a radial believer), and finally a failed but often too short attempt.
What is the truth in the background of this resistance? The truth is TRA is not and will never be an easy way to perform cardiac catheterization, the learning curve is long (and never ends), and TRA requires from the operator a true personal investment. Hopefully—and it has to be written somewhere—the return on investments in the TRA technique is large, and succeeding in a difficult case is usually even more gratifying for the physician and his patient when the procedure involved only TRA.
“TRA for everybody” is a personal crusade, and it lets the author to succeed a “non-femoral” vascular route for 1019 of his last 1023 procedures (from mid-March 2017 to mid-November 2018). The 1023 procedures included primary PCI for 152 ST elevation myocardial infarct (STEMI) patients—femoral access for 2 of them—coronary angiography (and ad hoc PCI when requested) for 108 post-CABG patients, and a total of 568 PCI were performed (73% with 5 Fr guide catheters).
Common challenges associated with a “TRA for everybody” strategy and possible solutions must be considered. Subjects being discussed will be:
The vascular access.
Some patient populations “at risk” to be catheterized by TFA:
The CABG population.
Myocardial infarct (MI) patients in unstable condition.
Frailty and small body-sized ill patients.
The radial artery occlusion problem.
Cannulation failure, which is the main cause of TRA failure, is disgracefully received by the majority of interventional cardiologists and stays subsequently hidden. And yet it is not a shame to fail the radial artery cannulation: it is a difficult task and so for many reasons. First, the artery is usually small-sized, its diameter being around 2–3 mm [2] depending of the individual body height as demonstrated in one recent study [3]. The arterial wall may be difficult to go through; the vessel may flee away the tip of the needle or may simply “disappear” when a so frequently—and wrongly—invoked “spasm” occurs after a first unsuccessful stick (see discussion below). Although permeable and functional, a radial artery may be unpalpable due to a thick arterial wall or a low flow state. As any other arterial bed, the radial artery is not spared by the inverse remodeling process associated with diabetes, arteritis, and aging. Finally, the patient may be hypotensive with a more difficult vascular access.
So, the first step to optimize the TRA success rate and therefore “TRA for everybody” is investing in solving the problem of the puncture/cannulation of the radial artery.
Data clarifying the causes of TRA failure will now be presented, and secondly, some clues helping in the problem’s resolution will be explored.
A prospective study about the TRA, conducted by two TRA “believers” and with two major objectives in mind, started in 2015 [4]: firstly, defining the rate of conversion to transfemoral access when the operator must first attempt (and fail) both radial arteries before converting to transfemoral and secondly, the study was designed to record daily and on a case-by-case basis the causes/location of radial artery attempt failure and to define their relative occurrences. The protocol also required grading (1) the ease for cannulation (before catheterization, as assessed at the bedside), (2) the real ease for the attempt, and (3) the ease for the catheterization itself (catheter manipulation).
By protocol, every single consecutive left heart cardiac catheterization, diagnostic or interventional, elective or urgent, has to be first attempted by TRA (right or left or both). Only non-palpable radial artery (on both sides) or abnormal Allen test (Barbeau type D on both sides) and patient refusal were excluded. Let us say immediately that the two operators never encountered a patient with a Barbeau type D present on both sides and that non-palpable radial artery may be permeable and functional as easily assessed with a Doppler probe. Thus, basically, no patient was excluded from the study for such reasons: “TRA for everybody” is feasible at the level of the initial assessment for an arterial access.
As designed by the protocol, all sorts of patient populations were attempted by radial artery, including post-CABG surgery patients, even patients grafted with both left and right internal mammary artery. Some local surgeons also used the gastroepiploïc artery as graft (and not as free graft). Such patients were also included.
Even shock patients were included in the study.
From January 2005 to June 2007, both operators successively and prospectively proceeded to catheterize 1826 patients, starting from right or left TRA, at the operator discretion. PCI accounted for 40% of the procedures. The study was published as an original contribution in the Journal of Invasive Cardiology in September 2010 [4].
The first and major contribution of the study was to offer strong data for the cornerstone of an effective politic of “TRA for everybody”: to have to attempt both radial arteries before converting to a femoral access. The study succeeded in offering a “TRA only” procedure for 98.8% of the study population (Figure 1). This high success rate was obtained after attempting the second radial artery for the 6.2% missed first radial artery, 4.4% when excluding the patients with previous CABG surgery. Attempting the second radial artery was successful in about 80% of the cases.
TRA success rate for 1826 consecutive procedures.
As illustrated in Figure 1, the study did not identify a special population who will not benefit from TRA. It also dismisses some apprehensions regarding TRA: rate of truly difficult cannulation was half less than anticipated, and difficult catheterizations were 50% less frequent than anticipated (and this rate stays stable at 6%), Figure 2.
TRA: Real versus anticipated difficulties.
Multivariate analysis (GEE, RMGEE program, K.Y. Liang and S.I. Zeger, Longitudinal data analysis using generalized linear models, Biometrika 73, 1986) strongly proved the learning curve existence and identified some of the major factors playing in the TRA world, namely, the artery size and a diffusely diseased arterial bed (peripheral artery disease). Four predictive variables for a first radial attempt failure emerged in the study:
Year of the procedure, variable related to the learning curve, and operators getting better and better with time, OR 0.6, 95% C.I. 0.4–0.8, p < 0.001.
Presence of peripheral artery disease, OR 1.8, 95% CI 1.1–2.8, p 0.016.
Pre-procedure clinical evaluation for a difficult access, OR 2.5, 95% C.I. 1.3–4.9, p 0.006.
Small radial artery size as assessed clinically before catheterization, OR 2.6, 95% C.I. 1.4–5.0, p 0.003.
The second major contribution was to reveal that the main cause of TRA failure was not at all related to difficult anatomies as commonly reported and taught (Figure 3). At the start of a TRA business, the radial artery cannulation is accounting for about 75% as the main cause to fail. It accounts for 90% of attempt failures when operator had gained more experience. There are several ways to fail an artery cannulation, reflecting the three steps involved: (1) the puncture itself, (2) wiring the needle or the plastic cannula when they sit in the lumen vessel, and (3) after needle/cannula removal, pushing the sheath over the wire.
Causes of TRA failure at first attempt.
When analyzing the three different steps, the far most prevalent problem arises at the wiring step: operator reaches the lumen artery, usually with a good blood’s backflow, but he cannot forward the wire. Identifying this problem lets to develop better strategies and material (see below).
Thereafter 2007, enrollment in the study protocol was extended, allowing the creation of a large radial access database. With time and experience, more expertise arose [5], and looking at the same data in 2010, failures related to anatomical consideration were actually avoided: failure to cannulate the artery emerged as the cause for 92% of failed attempts (again mainly because of the wiring problem). Crossover to femoral access declined to 0.9% (2010) and is now 0.4% (2017–2018).
Let us talk about sticking the artery, first. Two techniques for radial artery cannulation are at works in the cardiac catheterization world and both gets around 50% of the actual “market.”
