trans-radial interventions
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Trans-Radial Interventions. Eli Lev, MD Director of Interventional Cardiology Hasharon Hospital, Rabin Medical Center and Tel-Aviv University, Israel. Objectives. Learn the main scientific literature supporting radial access for PCI - PowerPoint PPT PresentationTRANSCRIPT
Trans-Radial Interventions
Eli Lev, MD Director of Interventional Cardiology
Hasharon Hospital, Rabin Medical Center
and Tel-Aviv University, Israel
Objectives
• Learn the main scientific literature supporting radial access for PCI
• Learn the basic methodology in performing trans-radial PCI
History
Transradial catheterization first described by Radner in 1948.
In 1989, Campeau et al revisited Radner’s idea & reported on percutaneous entry into distal radial artery for selective coronary angiography in 100 pts.
In 1992, Kiemeneij et al used Campeau’s work as the basis for developing TRI.
1. Radner S. Thoracal aortography by catheterization from the radial artery; preliminary report of a new technique. Acta radiol. 1948;29:178-80.
2. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn. 1989;16:3-7.
3. Kiemeneij F, Laarman GJ, de Melker E. Transradial coronary artery angioplasty. Am Heart J. 1995;129:1-7.
5.3%
2.1%
4.00%
0.7%0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
Non-obese Obese
Femoral Radial
P= 0.048 P= 0.040
Cox, N. Am J Cardiol 2004; 94 1174-1177
Risk of vascular complications associated with femoral and radial access
Retrospective review of 5,234 cath and PCIVascular complications by BMI: lower rate of vascular complications using TR vs.
TF approach for obese and non obese patients
Jolly SS et al.Am Heart J 2009;157:132-40
Radial versus femoral access for coronary angiography or PCI: A systematic review and meta-analysis of randomized trials (total of 4458 patients)
Jolly SS et al. Am Heart J 2009;157:132-40
Radial vs. femoral access for coronary angiography or PCI: A systematic review and meta-analysis of randomized trials
NSTE-ACS and STEMI(n=7021)
Radial Access(n=3507)
Femoral Access(n=3514)
Primary Outcome: Death, MI, stroke or non-CABG-related Major Bleeding at 30 days
Randomization
RIVAL Study Design
Key Inclusion: • Intact dual circulation of hand required
• Interventionalist experienced with both (minimum 50 radial procedures in last year)
Jolly SS et al. Lancet 2011.
Blinded Adjudication of Outcomes
Baseline CharacteristicsRadial
(n =3507)Femoral (n =3514)
Mean Age (years) 62 62
Male (%) 74.1 72.9
Diabetes (%) 22.3 20.5
Diagnosis at presentation
UA (%) 44.3 45.7
NSTEMI (%) 28.5 25.8
STEMI (%) 27.2 28.5
Jolly et al, Lancet 2011
Primary and Secondary Outcomes
Radial(n=3507)
%
Femoral (n=3514)
%HR 95% CI P
Primary OutcomeDeath, MI, Stroke, Non-CABG Major Bleed
3.7 4.0 0.92 0.72-1.17 0.50
Secondary OutcomesDeath, MI, Stroke 3.2 3.2 0.98 0.77-1.28 0.90
Jolly et al, Lancet 2011
Other Outcomes
Radial(n=3507)
%
Femoral (n=3514)
%HR 95% CI P
Major Vascular Access Site Complications
1.4 3.7 0.37 0.27-0.52 <0.0001
Major Bleeding
TIMI Non-CABG Major Bleeding
0.5 0.5 1.00 0.53-1.89 1.00
ACUITY Non-CABG Major Bleeding
1.9 4.5 0.43 0.32-0.57 <0.0001
Jolly et al, Lancet 2011
RIVAL study 7021 patients with
ACS undergoing PCI No difference in
MACE – death, MI, stroke
Trend for less major bleeding with radial access, depending on the bleeding definition
Less vascular complications with radial access
Special benefit for radial in STEMI pts Jolly et al, Lancet 2011
Primary endpoint - NACE
