radial or bust the only choice for vascular access jim nolan university hospital of north...
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RADIAL OR BUSTRADIAL OR BUSTThe only choice for vascular The only choice for vascular
accessaccess
Jim NolanJim NolanUniversity Hospital of North StaffordshireUniversity Hospital of North Staffordshire
United KingdomUnited Kingdom
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CONFLICTS OF INTERESTCONFLICTS OF INTEREST
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ARTERIAL ACCESS – WHY AM I ARTERIAL ACCESS – WHY AM I INTERESTEDINTERESTED
(Heart 1995, Am Heart J 1997)(Heart 1995, Am Heart J 1997)
18
8
1.40
5
10
15
20
Leeds FemoralBailout
Leeds FemoralElective
Leeds Brachial
%
%
%
Majo
r V
asacu
lar
Com
plicati
on
s
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BRACHIAL CUT DOWN BRACHIAL CUT DOWN COMPLICATIONSCOMPLICATIONS
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NEURO-ANATOMY OF THE FEMORAL TRIANGLE
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FEMORAL ACCESS PRACTICE FEMORAL ACCESS PRACTICE Two weeks at UHNSTwo weeks at UHNS
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FEMORAL ACCESS FEMORAL ACCESS COMPLICATIONSCOMPLICATIONS
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ACTIVE RETROPERITONEAL ACTIVE RETROPERITONEAL BLEEDBLEED
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FEMORAL VASCULAR COMPLICATIONS FEMORAL VASCULAR COMPLICATIONS IN CONTEMPORARY UK PRACTICEIN CONTEMPORARY UK PRACTICE(Berry et-al, AJC 2004, n = 311)(Berry et-al, AJC 2004, n = 311)
2726
7
4
6
1.3
0
5
10
15
20
25
30
Pe
rce
nta
ge
Haematoma Groin pain Largehaematoma
(>5cm)
Vagal Prolongedadmission
Vascularintervention
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MAJOR VASCULAR MAJOR VASCULAR COMPLICATIONSCOMPLICATIONS
1 RPH, 3 Pseudo-aneurysms
3 GA emergency surgery
13 units of blood
Total of 61 extra days in hospital
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ANTITHROMBOTIC THERAPY AND ANTITHROMBOTIC THERAPY AND FEMORAL COMPLICATIONSFEMORAL COMPLICATIONS
0
5
10
15
20
%
DIAGNOSTICPOPULATIONBerry 2004
ANGINA PCIPOPULATIONMoutralescot 2005
MI/REO-PROPCI POPULATIONOtavio 2004
1.12.2
5.9
RESCUE PCIDauermau 2000
17.5
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VACD – DEVICE FAILURE RATEVACD – DEVICE FAILURE RATE(Sesana et-al, JIC 2000, n = 827)(Sesana et-al, JIC 2000, n = 827)
9
11
0
2
4
6
8
10
12
COLLAGEN PLUG SUTURE
FA
ILU
RE R
ATE (
%)
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VCD META ANALYSIS – RANDOMISED + OBSERVATIONAL
(Nikolsky et-al, JACC 2004, n = 37,066)
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DOES IT ALL MATTER?DOES IT ALL MATTER?COMPLICATIONS OF PCI IN CONTEMPORARY COMPLICATIONS OF PCI IN CONTEMPORARY
PRACTICEPRACTICE(Heart 2005, n = 3071)(Heart 2005, n = 3071)
0
0.5
1
1.5
2
2.5
3
CVA MI DEATH MAVE
%
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DOES IT ALL MATTER?DOES IT ALL MATTER?MEDICO-LEGAL CASES ARISING FROM MEDICO-LEGAL CASES ARISING FROM
CARDIAC CATHETERISATION CARDIAC CATHETERISATION PROCEDURESPROCEDURES (1992-2002 - MDU)(1992-2002 - MDU)
VASCULAR
CARDIAC
CNS
OTHER
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NEURO-ANATOMY OF THE WRIST
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VASCULAR COMPLICATIONSVASCULAR COMPLICATIONS(uhns transradial programme)(uhns transradial programme)
Heart 2003Heart 2003
RADIALRADIAL FEMORALFEMORAL
(n=1000)(n=1000) (n=727)(n=727)
TRANSFUSIONTRANSFUSION 0 (0%) 0 (0%) 4 (0.6%) 4 (0.6%)
VASCULAR INTERVENTIONVASCULAR INTERVENTION 1 (0.1%) 1 (0.1%) 6 (0.8%) 6 (0.8%)
INFECTIONINFECTION 2 (0.2%) 2 (0.2%) 2 (0.3%) 2 (0.3%)
3 (0.3%)3 (0.3%) 12 (1.7%) 12 (1.7%)
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RADIAL VS FEMORAL ACCESS RADIAL VS FEMORAL ACCESS ––
RCT meta analysisRCT meta analysis(Agostoni et-al JACC 2004)(Agostoni et-al JACC 2004)
Grinfield Mann ACCESS BRAFE Mann Cooper CARAFE Gorge Moriyama
OCTOPLUS TEMPURA
MACE Procedural success
Procedural success 1999-2003
Access site complications
number
279
152
600
112
142
200
210
420
200
371
149
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ARE RADIAL CASES TOO HARD TO DO ARE RADIAL CASES TOO HARD TO DO (Rao et al, JACCI 2008)(Rao et al, JACCI 2008)
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DOES EVERYBODY BENEFIT FROM RADIAL ACCESSDOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)(Rao et-al JACCI 2008)
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DOES EVERYBODY BENEFIT FROM RADIAL ACCESSDOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)(Rao et-al JACCI 2008)