The first one is derived from the femoral world and is the Seldinger technique. It uses a bore metal needle (usually a 21 Gauge) wired with a short metallic 0.021″ straight or J wire. Its advantage is a sharper bevel, more able to penetrate a stiff arterial wall and a better echogenicity when puncturing with ultrasound guidance. Using the needle with a small body length is recommended: backflow at the hub, signing the puncture success, will happen quicker with a short needle like the Cook® needle 3.5 cm 21 G.
There is a major drawback with the bore metal needle technique: when the standard wire does not progress (either at the needle’s entry in the vessel or further away within the artery), the choice for an alternative wire is limited, and particularly all kind of hydrophilic or angioplasty wires may not be used (possible “peeling” of the coating). When you know that more than 75% of artery cannulation is missed because of the wiring problem, it is annoying to lose this possibility.
The second method is derived from the nursing world: it uses an over-the-needle cannula system (needles designed for puncturing veins and intravenous cannula insertion). Insertion of the small cannula within the first mm of the radial artery greatly facilitates the radial wiring and subsequent sheath insertion. Exchange for any hydrophilic or coronary dedicated angioplasty wires is possible and may help and saves many attempts failing with standard wires. The technique is in the author’s mind more successful addressing radial arteries of small diameter. Using a 22 gauge system, the vessel injury at the tip of the needle is minimal and allows a through-and-through puncture. The technique is easy to standardize and thus to teach: beginners are instructed to push more deeply the over-the-needle cannula system once the needle reaches the artery lumen (backflow at the hub): doing so, the bevel of the needle is now lying beyond the arterial’s posterior wall. Keeping firmly the cannula in place, the metallic part of the system is removed. Then the plastic cannula is gently and mm per mm withdrawn until the blood flows again: the cannula is now perfectly lying in the arterial lumen, and wiring is easier (with the standard or optional wires). For wiring attempts, it is easier to secure in position a plastic cannula than a bore metallic needle. The drawback of the technique is quite minimal: the bevel of the needle is usually not well sharpened for crossing an arterial wall (stiffer and thicker than a venous one); the echogenicity is less than the bore metallic needle (smaller size); some plastics are not well supportive for the standard metallic wire when it has to enter the arterial lumen (all brands of intravenous cannula are not equivalent for that purpose).
Investing in the over-the-needle cannula system, a needle dedicated for the radial access was designed, several prototypes were successfully tested, and the needle is now patented in the USA and Japan and patent pending in the EU [6, 7]. The invention lies in a small distal aperture near the metallic needle tip combined with at least one reinforcing shoulder at the inner surface of the overlying plastic cannula: the system allows a very fast visualization of the tip needle entering the vessel lumen, faster than when you have to wait until the blood flow reaches the more distant needle hub: with the invention, the operator sees first the blood entering the needle’s body and then reaching the hub. This feature helps for the first step of sticking the vessel, shortens the cannulation time, and enhances the success rate (no need to re-puncture, less chance to have “spasm” after a first unsuccessful stick). The needle is waiting investors/manufacturers to get in production.
So, the first recommendation for resolution of the cannulation problem is to invest in the over-the-needle cannula technique for puncturing, giving attention to the choice of the puncture material and to the alternative wires.
The radial artery is a quite superficial structure easily assessed by ultrasound. The technique requires only a small-sized probe, and setup is easy and fast: puncturing while viewing the artery is obviously easier, and in the most recent author’s practice, its use allowed to succeed when blinded attempt had failed. Since its introduction in January 2018 as a bailout technique, and for 439 consecutive procedures, the ultrasound-guided puncture accounted for 43 patients. The visualization of an artery just attempted blindly offered the explanation for the probably most frequent mechanism in play when reattempting unsuccessfully to re-puncture or rewire the vessel: hematoma arising around and within the wall of the vessel, reducing further its lumen (and the pulse). So the “spasm” frequently invoked is in reality hematoma compression/expansion: it explains why the artery is no more palpable and more difficult to re-stick. Furthermore, the ultrasound guidance lets the operator decides to stick at another position or to skip to the ulnar or the contralateral radial/ulnar artery. The ultrasound-guided puncture allows the operator to stick more successfully the artery, but it does not resolve the problem of wiring.
Since many years, as soon as a Doppler signaled the presence of an arterial flow, cannulation of unpalpable radial arteries was attempted. With the ultrasound guidance, it is now far easier to perform this task (and to confirm that the operator may attempt the cannulation, the views allowing the diagnosis of an occluded artery). With the help of ultrasound, the operator may also decide to attempt a less disease or a larger vessel (ulnar or contralateral).
Clearly, the use of ultrasound-guided puncture has a major role to play in a modern strategy of “transradial (or transulnar) access for everybody,” and it is the second recommendation for solving the cannulation problem.
You may be an excellent PCI operator and be quite “ordinary” regarding the puncture task (and some hate this fundamental step). On another hand, in every catheterization laboratory, there are individuals very efficient for sticking vessels, and there are individuals well trained for surface ultrasound. A few years ago, nurses interested in the cannulation task were trained for radial artery puncture. The over-the-needle cannula technique was taught, nurses being well customized with this kind of needle and technique. The fundamental difference between their usual way of working with an over-the-needle cannula and for intravenous cannulation is that they absolutely need to go through and through the vessel for a successful radial artery cannulation. They also have to learn the use of the different wires at (good) works. Recently, the same teaching program was successfully offered to technicians in radiology working in the catheterization laboratory: it provided the advantage of adding peoples trained for ultrasound techniques. Actually, the trained nurses and technologists perform 70% of the author’s artery cannulations without any undesired crossover to a femoral access.
So, the next recommendation is to train willing and well-skilled nurses and technologists to perform the cannulation task.
The ulnar artery has been shown to be a safe alternative route for left heart catheterization [8]. It is anyway a safer route than the femoral access and is sometimes larger than the radial artery. It seats deeper and a sensitive nerve is present along the vessel at the puncture level. Hemostasis is easily performed with the material dedicated for the radial artery compression. So, when a radial attempt fails, the ulnar artery cannulation may be a good alternative even at the same wrist. Of course, ultrasound-guided puncture is also an excellent way to optimize the success cannulation rate. Left distal radial TRA is actually in evaluation as a possible way to further improve operator and mainly patient comfort and safety, at least when starting from the left hand. Large series looking at the ease and effectiveness of the hemostasis together with vessel patency and avoidance of ischemic/sensitive problems are mandatory.
The last recommendation will be to become familiar with ulnar artery cannulation, and ultrasound-guided puncture should be a must.
Patients with previous CABG surgery are difficult to angiography by comparison with non-CABG surgery patients. They are older and have advanced coronary artery disease for many years. Peripheral artery disease and other comorbid conditions such as some degree of chronic kidney failure and chronic obstructive pulmonary disease are frequently found. Graft assessment is an additional task after coronary angiogram and may be tricky due to nonstandard vein graft’s ostial location and unavailable dedicated efficient pre-shaped catheters. Arterial grafts are also uneasy to reach: both mammary arteries are originating at a sharp angle from their subclavicular arteries that are to be engaged: the right subclavicular artery may particularly be tricky to reach, except when starting from the right upper extremity. Finally, the gastroepiploic artery, a branch of the coeliac trunk artery, used by some surgeons to graft the right posterior descending artery, may also be difficult to adequately angiography. The additional task of graft angiography and the higher-risk profile of these patients let to more catheters use, more manipulations, and therefore a greater risk of neurological complications [9].