Non CABG major bleeding
Death, MI, Stroke or non-CABG major Bleed Subgroups: Primary OutcomeR I V A L
0.25 1.00 4.00Radial better Femoral better
Hazard Ratio (95% CI)
<75 ≥75
FemaleMale
<2525-35>35
≤7070-142.5>142.5
Lowest TertileMiddle TertileHighest Tertile
NSTE-ACSSTEMI
Age
Gender
BMI
Radial PCI Volume by Operator
Radial PCI Volume by Centre
Diagnosis at presentation
Overall
0.786
0.356
0.637
0.536
0.021
0.025
Interactionp-value
Jolly et al, Lancet 2011
Other Outcomes Radial(n=3507)
Femoral (n=3514) P
Access site Cross-over (%) 7.6 2.0 <0.0001
PCI Procedure duration (min) 35 34 0.62
Fluoroscopy time (min) 9.3 8.0 <0.0001
Persistent pain at access site >2 weeks (%) 2.6 3.1 0.22
Patient prefers assigned access site for next procedure (%)
90 49 <0.0001
• No differences in PCI success rate
RIFLE-STEACS study (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome)
• 1001 pts with ST elevation ACS randomized TRI vs TFI at high volume centers• NACE at 30 days (cardiac death, stroke, MI, TVR, bleeding): 13.6% TRI VS. 21% TFI (P=0.003)
• Cardiac mortality : 5.2% TRI vs. 9.2% TFI (P=0.02)
• Bleeding: 7.8% TRI vs. 12.2% TFI (p=0.026)
• Shorter hospital stay with TRI
Romagnoli et al JACC, 2012
Meta-analysis of Radial vs. Femoral in STEMI pts
Mortality
Access site complications
Bleeding
Mamas et al Heart 2012
Adoption of Radial Access and Comparison of Outcomes to Femoral Access in Percutaneous
Coronary Intervention An Updated Report from the National Cardiovascular Data Registry
(2012–2007)
Dmitriy N. Feldman DN et al, Circulation. 2013;127:2295-2306
NCDR registry, >2,800,000 patients, >1300 sites
Trends of use of r-PCI over time
The proportion of r-PCI procedures accounted for 6.33% of total procedures (n=178,643),
increasing from 1.18% in the 1st quarter of 2007to 16.07% in the 3rd quarter of 2012 (P<0.01).
Outcomes
Main Findings
1. Use of ↑ r-PCI X13 over 6 yrs in the US2. Lower risk of bleeding and vascular
complications with r-PCI3. Underuse of r-PCI at ↑ risk groups for
bleeding (older, women, ACS)4. The greatest benefit of r-PCI in terms of the
absolute reduction of bleeding & vascular complications is seen in high-risk groups of pts aged ≥75 years, women, & pts with ACS
5. r-PCI associated with longer fluoroscopy times
Q2_07
Q4_07
Q2_08
Q4_08
Q2_09
Q4_09
Q2_10
Q4_10
Q2_11
Q4_11
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
femoralradial
Frequencies of transradial and transfemoral interventions from April 2007 until December 2011, Rabin Medical Center
G. Greenberg et al . A Comparative Matched-Analysis of Clinical Outcomes Between Transradial versus Transfemoral PCI. Under Review…..
The Anatomy
The Anatomy
Allen’s Test - Can be performed ± Oximetry test
Peripheral vascular diseases. Edgar van Nuys Allen, MD and others with associates in the Mayo Clinic and Mayo Foundation; 2nd edition, Philadelphia, Saunders, 1955.
Allen’s Test - Can be performed ± Oximetry test
We recommend that, in the presence of an abnormal AT, the RA should not be used for cardiac catheterization unless the risk of using the femoral approach is excessive. Greenwood et al. JACC Vol. 46, No. 11, 2005, 2005:2013–7
Optimal Candidates for TR Access
• Most of the population who have dual circulation to the hand
• Obese individuals who are at increased risk of complications from TF access
• Individuals with severe PVD or AAA• Diagnostic procedures (e.g. prior to
cardiac surgery)
Today TR is the default approach in many centers
Radial Access: proximal to styloid process – Not really the wrist!
