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Radial Access: state of the art

Radial Access: state of the art. Y. Louvard Massy, France. Transradial approach: the best way to reduce the vascular complication rate and the cost, and to improve patient comfort. Impact of Access Site Hematoma With Transfusion in Patients Undergoing PCI.

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Radial Access: state of the art

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  1. Radial Access: state of the art • Y. Louvard • Massy, France

  2. Transradial approach: the best way to reduce the vascular complication rate and the cost, and to improve patient comfort

  3. Impact of Access Site Hematoma With Transfusion in Patients Undergoing PCI 6613 PCI (98-00)(NHLBI): hematoma w transfusion 1.8% (97% femoral) Independent predictors: Older age, female, thrombotic lesion, 3-VD, renal disease, emergent PCI, prior aspirin HWT no HWT p Procedural death (%): 10.3 1.2 <0.001 death/MI (%): 18.1 3.55 <0.001 HWT is a predictor of death/MI (OR = 3.49; 95% CI: 1.98-6.14) J. Slater Am J Cardiol 2003 (suppl) 92: 18L

  4. Clinical Significance of Bleeding Complications From Blankenship Am Heart J 1999; 138: S287-S296

  5. Radial / Femoral Approach meta-analysis: Entry site complications Agostini P personal communication

  6. Transradial approach: for PCI, for Diagnosis, for Both?

  7. ACCESS Study Radial Brachial Femoral p Approach failure (%) 7 4.3 0.3 <0.001 Procedural success (%) 91.7 90.7 90.7 NS Equipment: Guiding cath. (n) 1.3 1.3 1.3 NS Balloons (n) 1.3 1.3 1.3 NS Stenting (%) 4.7 7 4.7 NS Procedural time (Min) 40+24 39+25 38+24 NS Fluoro. Time (Min 13+11 12+10 11+10 0.06 Hospital stay (days) 1.5+2.5 1.8+3.8 1.8+4.2 NS Kiemeneij JACC 1997;29:1269-75

  8. Radial Artery Diameter (Ultrasound)n=120 5f 6f 7f 8f 2,9+0,6 mm Y. Louvard unpublished

  9. Catheters / Devices / Technique Compatibility

  10. A randomized trial of 5 vs. 6 French transradial percutaneous coronary interventions 5 Fr / 6 Fr guiding catheter, 171 pts with coronary lesions suitable for 5 Fr transradial approach 5 Fr 6 Fr p Procedural success (%) 95.4 92.9 Cor. cannulation failure (%) 1.1 4.8 0.08 Minor hematomas (%) 1.1 4.8 0.07 Loss of radial pulse (%) 1.1 5.9 0.05 Dahm JB CCVI 2002; 57(2):172-6

  11. CARAFE (Technical Data) Femoral Right Radial Left Radial N= 70 70 70 Cross over 0 1 (1.4%)* 0 LCA catheter (n) 1.1+0.3 1.2+0.6 1.1+0.3 RCA catheter (n) 1.0+0.2 1.1+0.3 1.0+0.2 Total catheters (n) 2.1+0.4 1.4+0.7** 2.1+0.4 * p=ns : L Rad , ** p<.000 vs Femoral and L Rad Y. Louvard CCVI 2001; 52: 181-187

  12. Looking for the best multipurpose catheter for Right transradial coronary angiography • Multipurpose (too much rotation) • Amplatz AL2 (AL1) • Champ (dead…) • JL 3.5 (for left and right!) • Tiger II +++

  13. Transradial Approach Reduces Bleeding Complications and Length of Stay in Patients With GP IIb/IIIa Inhibitors FA RA p value N= 2432 164 GPIIbIIIa – (%) 61 90 Major bleeding (n) 164 0 <0.05 Major complication (n) 21 0 <0.05 Minor complication (n) 59 6 <0.05 Thrombocytopenia (n) 17 3 <0.05 Length of stay (hrs) 70.6 36.6 <0.05 *p <0.05, major bleeding (TIMI criteria), major (requiring surgical repair), and minor (pseudoaneurysm or charted hematoma) access site complications G. Revtyak Am J Cardiol 2001; 88: 39G

  14. Transradial vs. transfemoral approach in primary stent implantation for patients with acute myocardial infarction: TEMPURA trial 149 pts with AMI < 12 hr, randomized into 2 groups TRI TFI N= 77 72 Cross over (n) 1 0 Severe bleeding complication (n) 0 2 Success of reperfusion (%) 96.1 97.1 in-hospital MACE (%) 5.2 8.3 Saito CCVI 2003; 59(1):26-33

  15. OCTOPLUS: Primary endpoint, Intention to treat analysis $ surgery, transfusion, Hb loss>3g/100ml-Ht loss>10%, ischemia, FA, vasc. Complic. leading to discharge delay *Large hematoma: discharge delay

  16. Safety of same-day-discharge radial percutaneous coronary intervention 943 Pts same-day discharge radial PCI: entry site complications or repeat angiogram and/or PCI within 24 hours and 1 month , 811 patients responded , 38 patients died, 94 alive but refused to participate/impossible to contact 24 h 1 month Access complication (%) 2.8 0 Chest pain (%) 2 11.5 repeat angio (%) 0.1 1.3 Vessel occlusion (%) 0 0.5 (+ lost for FU pts) 0.2 Ziakas Am Heart J. 2003; 146: 699-704