Due to the anticipated complexity of this procedure and concerns about possible greater X-ray exposition, TRA—and its associated clinical benefits—is often denied to this population.
Louvard et al. [10] and Yabe et al. [11] reported in 1998 the feasibility of graft angiography and particularly left internal mammary artery (LIMA) angiography through a right radial artery approach. Kim [12] and Kwang [13] described bilateral selective internal mammary artery angiography via the right radial approach as early as 2001. Sanmartin et al. published in 2006 their feasibility analysis and comparison with transfemoral approach [14]. They concluded that there is no excessive delay or greater radiation exposure and that the TRA appears at least as safe as TFA. Their study was retrospective, excluded patients with bilateral mammary grafted, and the left radial access was predominant (133 of the 151 TRA compared to the 154 TFA). They reported four failures of cannulation, one puncture failure, one LIMA, and one saphenous vein graft (SVG) not reached. Only 15% of ad hoc PCI were carried out. In 2008, Burzotta [15] and experienced TRA operators described tips and tricks available for addressing post-CABG patients and already pointed out the right radial access as the best first option in case of bilateral mammary artery grafts.
In 2009, Rathore et al. [16] reported a similar technical TRA success rate for SVG-PCI compared to TFA. Periprocedural MI, access-site bleeding-related complications, and large hematomas were higher in the TFA group. They reported a 5.8% crossover to the femoral route. The Transradial Committee of the SCAI in a 2011 publication concluded that TRA for CABG patients might safely be integrated into routine practice as experience increases [17].
The published 2010 prospective study of 1826 consecutive procedures [4] looking at the conversion rate from TRA to TFA when both radial arteries have to be attempted before the crossover to femoral included 187 patients with previous CABG surgery. The study was extended for the CABG population until 2012, and results were presented at the 2012 ACC meeting [18].
The study differs from the previously reported series: it prospectively addressed patients with previous CABG surgery; the choice of the radial artery to be attempted at first, right versus left, was free, but both radial arteries had to be attempted before converting to femoral access. Patients grafted with both mammary arteries were not excluded, and the study also included patients with gastroepiploïc arteries used as graft. Ad hoc and elective PCI were performed. Importantly, all causes of failed attempts were analyzed and classified.
This study reinforces the previous conclusions about TRA feasibility. When considering angiography for the CABG population, particularly when only one mammary artery is grafted, TRA performs as well as for the general population. A success rate above 98% was obtained with a very low requirement for a second artery access (7.2%) in case of only one internal mammary artery (IMA) grafted. Of course, the radial artery to be attempted at first must be ipsilateral to the utilized IMA, and it is better to start with in hand the description of the performed surgery. In case of bilateral IMA, the strategy of attempting the right radial artery at first enhances the chance of completing the procedure through one arterial access (actual chance of success is around 60%). To be noted, in the published series, about 35.5% of procedures included angioplasty and stenting (mainly ad hoc). Tables 1–3 describe the CABG population (from 2007 to 2012) compared to the non-CABG population of the 2010 publication.
Population | Any previous CABG surgery | Previous CABG surgery | p | Previous CABG surgery ≤1 IMA | p (vs. no previous CABGs) | Previous CABG surgery 2 IMA | p (vs. no previous CABGs) |
---|---|---|---|---|---|---|---|
N | 1639 | 507 | 320 | 187 | |||
Age | 65 ± 11 | 71 ± 9 | <0.001 | 72 ± 10 | <0.001 | 70 ± 9 | <0.001 |
Female (%) | 31% | 18% | <0.001 | 20% | <0.001 | 14% | <0.001 |
Diabetes (%) | 17% | 29% | <0.001 | 28% | <0.001 | 32% | <0.001 |
HTN (%) | 44% | 56% | <0.001 | 54% | 0.001 | 58% | <0.001 |
Peripheral vascular disease (%) | 21% | 41% | <0.001 | 43% | <0.001 | 38% | <0.001 |
Weight (kg) | 79.0 ± 16 | 81.6 ± 15 | 0.001 | 80.8 ± 15 | 0.037 | 83.0 ± 16 | 0.001 |
Height (cm) | 168 ± 9 | 169 ± 8 | 0.26 | 168 ± 9 | 0.82 | 170 ± 8 | 0.021 |
BMI | 27.8 ± 5 | 28.6 ± 9 | 0.001 | 28.6 ± 6 | 0.009 | 28.6 ± 5 | 0.017 |
BMI ≤ 22 (%) | 10.5% | 4.3% | <0.001 | 4.1% | <0.001 | 4.8% | 0.014 |
Radial artery looks not easy to puncture | 13.9% | 12.6% | 0.46 | 13.8% | 0.94 | 10.7% | 0.224 |
Volume of contrast (ml) | 156 ± 78 | 226 ± 92 | <0.001 | 218 ± 87 | <0.0001 | 239 ± 97 | <0.0001 |
Percutaneous coronary Intervention (ad hoc + elective) | 40.5% | 35.5% | 0.04 | 41% | 0.8 | 26% | <0.001 |
TRA and CABG vs. non-CABG populations.
CABG, coronary artery bypass graft; IMA, internal mammary artery.
All | Non-CABG patients | CABG patients | p | CABG ≤1 IMA | p | CABG 2 IMA | p | TRA-IMA same side | p | |
---|---|---|---|---|---|---|---|---|---|---|
N Patients | 2146 | 1639 | 507 | 320 | 187 | 298 | ||||
TRA success | 2118 | 1621 | 497 | 314 | 183 | 293 | ||||
(%) | 98.7 | 98.9 | 98 | 0.13 | 98.1 | 0.247 | 97.9 | 0.216 | 98.3 | 0.395 |
N radial attempted | 2327 | 1711 | 616 | 339 | 277 | 311 | ||||
N of radial attempts/patient | 1.084 | 1.044 | 1.215 | <0.001 | 1.059 | 0.23 | 1.481 | <0.001 | 1.047 | 0.981 |
Right radial as first attempt | 1560 | 1359 | 201 | 62 | 139 | 41 | ||||
Right radial failed at first attempt | 139 (8.9%) | 68 (5.0%) | 71 (35.3%) | <0.001 | 10 (16.1%) | <0.001 | 61 (43.9%) | <0.001 | 4(9.7%) | 0.175 |
Left radial as first attempt | 586 | 280 | 306 | 258 | 48 | 257 | ||||
Left radial failed at first attempt | 56 (9.6%) | 12 (4.3%) | 44 (14.4%) | <0.001 | 13(5.0%) | 0.678 | 31 (64.6%) | <0.001 | 12 (4.7%) | 0.83 |
All failures (first attempt) | 195 | 80 | 115 | 23 | 92 | 16 | ||||
One (first) failure/patient | 9.1% | 4.9% | 22.7% | <0.001 | 7.2% | 0.091 | 49.2% | <0.001 | 5.4% | 0.721 |
Radial artery cannulation: failures at first attempt.