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DOES EVERYBODY BENEFIT FROM RADIAL ACCESSDOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)(Rao et-al JACCI 2008)
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IS PCI RELATED BLEEDING A BAD THINGIS PCI RELATED BLEEDING A BAD THING(MORTAL study, Heart 2008, n=38,872)(MORTAL study, Heart 2008, n=38,872)
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DOES PREVENTION OF ACCESS SITE DOES PREVENTION OF ACCESS SITE BLEEDING IMPROVE OUTCOMEBLEEDING IMPROVE OUTCOME
(MORTAL study, Heart 2008, n=38,872)(MORTAL study, Heart 2008, n=38,872)
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VASCULAR COMPLICATIONS – ECONOMIC IMPACTVASCULAR COMPLICATIONS – ECONOMIC IMPACT(Nowamagbe et-al, JACC 1995, n = 1,012 CAVEAT-1)(Nowamagbe et-al, JACC 1995, n = 1,012 CAVEAT-1)
5.2
12.1
0
2
4
6
8
10
12
14
NO COMPLICATION FEMORALCOMPLICATION
15,499
28,003
0
5,000
10,000
15,000
20,000
25,000
30,000
NO COMPLICATION FEMORALCOMPLICATION
LO
S (
DA
YS
)
LENGTH OF STAY HOSPITAL COSTS
CO
ST (
$)
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TRANSRADIAL APPROACHTRANSRADIAL APPROACHPATIENT PREFERENCEPATIENT PREFERENCE
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TRANSRADIAL APPROACHTRANSRADIAL APPROACHNURSING PREFERENCENURSING PREFERENCE
(Amoroso, EJCVN, 2005, n = 260)(Amoroso, EJCVN, 2005, n = 260)
Femoral Radial Femoral Radial
Cath lab Ward
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RADIATION EXPOSURE IS IMPORTANTRADIATION EXPOSURE IS IMPORTANTSkin injury due to cardiac interventionSkin injury due to cardiac intervention
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RADIATION EXPOSURE IS IMPORTANTRADIATION EXPOSURE IS IMPORTANTAccessory pathway ablationAccessory pathway ablation
3 weeks
5 months6.5 months
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OPERATORS ALSO GET RADIATION OPERATORS ALSO GET RADIATION INDUCED SKIN INJURYINDUCED SKIN INJURY
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2.4 1.5
21.9 22.4
6.5 5.9
0
5
10
15
20
25
FT (min) DAP(Gycm2)
Operatordose (uSv)
Radial Femoral
UHNS RADIATION EXPOSURE STUDYUHNS RADIATION EXPOSURE STUDYMean fluoroscopy time and patient Mean fluoroscopy time and patient
and operator radiation dosesand operator radiation doses(Heart 2007)(Heart 2007)
P<0.05
P=NS
P=NS
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UHNS RADIATION EXPOSURE STUDYUHNS RADIATION EXPOSURE STUDYMean procedure duration (min) and time to ambulation (min)Mean procedure duration (min) and time to ambulation (min)
(Heart 2007)(Heart 2007)
12.6 6.2 7.2
257.2
0
50
100
150
200
250
300
Procedural time Time to ambulation
Radial Femoral
P<0.005
P<0.0001
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PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004TLD BADGE READINGS - UHNSTLD BADGE READINGS - UHNS
0
5
10
15
A B C D E
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Mont Blanc Summit Ridge Mont Blanc Summit Ridge September 2007September 2007
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TRANSRADIAL APPROACHTRANSRADIAL APPROACHTHE LEARNING CURVETHE LEARNING CURVE
Lefevre TCT 2003Lefevre TCT 2003
Puncture failure, spasm, different guide manipulationPuncture failure, spasm, different guide manipulation
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“…“…the radial approach has become increasingly popular the radial approach has become increasingly popular with the potential advantage of a greater opportunity for with the potential advantage of a greater opportunity for same day discharge”same day discharge”
“…“…shorter bed rest and hospital stay when the radial shorter bed rest and hospital stay when the radial approach is used”approach is used”
“…“…the use of the radial approach is likely to increase”the use of the radial approach is likely to increase”
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RADIAL Vs FEMORAL PCIRADIAL Vs FEMORAL PCI(BCIS DATABASE)(BCIS DATABASE)
10.3
15.7
27
36.1
0
5
10
15
20
25
30
35
40
2004 2005 2006 2007
% of total PCI
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THE RADIAL ARTERYTHE RADIAL ARTERY
Reduces access site bleedingReduces access site bleeding Impact on mortalityImpact on mortality EfficientEfficient Preferred by patientsPreferred by patients Endorsed by BCISEndorsed by BCIS Taken up by increasing numbers of UK Taken up by increasing numbers of UK
interventionistsinterventionists
THE ONLY CHOICE FOR VASCULAR ACCESSTHE ONLY CHOICE FOR VASCULAR ACCESS
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THANKS TO MARK GUNNINGTHANKS TO MARK GUNNING