  17. Transradial Approach for non- Coronary Diagnosis and Intervention ?

  18. Right Transradial selective vertebral and carotid angiography

  19. Transradial carotid bifurcation stenting J. Théron, Caen, France, personal communication

  20. Transradial Approach Drawbacks ?:It has to be learned (!)…and teached

  21. Radial approach learning curve in non selected population 52% 69% 89% Y. Louvard, preliminary

  22. Radial approach learning curve in non selected population 96% 97% 98% Y. Louvard, preliminary

  23. Transradial Approach Failure in Relation to Volume % *Failure to enter ascending aorta p= 0.002 Y. Louvard, unpublished

  24. Predictive Factors of Radial Approach Failure Success Failure* p n= 2347 53 Age (years) 61.6+11.3 65+11.2 0.03 Male (%) 84 73.7 0.068 Hypertension (%) 42.2 43.4 ns Dyslipidemia (%) 72.9 69.8 ns Diabetes (%) 8.4 13.2 ns Smoking (%) 26.9 22.6 ns Left radial (%) 3.2 18.9 0.000 Re-radial (%) 21.9 17 ns N° of Same Radial (n) 1.3+0.7 1.3+0.6 ns N° Dis. Coro. Vessels (n) 1.8+0.8 1.7+0.7 ns Weight (kg) 76.9+13.5 72.8+13.8 0.029 Height (cm) 169.3+8.3 166.4+10.3 0.03 *Failure to enter ascending aorta

  25. Radial Approach Failure Rate in Relation to Age % Y. Louvard, unpublished

  26. Radial Approach Failure Rate in Relation to Weight Y. Louvard, unpublished

  27. Predictors of Failure of Transradial Approach for Coronary Angiography and Interventions A multivariate analysis of a large series: 6,962 TRA (94-98) Causes of the 475 TRA failures (7%): unsuccessful puncture (69%), difficult anatomy (16%), brachial artery spasm (8%), unsuccessful canulation (5%) or miscellaneous (2%) G.Barbeau AHA 1999

  28. Evaluation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures Automatic pullback device, efficacy of an intra-arterial vasodilating cocktail (verapamil 5 mg, nitroglycerine 200 µg) in reducing radial artery spasm Cocktail No cocktail p value N= 50 50 Pain (%) 14 34 0.019 Pain score 1.7 + 0.94 2.08 + 1.07 = 0.03 Maximal pullback force (kg) 0.53 + 0.52 0.76 + 0.45 = 0.013 MPF > 1.0 kg (%) 8 22 = 0.029 Kiemeneij CCVI 2003; 58: 281-4

  29. Tortuous Right Subclavian Artery: Prevalence and Predictive Factors 2,341 consecutive right radial approaches Prevalence (%) 10.8 Cross-over to Left Radial or Femoral (%) 4 Complications (%) 0 Independent predictive factors: OR 95% CI p Hypertension 1.6 1.3-2.1 <0.0003 Age 1.4 1.2-1.7 0.0001 BMI 1.2 1.0-1.4 0.015 Cha CCVI 2002; 56: abst 69

  30. Transradial Approach Drawbacks ?:Complications

  31. A New and Objective Method for Transradial Approach Screening: Comparaison With the Allen's Test in 1010 Patients 1010 pts, 32% female, 19% diabetics, age 62y, weight 76 kg, height 1.66 m Right Left Right or Left MAT < 9 seconds (%) 87 86 Positive PL* + Ox (%) 96 95 MAT exclusion (%) 6.3 PL + Ox (%) 1.5 MAT: modified Allen’s test, plethysmography (PL) and oxymetry (Ox) Barbeau 2001, 37, 2, Suppl A, 1A-648A

  32. Early ultrasonic results 270 patients 4 radial occluded (1.3%) : - 2 with a negative flow - 2 without flow J. Monsegu

  33. Radial Artery/Sheath Diameter Ratio: A Predictor of Severe Radial Artery Flow Reduction Saïto CCVI 46: 173-178, 1999

  34. IVUS after transradial approach JACC 2003;41;1109-14

  35. Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit? 67 pts underwent isolated CABG using the radial artery (RA) preop. transradial no transradial p value catheterization catheterization N= 22 45 Stenosis-free graft patency Left mammary artery (%) 88 90 = 0.87 Radial artery (%) 77 98 = 0.017 Saphenous vein (%) 87 84 = 0.42 Intimal hyperplasia of RA (%) 68 39 = 0.046 Kamiya Ann Thorac Surg. 2003; 76(5): 1505-9

  36. False Aneurysm after PTCA From P Garot

  37. Conclusions (1) • Transradial approach is the best way to reduce the vascular complication rate of diagnostic and therapeutic coronary (vascular) catheterism: less expensive, preferred by patients and nurses… • At the price of a slight increase in procedural duration and X-Ray exposure for diagnosis only • It is specially effective in high risk populations like old patients, AMI, patients treated with powerful anticoagulant or antiplatelet drugs

  38. Conclusions (2) • Transradial approach allows the use of all devices and techniques of modern coronary intervention • Peripheral vascular diagnosis and intervention is feasible with the same advantages: Subclavian, Renal, Mesenteric, Carotid? • Learn it in Kamakura Live Course…

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