CABG, coronary artery bypass graft; IMA, internal mammary artery; TRA, transradial access; TRA-IMA same side, transradial access for ipsilateral IMA.
Non-CABG patients | CABG patients | p | CABG patient ≤1 IMA | p (vs. no CABG) | CABG patient 2 IMA | p (vs. no CABG) | |
---|---|---|---|---|---|---|---|
N | 1639 | 507 | 320 | 187 | |||
N R ± L radial failed (% patients) | 90 (5.5%) | 119 (23.5%) | <0.001 | 25 (7.8%) | 0.106 | 94 (50.3%) | <0.001 |
N puncture/wiring failed (% total failures) | 67 (74.4%) | 14 (11.8%) | <0.001 | 12 (48%) | 0.012 | 2 (2.1%) | <0.001 |
N “route to aorta” failed (% total failures) | 12 (13.3%) | 5 (4.2%) | 0.017 | 2 (8%) | 0.471 | 3 (3.2%) | 0.012 |
N “coronary or SVG ostium” failed (% total failures) | 11 (12.2%) | 12 (10.0) | 0.625 | 5 (20%) | 0.32 | 7 (7.5%) | 0.276 |
N “IMA contra not reached” (% total failures) | 0 (0%) | 88 (74.0%) | <0.001 | 6 (24%) | <0.001 | 82 (87.2%) | <0.001 |
TRA CABG vs. non-CABG, causes of failed attempt.
CABG, coronary artery bypass graft; IMA, internal mammary artery.
Causes of radial attempt failure, puncture/wiring the radial artery; catheter, route to aorta failure; catheter, coronary/saphenous vein graft (SVG) ostia cannulation; catheter, contralateral IMA not cannulated (right TRA for left IMA or left TRA for right IMA).
To summarize the published statistics, for a general population and excluding patients with previous CABG surgery, cannulation failed in 4.9% (requiring crossover to the second radial artery or to an ulnar artery). For the CABG population when the surgeon protocol is available and when only one IMA is grafted, the ipsilateral to the IMA radial cannulation fails for 5.4% of patients and requires use of the ipsilateral ulnar artery. When both IMA are grafted, starting from the right TRA succeeds for about 60% of patients; 40% will further need cannulation of the left TRA (mainly for an adequate LIMA graft patency assessment). In terms of patient safety and avoidance of vascular access-related complications and hemorrhage, a bilateral radial cannulation is far less dangerous than one femoral access, particularly in case of coronary/graft angioplasty. By the way and as reported [19], the PCI success rate stays unaltered by the vascular access.
The TRA lifesaving benefit is directly linked to the illness severity: the STEMI and the unstable non-ST elevation myocardial infarct (NSTEMI) patients are the more likely to require a high level of several anticoagulants/antiplatelet therapies paving the road for serious hemorrhagic events mainly at the vascular (femoral) access site [20]. Vascular closure devices have not been demonstrated to be effective in reducing these vascular complications in the setting of ACS. On the contrary, hemostasis is easily obtained after TRA, even in situation of high anticoagulation level. Performing through a radial artery access in these circumstances removes the fear of “collateral damages” related to intense anti-clot treatments and allows retaining the benefits linked to their use. When the situation requires the use of intra-aortic counterpulsation, the TRA PCI saves at least this access from hemorrhage, the intra-aortic balloon being usually removed some days later, when the degree of anticoagulation is far less intense. Door-to-balloon time is only one of the important lifesaving parameters and must not serve as a pretext to skip a well-performed TRA attempt: speed may not lead to haste! Acute MI patients usually maintain initially a decent radial pulse, and cannulation may succeed as in stable condition. Particularly in the setting of acute coronary syndrome (ACS), a failed first attempt must lead to attempting the second radial artery (or the ulnar artery) before crossing over to the less safe femoral route. The author’s most recent statistics in STEMI patients will illustrate the TRA feasibility “in real world.”
Since mid-March 2017 to mid-November 2018, from a total of 1023 procedures, 152 STEMI patients were primarily addressed by PCI. A grand total of two primary PCI were performed through a femoral access: one MI patient had previously a thoracic vascular repair after a thoracic trauma (car accident): his right arm was unavailable for left heart catheterization, and cannulation of the left radial artery led to an occluded left subclavicular artery. The second femoral case was a small-sized lady, and the attempts to wire radial (and ulnar) arteries failed at both wrists. This case happened before the availability of the ultrasound technique for rescuing the failed attempts. Seven STEMI cases required simultaneous use of the femoral artery for left ventricular assistance (intra-aortic balloon pump). The hemorrhage-saving TRA feature lets to more liberal use of potent antiplatelet drugs and high heparin doses: it may lead to less distal thrombus embolism and less no-reflow post-reperfusion states. As already stated, femoral access accounted for only 4 cases of the last 1023 author’s procedures.
There is another category of patients likely to get catheterized by the femoral route: the small body-sized ill patients, particularly if a frailty condition is associated. Excuses to skip the radial access stay similar: anticipated—but not objectively assessed by ultrasound—too small radial artery, need of a large guide catheter for a quicker intervention, speed required by the degree of illness, etc. Nevertheless, this kind of patient will very badly recover from any hemorrhagic event, and their condition increases greatly the vascular risk [20]. The reader is invited to look at the way a cohort of such frailty; old and severely diseased patients were successfully TRA managed through a double radial route for addressing distal left main or proximal left coronary artery disease [21]. It allowed to position and to work simultaneously with two 5 French-sized guide catheters at no cost of vascular-related complication (Table 4).
Case 1 | Case II | Case III | Case IV | Case V | |
---|---|---|---|---|---|
Age | 81 | 70 | 86 | 87 | 89 |
M/F | M | F | M | F | F |
BMI/height (cm)/weight (kg) | 25/174/75 | 33/159/85 | 30/160/78 | 22/160/56 | 22/160/56 |
Frailty (0–3+) | 2+ | 1+ | 3+ | 3+ | 3+ |
Symptoms at presentation | New chest pain and SOB CCVS Class 3 | Progression of chest pain, SOB CCVS Class 3 | Chest pain and SOB CCVS Class 4 | Acute pulmonary edema NSTEMI VT, persistent HF | Acute pulmonary edema NSTEMI VT, persistent HF |
Associated medical conditions | Severe COPD Gold IV, permanent O2 therapy | Severe COPD Gold III Past CVA and CAD | Valvular aortic stenosis, severe (< 1 cm2), COPD, transient AV block | HBP, paroxysmal atrial fibrillation Low Ef (recent) | HBP, diabetes, low Ef (recent) |
CAD, syntax score (SS) | Distal LMCA Medina 1,1,1 Left dominance Syntax score 30 | Distal LMCA Medina 1,1,1 Syntax score 23 | distal LMCA, medina 1,1,1 occluded RCA (3VD), Syntax score 48 | LMCA equivalent, 100% RCA Syntax score 28 | Prox. and mid-LAD a. 75% CX a., 95% RCa. lesion 70%, syntax score 35 |
Addressed vessel(s) | LMCA | LMCA | LMCA | Ostial-LAD/ostial CX arteries | Prox. to distal LAD-Diag a. |
Arterial access | R TUlnA/L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath | R+ L TRA, 5F Glidesheath |
Fluoroscopy time/volume of contrast/DAP/CPK 24 h | 44′/290 ml/228 Gy/cm2 CPK (−) | 17′/212 ml/143 Gy/cm2 CPK (−) | 20′/148 ml/114 Gy/cm2 CPK (−) | 15′/140 ml/73 Gy/cm2 CPK (−) | 20′/128 ml/173 Gy/cm2 CPK (−) |
Follow-up | Alive > 1 year, acute pneumonia at 1 month | Alive > 1 year, no angina | Alive > 1 year, aortic valve stenosis said moderate | Alive > 1 year, class 1, normalized LV function | Alive > 1 year, class 1, normalized LV function (had 2 weeks re-hosp for HF) |
TRA PCI and frailties, adapted from ACC, 18;3, 45-52.