Technical Tips for Successful Transradial Cannulation
• Use a 21 G x 2.5 cm thin wall needle to cannulate the radial artery
• Advance a 0.025 inch guidewire through the needle• After the introducer is inserted, give “cocktail” of
Verapamil 2 mg diluted in saline, or 100-200 mcg of nitroglycerine, with by 50 units/kg heparin bolus
Quesada et al, “Transradial Coronary Interventions”, Interventional Cardiology Secrets, 2003, pp. 203-210
Sedation and Verapamil / Nitro Virtually
Eliminate the Spasm Problem
Before After
Radial Loop and Radial Recurrent Artery
How do you deal with tortuousity?• Use a Benson or Wholey or Terumo wires into the
ascending aorta. • Pull the wire into the shaft of the catheter in order to
facilitate torquing for coronary cannulation.• Low threshold for crossing over to femoral• Always use a diagnostic catheter and then
exchange for a stiffer guiding catheter.• Use JR or MP as your initial catheter to access the
ascending aorta and then exchange for the PCI catheter
Quesada et al, “Transradial Coronary Interventions”, Interventional Cardiology Secrets, 2003, pp. 203-210
The Learning Curve: Transradial Pitfalls
• Getting access• Radial Artery Spasm
Prevention and management• Anatomical Variations
Tortousity, vascular anomalies• Transversing the subclavian – Rt vs. Lt
Respiration maneuversNeed for TF conversion
• Catheter shape selection for cannulation• Catheter control and backup support• “Patent Haemostasis” after pulling out the sheath
Commonly Used Guiding Catheter Shapes
Left Arm Approach Right Arm Approach For Lesions in LCA For Lesions in LCA
- XB 3.5 - JL 3.5 - JL 4 - XB/EBU 3.0
- Kimny - Kimny For Lesions in RCA For Lesions in RCA
- JR 4 - JR 4 , 3DRC- AL I or AL II - HS1, AL I
- HS 1 & 2 - Barbeau - Kimny - Kimny
Sheathless Catheters
Patent Haemostasis
N=57• Dedicated and better TR access tools
hydrophilic sheathsSheathless guiding cathetersSingle catheter diagnostics (e.g. Tiger)
• 5 French compatible PCI equipment• Ability to perform complex interventions
STEMI, bifurcations, CTO, LM, long lesions etc.
Developments with trans-radial equipment
Transradial Access Site Complications
• Radial artery occlusion (≈5%, higher rates when routine doppler is used, mostly asympt.)
• Forearm hematoma and/or pain• Radial artery pseudoaneuyrsm• Radial or brachial or artery perforation• Uncontrolled bleeding with resultant
compartment syndrome• Pain during catheter insertion• Need for femoral conversion (5-10%)
Radial Artery Occlusion Factors
• Artery size: higher incidence with smaller artery• Larger catheter (>6 French) • Lack of heparinization or ↓ heparin dose• Artery spasm: pretreatment with verapamil / nitro• Hemostasis device: minimize over-compression
Ruo S, EHJ 2012
Radial Artery Complications
• 1372 ProceduresAsymptomatic radial occlusion
4.7%Symptomatic radial occlusion
0.2%Significant hematoma
0.2%Significant pseudoaneurysm
0.2%• Worst Complication
Perforation →Compartment Syndrome 1 Case GR. Barbeau, et.al. ACC 2006)
Radial Access - Disadvantages
• Associated with a significant operator learning curve• Has limited compatibility with very large equipment• Elderly patients may have increased tortuousity of
the radial and subclavian arteries which makes the procedure more challenging
• May have limited guiding catheter support in most challenging PCI scenarios (tortousity, heavy
calcifications, complex bifurcations)• Associated with upper limb arterial complications
(rare) • Higher radiation exposure to the operator
Radial Access - The Advantages
• Decrease the incidence of major vascular complications• Decrease the incidence of bleeding complications• Appears to decrease MACE in patients with ACS• Better control over vascular access and hemostasis for
obese and overall patients• Decreased time to ambulation• Improved patient movement and comfort• Allows early discharge policy• May decrease cost
Thank you