SOB, shortness of breath; CCVS, Canadian Cardiovascular Society classification;
VT, ventricular tachycardia; HF, heart failure; NSTEMI, non-ST elevation myocardial infarction; COPD, chronic obstructive pulmonary disease (severity as assessed by the GOLD classification); CVA, cerebrovascular accident; CAD, coronary artery disease;
Ef, left ventricular ejection fraction; LMCA, left main coronary artery; RCA, right coronary artery; 3VD, triple vessel disease; LAD, left anterior descending (artery); CX, circumflex (artery); R TUlnA, right transulnar artery; L TRA, left transradial access;
R TRA, right transradial access; DAP, dose area product (Gy/cm2); CPK, creatine phosphokinase.
Coronary artery disease (CAD) is a progressive disease, and many patients “enjoying” a first successful TRA PCI will require in the future one or more interventions, evenly in emergency (subacute stent thrombosis, new STEMI or new acute coronary syndrome, etc.). So, preserving a well-patent radial artery may be lifesaving later.
In 2016, 1 year before the CRASOC studies were accepted for publication in the American Journal of Cardiology [3] as the largest randomized and prospective study analyzing the hemostasis role in radial artery occlusion (RAO). Rashid et al. published a well-documented systematic review and meta-analysis [22] about the TRA-related radial artery occlusion. It is easy to summarize the problem and to understand the different ways we must follow to reduce the RAO rate. RAO is the direct consequence of the vessel injury associated with any TRA. Injury happens at three levels, and we have to minimize the trauma at each of these levels: first, the puncture; second, the sheath insertion and catheter manipulations (within the sheath); and finally, the compression/hemostasis following the catheterization. Mention for selecting the best technique and material for artery puncture and cannulation was already made. The author makes the hope that, someday, TRA operators will get the chance to handle the specifically designed and actually patented radial artery needle: it should be the best way to reduce as far as possible the puncture-related aggression. In the same way, it is obvious that reducing the size of the sheath is another excellent way to reduce the related harm against the artery wall. Not only should the size be reduced as far as possible, but also the material must be hydrophilic: non-hydrophilic sheath should be banished from a good TRA practice. The “slippery” problem of the hydrophilic sheath is the best proof of the appropriately reduced parietal stress. This problem may be easily “fixed” at the skin level: a simple “opsite” film placed over the sheath does the job. The introduction of the Terumo® “Glidesheath” family of radial introducers represents a welcomed improvement: The company cleverly worked to offer a reduced outside diameter of the sheath (what the artery” feels”) together with a normal inside diameter. It allows operators working predominantly in 5 French (including for PCI), to offer a “virtual 4F” TRA procedure for the majority of their patients.
The post-catheterization hemostasis step contributes to the global artery’s damage: as proven effective thanks to the 3616 analyzed patients in the CRASOC studies, a gentle and short hemostasis with pneumatic compression (TR Band® compression device, 10 cc of air/90 minutes) represents today the best and most elegant way to minimize the RAO rate. A TRA operator has to be reminded that the hemostasis step is his last chance to save the radial artery patency.
“TRA for everybody” is highly desirable for patient safety and comfort. This strategy is achievable, and solutions for more complex populations are provided. Ways to maintain the artery patency are described. Better-suited materials for easier TRA are already offered, and innovations will continue [23, 24]. The author still believes that in year 2018 the radial way requires a gentleman attitude (at least for the radial artery), demands a rebel inclination—to discard all the negative thinking about the TRA feasibility—and is best served by a “believer” behavior: a believer always will try to find indication rather than contraindication for TRA.
In dairy farms, biosecurity, surveillance, resilience/immunity, biocontainment, and control of disease spread within the herd are the pillars that need to be appropriately managed to ensure the healthy herd [1].
\nBiosecurity is focused to reduce and prevent the introduction of diseases or pests of animals on a farm, and to minimize the spread of diseases or pests within a farm. Biosecurity action plans need to be implemented mainly in large dairy farms where the disease agents can be introduced by various sources such as labor, advisers, replacement cattle, supplies, feedstuffs, and vehicles [2].
\nSurveillance programs are developed for early detection of emerging pathogens, to establish disease-free status or the prevalence of a specific disease in a herd [3].
\nRelation resilience immunity is based on the individuals’ resistance to diseases that can be modulated by the ability of animals to adapt to adverse conditions (stress factor) and recover from them [4].
\nBiocontainment and control programs are important backup systems for biosecurity plans that will prevent the emerging disease spreading within the herd or the endemic diseases spreading between animals into the farm [2, 5].
\nThe overall biosecurity of dairy farm uses different levels or shells of actions (national or supranational, regional, and local), linked with the epidemiological profile of the pathogen. For highly contagious infectious agent (e.g., foot-and-mouth disease), the most efficient biosecurity plan is at national or European Union level, while for infectious agents transmitted by close contact between animals (e.g., bovine tuberculosis), the regional biosecurity measures such as movement controls will protect the status of the region [1].
\nBiosecurity practices on livestock farms have been described and prioritized in various ways [1, 2, 5, 6]. In this chapter, we grouped biosecurity measures in the following categories: dairy farm sanitation, facility biosecurity, animal biosecurity, feed biosecurity, and manure biosecurity.
\nSome infectious agents are specific for dairy cattle and others are zoonotic, affecting both bovine and human health. Employees and visitors can contribute to the spread of all these infectious agents on a dairy farm [7]. The transmission of pathogens by humans can be reduced or even stopped by providing on-farm laundry facilities for all protective clothing used on the farm, using only clean overalls during farm visits, providing disposable clean booties for visitors and cleaning of boots with disinfecting solution after scrubbing off any visible dirt at the end of the visit, and washing of hands before and after working with sick or young animals [7, 8, 9].
\nMilking parlor personnel should wear latex gloves while milking to reduce the spreading potential of the contagious mastitis pathogens [9]. Sometimes, these hired personnel can take care of other animals outside the dairy farm and carry pathogens on the farm. Employees should be regularly trained in good practices to prevent the spread of disease (the principles of hygiene and disease security). They need to know that calves are susceptible to diseases carried by adult animals, and daily activities should be organized so that employees work with younger animals before working with older animals. Prevention of the infectious agent’s introduction and spreading from outside and inside sources should also be considered in the education of hired personnel in basic hygiene and disinfection [10]. The main actions included in the biosecurity plan for dairy farms should reduce the risk of infectious diseases to be introduced by employees and visitors (Table 1).
\nBiosecurity measure | \nAction | \n
---|---|
Record in the logbook all farm visitors | \nPlace the visitor logbook at the farm entrance | \n
Restrict the access of visitors to the stable | \nLocking the stable doors | \n
Inform unauthorized persons that they are not allowed to enter the stable | \nPost-warning signs asking visitors not to pass inside stable and several directing signs to the farm offices | \n
The visitors can access the stable only with clean clothes and boots, which they have not used in other farms | \nProvide clean boots and overalls for all visitors | \n
The visitors should use a footbath with disinfectant and clean their boots before entering the stable | \nPlace a disinfectant footbath and brushes outside the stable | \n
The dealer or transporter of the newly arrived animals is not allowed to enter in stable or in contact with the farm animals | \nThe access of the cars is made on a route that avoids contact with the farm animals, directly toward the quarantine area located at a distance from the herd | \n
The livestock renderer access in the stable or the contact with cattle is restricted | \nStore dead animals away from the stable and main roads | \n
Biosecurity measures designed to reduce the risk of the infectious disease’s introduction in dairy farms by employees and visitors.
The access of visitors must be limited and recorded in a logbook; the farm touring must start from younger to older animal groups; barn doors are recommended to be locked and a warning sign must be posted to keep out unauthorized personnel [9].
\nAlso, along the access road of the farm must be displayed signs directing visitors to the administrative area and to the visitor parking, as well as warning signs to limit direct contact of visitors with farm feed and animals [11].
\nEquipment can be contaminated with infectious secretions, excretions, and blood and the movement of equipment between stalls and farms may also transport pathogens [12].
\nAll equipment used on the farm must be regularly cleaned and disinfected [11]. To prevent contamination of equipment, storage containers need to be used for all tools and feeding equipment. Also, all storage containers are regularly cleaned and disinfected. The storage containers must protect equipment from diseases, pests, or weeds [13]. Before use in healthy animals, equipment that has been used on sick animals must be cleaned and disinfected. However, it is better not to use clothing, shoes, and tools dedicated to the compartment of sick animals [14]. Dehorners, ear taggers, hoof knives, clippers, and all shared and hired equipment will be cleaned and disinfected between uses [11, 14].
\nNursing bottles and buckets must be sanitized before each feeding [14], calves kept indoors must have fresh clean dry bedding, and plastic calf hutches will be cleaned and disinfected after use [11].
\nThe equipment used for manure disposal will not be used for transporting or delivering feed [13].
\nDisposable clothing and used veterinary equipment must be removed safely [11].
\nVehicles are considered fomites mainly for pathogenic robust organisms that can survive a long time in the environment [1]. Mainly external vehicles that collect milk, calves, and carcasses or deliver feedstuffs, pharmaceuticals, and semen can be involved in the transmission of infectious disease because they travel daily from farm to farm [2, 10]. A high biosecurity risk is associated with carcasses (dead stock) collectors because they are usually in contact with diseased animals [15, 16].
\nTo prevent the introduction of infectious agents, vehicles must be kept clean and should not have access to the zones where the animals are housed [10, 11, 17].
\nExternal vehicles should not be allowed on the farm [18]. If vehicles are necessary on the farm, then ensure that vehicles and trailers are clean when entering the farm and disinfected before and after use [6, 11, 18, 19]. Cleaning and disinfection will cover both the exterior and the interior of the vehicles, with greater attention to areas where dirt may be hidden (e.g., wheel arches and tires) [11]. Because the transport by dealers may pose additional risks of infectious disease transmission between farms, it is recommended that the animal moving will use only farm-owned vehicles [20], with clean and ample bedding to prevent both injuries and disease [14].
\nGuidance indicators and warning and restricting access signs to unauthorized vehicles must be placed at the entrance to the farm road and along the road. The farm must have a designated area for visitors’ vehicles that are at the entrance of the farm and away from the animal and animal stalls [6, 10, 14]. Also, service vehicles should not drive over the routes of feed delivery or manure handling [14].
\nIn a dairy farm, the building’s design can help prevent the spread of pathogens to sick cows, periparturient cows, and newborns [2]. Buildings should have a well-established destination, in correlation with the categories of animals present on the farm. Dairy farms can secure their premises against domestic and wild animals by installing various types of fences (e.g., electric fence) around the buildings. Disinfectant footbaths should be at the entry of livestock housing. All farms should have isolation building (the quarantine facility) where the health status of the newly purchased cows will be observed before they join the rest of the herd [21]. To prevent direct and indirect contact between residents and new animals, the quarantine facility should be located in the farthest possible place on the dairy farm [10]. The farm must have a biosecurity plan that includes building maintenance activities (e.g., check and maintain fences, replace bird netting, and repair holes in buildings), which will reduce the contact of cattle with wild animals and the feed contamination with birds droppings or badger feces [14, 21].
\nThe introduction of new cattle is one of the most important biosecurity risks for dairy farms [10]. In modern dairy farming, the sale and movement of cattle is an intrinsic part of the business as a consequence of the increased herd replacement rate of adult milking cows, the forced culling, and the need to increase the size of the herd [1]. Therefore, keeping a closed herd is the most effective biosecurity measure but is the least practical [6]. To reduce the risk of diseases spreading between farms, the new animals are purchased only from herds with known health status and known vaccination protocols [9, 10].
\nThe best solution to prevent the introduction of diseases through the acquisition of new animals is the hosting of the newly purchased cows in a quarantine facility with trained personnel to handle isolated animals [10, 21]. Quarantine is one of the most important biosecurity tools and consists of the separation of specific groups of animals to prevent the transmission of infectious diseases. Prophylactic quarantine is designed to separate the resident herd from newly acquired animals for 1 month or more. During the 30 days of isolation, the personnel from the quarantine facility will monitor cattle health status and prevent direct and indirect contact between new and resident animals [9, 10]. If the infections have short incubation times, then the animals will develop acute diseases during the quarantine period. In other cases, to prevent the diseases spreading from animals that might be hiding an infectious agent without exhibiting clinical signs to resident animals, the quarantined animals will be tested for various diseases such as bovine tuberculosis, Johne’s disease, brucellosis, leptospirosis, salmonellosis, campylobacteriosis, leucosis, bovine viral diarrhea (BVD), infectious bovine rhinotracheitis (IBR), trichomoniasis, neosporosis, ringworm, liver fluke, lungworm, digital dermatitis, and contagious mastitis pathogens (Streptococcus agalactiae and Staphylococcus aureus) [10, 14]. The testing of animals in the prophylactic quarantine is a valuable biosecurity tool when properly applied.
\nTo prevent the bovine tuberculosis introduction, the biosecurity plan should take into consideration all possibilities of Mycobacterium bovis transmission. Cattle are the main reservoir and spread microbes through aerosols (adults) or manure (calves) to many domestic and wild mammalian species. Sheep, goats, pigs, horses, and dogs are spillover hosts and spread M. bovis spread microbes in various ways (respiratory, digestive, by bites, or scratches). After infection, badgers, brush-tail opossums, wild boars, deer, and other wildlife species become wildlife reservoirs (maintenance host). Humans are susceptible and contract the infection mainly by drinking raw milk and raw milk products. People with pulmonary or urogenital tuberculosis can retransmit the infection to cattle [22].
\nCalves are more susceptible and should be kept in a separate area to minimize their exposure to infectious agents [14]. Calves can carry many infectious diseases without clinical signs and positive results on the laboratory tests (e.g., Johne’s disease). This risk can be reduced by purchasing calves only from herds officially certified as disease-free [1].
\nBecause one of the most common ways of the BVD virus introduction in a free farm is via a pregnant heifer (“Trojan cow”) carrying a persistently infected fetus, all calves from purchased cattle should be tested at birth to detect persistently infected animals with BVD virus [1, 9, 10]. Persistently infected animals are the main route of the BVDV spreading between herds because they cannot be detected by serological tests (immunotolerant calves), but excrete massive amounts of virus [1, 23]. The risk of farm contamination can be reduced by purchasing animals only from herds officially certified as BVDV-free. If the BVDV status in the herd of origin is unknown, then pregnant females should be isolated on arrival (the contact with any animal of breeding age must be restricted), tested for BVD antibody and BVD antigen, and released from isolation only if they are negative results at both tests or antibody positive, antigen-negative, calved, and the calf was tested negative or removed from the herd [1]. To prevent BVDV introduction into a free farm, the following risk factors should be considered: trade with live animals, embryo transfer and semen recipients, return of animals from animal exhibitions, direct contacts between cattle on pasture or over fences, density and activity of arthropod vectors, vaccination, and employee and visitors contact with animals [9, 24].
\nSick and suspicious animals should be isolated in a specific area and always handled at the end. In the control of contagious mastitis, the latter are milked cows suspected of the disease [9].
\nImplementing effective biosecurity programs will bring long-term economic benefits. Dutch studies have shown that the main benefits of a closed dairy herd with good biosecurity are better fertility and lower slaughter rates. The USA comparative studies in Johne’s disease-positive herds and Johne’s disease-negative herds revealed an economic loss of almost US$ 100 per cow in positive herds. Spread of an infectious disease onto a farm can lead to large economic losses. An outbreak of BVD in an Australian farm with 320 milking cows caused losses of $AUD 144,700 [25].
\nVaccination is another important biosecurity tool designed to protect resident cattle from infectious agents that could have been brought in by the newly purchased cows [26]. In dairy cattle, immunization mainly targets common infectious agents such as BVD virus, IBR virus, parainfluenza-3 (PI3) virus, bovine respiratory syncytial virus (BRSV), leptospirosis, and clostridial infections [27]. Vaccination programs should be established in collaboration with the herd veterinarian and adapted to the risk of the disease spreading on the farm, including infectious agents that evolve in the area [25, 28]. Vaccination should not be considered the primary or single biosecurity tool because no vaccine provides 100% immunity [26, 28].
\nDairy herd vaccination programs are affected by various factors such as age and category of production, disease history, housing, type of vaccine (killed or modified live), and costs [28]. Vaccination programs are designed by age categories and are applied continuously to maximize herd immunity and minimize the spread of the infectious agent [27, 28].
\nVaccination schedule for dairy heifers from birth to 6 months of age can be started with an oral modified live vaccine (MLV) for bovine rotavirus and bovine coronavirus given 30 minutes before the ingestion of colostrum to prevent the inactivation [28]. In the first hour of life, calves must receive 2.8 L of colostrum, and in the next 23 hours, the rest of 2.8 L [27]. Depending on the epidemiological situation, an intranasal vaccination of neonatal calves with respiratory vaccines (IBR/PI-3/BRSV) can be started at 3 days of age or older [28]. At 6 weeks old, dairy heifers can receive an injectable modified-live IBR/PI3/BRSV/BVD vaccine and a seven-way clostridial bacterin-toxoid [27]. The immunity of injectable vaccines is longer than the immunity of intranasal vaccines [28]. Following national and international regulations on brucellosis prophylaxis, at 4–6 months age replacement heifers should receive brucellosis RB51 vaccine. Also, depending on the epidemiological situation, calves can receive the appropriate vaccination for leptospirosis clostridial diseases and/or Histophilus somnus. At 6 months of age, heifers should be revaccinated with modified live IBR/PI3/BRSV/BVD virus vaccine, seven-way clostridial vaccine, and five-way leptospirosis bacterin [27, 28].
\nPre-breeding heifers (10–12 months of age) should be revaccinated with killed or modified live IBR/PI3/BRSV/BVD virus vaccine, five-way leptospirosis bacterin, and seven- or eight-way clostridial bacterin-toxoid [28]. Optionally, it can be done with vibriosis bacterin [27].
\nPre-calving heifers should be revaccinated 40–60 days before calving with killed IBR/PI3/BRSV/BVD virus vaccine, five-way leptospirosis bacterin, killed rotavirus and coronavirus vaccine, and Escherichia coli + Clostridium perfringens types C and D bacterin/toxoid. Three weeks before to calving, heifers should be revaccinated with killed rotavirus and coronavirus vaccine, and Escherichia coli + Clostridium perfringens types C and D bacterin/toxoid [27, 28]. Also, pre-calving heifers should be vaccinated with coliform mastitis bacterin [27].
\nAdult cows should be annually vaccinated, 40–60 days before calving for IBR, PI3, BRSV, and BVDV [27]. Depending on the history of diseases in the region and the associated epidemiological risks, the farm veterinarian should choose vaccines that immunologically protect dairy cows during the lactation period and the dry period for leptospirosis, vibriosis, Rotavirus, Coronavirus, Clostridium perfringens types C and D, and Escherichia coli mastitis. Types of vaccines recommended are killed or bacterin/toxoid and modified-live vaccines (MLV) [27, 28]. Adult dairy cattle should receive a booster vaccination at 3 weeks before calving with killed rotavirus and coronavirus vaccine and Escherichia coli + Clostridium perfringens types C and D bacterin/toxoid vaccine [27]. MLV vaccines should be used with prudence in pregnant cows and only after consultation with the veterinarian [28]. The annual vaccination for vibriosis should be performed in dairy herds where the artificial insemination is not practiced [27].
\nThe annual vaccination of adult dairy cattle for calf scours (rotavirus and coronavirus, Escherichia coli, and Clostridium perfringens types C and D) should be considered in all herds with recent history as a part of the preventative management practices [27].
\nMastitis is one of the most important diseases in dairy cows that affects the welfare, production, and duration of the economic life of the animals [29]. Economic losses are due to direct milk production losses (reduction of quantity, unsalable, or poor quality), culling or removal from the herd of animals with unsatisfactory treatment results, cost of veterinary care, cost of excessive use of antimicrobials and other medicines, and the risk of antibiotic resistance [30].
\nThe main pathogens targeted by mastitis vaccines are Staphylococcus aureus, Streptococcus agalactiae, and Escherichia coli [29]. Reduction in the incidence and duration of intramammary infections can be obtained by applying the combination of vaccination with high milking hygiene procedures, treatment of clinical cases, segregation, and culling of known infected cows [29]. The following preventive measures were proved to have a positive result in the management of mastitis in dairy herds: the use of milkers’ gloves, blanket use of dry-cow therapy, washing unclean udders, maintaining cows upright after milking, back-flushing of the milking cluster after milking an animal with clinical mastitis, and application of a treatment protocol [30] Also, to maximize the success of immunization, within 5 days of mastitis vaccines, dairy cows must not receive any other Gram-negative bacterin vaccines (e.g., Escherichia coli, Salmonella spp., Pasteurella spp., Campylobacter sp., and Moraxella bovis) [27].
\nTo evaluate the effects of mastitis vaccines in dairy cows, the following monitoring parameters are most commonly used:
Clinical and subclinical mastitis incidence and severity
Somatic cell count
Serum and/or milk immunoglobulin G concentrations
Milk bacterial culture or Staphylococcus aureus count in milk
Milk production
Cure or cull rate [29]
Newly acquired dairy herd bulls should be 30–60 days in prophylactic quarantine and tested with negative results for persistent BVDV infection, brucellosis, and tuberculosis. Recommended vaccination schedule for dairy herd bulls is an annual vaccination at the breeding soundness examination with IBR/PI3/BVD killed vaccine, five-way leptospirosis bacterin, and vibriosis bacterin [27].
\nIf there are animal species other than cattle, then the vaccination actions must take into account for these species as well. Farm dogs and cats should be vaccinated at least against rabies to protect humans and other animals [14].
\nAntibiotic overuse can be reduced by using a proper mixture of natural antibacterial peptides, biological response modifiers, prebiotics, probiotics, and correct development of the gut microbiome [31].
\nThe limited use of bacterial culture and sensitivity testing by veterinarians are other causes of the persistence of the multidrug resistance (MDR) isolates in dairy farms. The findings of the last decades highlight the necessity of using antimicrobial susceptibility testing each time before prescribing an antibiotic [32].
\nTo reduce the risk of pathogens spreading in farm animals, dead animals should be disposed of in the shortest time. Depending on the national regulations and farm’s possibilities, the disposal of carcasses can be done by a licensed dead stock collector, burial, or composting [14].
\nStudies designed to investigate what motivates and withholds farmers to implement biosecurity measures placed the carcass storage away from the stables on the second rank for feasibility, but with a lower score for efficacy [33].
\nRendering trucks have a particular risk for farm biosecurity because they are at high risk for carrying animals killed by infectious diseases [26]. To prevent farm contamination, mortality pick-up should be located away from the stable and feed storage bin and silo [34].
\nThe biosecurity of feed and water must start from the source, respectively, from the fields where crops are grown and from the water capture source. Manure used as a natural fertilizer can contaminate the soil, crop, and water used for irrigation and groundwater sources [2]. The quality and potability of water should be tested regularly, and samples from each feedstuff batch or lot should be stored for possible laboratory analyses (e.g., bacteria, toxins, molds, and mycotoxins) until that batch is consumed without incidents [2, 10].
\nTo reduce the risk of the diseases being introduced by contaminated feed, the dairy producer should record and monitor the manure application on its pastures and fields cultivated with feedstuffs [2]. The risk of a feed-related disease outbreak is increased when feedstuffs are purchased from multiple locations or the crops were fertilized with manure from other dairy farms [2, 10].
\nTo prevent feedstuffs to be contaminated through fecal material and urine from rodents, birds, dogs, cats, and any wildlife, dairy farmers should design food storage areas in a way to be inaccessible (e.g., opened bags can be placed into containers with tight lids; barns can have welded wire fence) [2, 14].
\nThe biosecurity plan of the dairy farm should include the frequency of storage areas cleaning, the way of feed bags storage off the floor on pallets, removing and disposing of the not consumed feed within 24 hours, rotation of feed inventory for the purpose to reduce the possible presence of detrimental organisms or toxins in stored feeds, and periodically checking of silos, bins, and bunks to detect and remove as soon as possible moldy or spoiled feedstuff [14].
\nAlthough not recommended, some cattle herds are still using surface water (e.g., lakes, ponds, and rivers) as a water source. Drinking water can be contaminated by animal carcasses (e.g., dead wild animals), manure from other livestock, bird droppings, urine and feces of wildlife, and human waste [2, 10, 14]. Water biosecurity programs should include several measures designed to prevent contamination with toxins and infectious agents such as restriction of the birds and wildlife access to farm water sources, filtration and chemical sterilization of water, and regular testing of water quality and potability [2]. Waterers should be cleaned once a week [14].
\nIn dairy farms, manure is the most problematic waste and should be treated as a biological risk material because it has a huge bacterial load [2]. Manure should be stored in an area inaccessible to cattle [14]. Contact with manure from infected cattle is the main means of spread for rotavirus, coronavirus, Escherichia coli, Salmonellosis, and Johne’s disease to other receptive animals. Manure handling should prevent environmental contamination and should not violate the legislation in force [14].
\nManure is rich in nutrients that could be recycled as fertilizer [35]. However, the use of this natural fertilizer should be done with caution to prevent contamination of crops, pastures, and groundwater sources [2]. Salmonella spp., Escherichia coli, Listeria spp., and Mycobacterium avium subsp. paratuberculosis can be killed by the process of manure composting but the process must be controlled before the use of compost in agriculture [2, 36, 37]. In the process of composting should not be used the manure from the hospital pen, where de infectious agents can be in a high concentration. Also, the temperature and microbial activity should be checked to confirm the complete sterilization [2, 14]. Also, manure can be recycled for bedding and to produce methane [2].
\nManure biosecurity programs should include measures to prevent the manure equipment used to handle feed, the environment infestation with files and intestinal parasites (manure must be removed frequently to prevent the pest life cycles completion), manure run-off or transfer from adults to calves, and feed contamination by manure-covered wheels of farm vehicles [14].
\nManure spreaders and slurry handling equipment are high-risk equipment and should be brought to the farm after proper cleaning or disinfection [1].
\nThe manure cleaning of vehicles and equipment must be done in areas specially designed for this purpose, where water or disinfectants would not splash onto feed or into drinking water. Throughout the entire cleaning and disinfection process, the equipment will be inspected visually to dispel any suspicion of cross-contamination [2].
\nThe development and implementation of biosecurity programs in dairy farms improve cattle health, welfare, and productivity. These programs must be monitored and evaluated continuously to identify new methods of control and new effective critical control points and to further improve the program to prevent the introduction and spread of infectious agents on the farm. The biosecurity program should be focused on the decision and adapted to the specific situations of each dairy farm. Many of the problems encountered can be prevented or minimized with the support of veterinary services. Staff and visitors should be trained on biosecurity measures applied on the farm.
\nThe authors declare no conflict of interest.
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