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Trans-Radial Interventions

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

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Trans-Radial Interventions

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  1. Trans-Radial Interventions Eli Lev, MD Director of Interventional Cardiology Hasharon Hospital, Rabin Medical Center and Tel-Aviv University, Israel

  2. Objectives Learn the main scientific literature supporting radial access for PCI Learn the basic methodology in performing trans-radial PCI

  3. 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. Radner S. Thoracal aortography by catheterization from the radial artery; preliminary report of a new technique. Actaradiol. 1948;29:178-80. Campeau L. Percutaneous radial artery approach for coronary angiography. CathetCardiovascDiagn. 1989;16:3-7. KiemeneijF, Laarman GJ, de Melker E. Transradial coronary artery angioplasty. Am Heart J. 1995;129:1-7.

  4. 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 P= 0.048 P= 0.040 Cox, N. Am J Cardiol 2004; 94 1174-1177

  5. 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

  6. Radial vs. femoral access for coronary angiography or PCI: A systematic review and meta-analysis of randomized trials Jolly SS et al. Am Heart J 2009;157:132-40

  7. RIVAL Study Design NSTE-ACS and STEMI (n=7021) • Key Inclusion: • Intact dual circulation of hand required • Interventionalist experienced with both (minimum 50 radial procedures in last year) Randomization Radial Access (n=3507) Femoral Access (n=3514) Blinded Adjudication of Outcomes Primary Outcome: Death, MI, stroke or non-CABG-related Major Bleeding at 30 days Jolly SS et al. Lancet 2011.

  8. Baseline Characteristics Jolly et al, Lancet 2011

  9. Primary and Secondary Outcomes Jolly et al, Lancet 2011

  10. Other Outcomes Jolly et al, Lancet 2011

  11. RIVAL study Primary endpoint - NACE • 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 Non CABG major bleeding Jolly et al, Lancet 2011

  12. Subgroups: Primary Outcome R I V A L Death, MI, Stroke or non-CABG major Bleed Overall p-value Interaction Age <75 ≥75 0.786 Gender Female 0.356 Male BMI <25 25-35 0.637 >35 Radial PCI Volume by Operator ≤70 70-142.5 >142.5 0.536 Radial PCI Volume by Centre Lowest Tertile Middle Tertile Highest Tertile 0.021 Diagnosis at presentation NSTE-ACS 0.025 STEMI 0.25 1.00 4.00 Radial better Femoral better Jolly et al, Lancet 2011 Hazard Ratio (95% CI)

  13. Other Outcomes • No differences in PCI success rate

  14. 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

  15. Meta-analysis of Radial vs. Femoral in STEMI pts Bleeding Mortality Access site complications Mamas et al Heart 2012

  16. 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

  17. 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 2007 to 16.07% in the 3rd quarter of 2012 (P<0.01).

  18. Outcomes

  19. Main Findings • Use of ↑ r-PCI X13 over 6 yrs in the US • Lower risk of bleeding and vascular complications with r-PCI • Underuse of r-PCI at ↑ risk groups for bleeding (older, women, ACS) • 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 • r-PCI associated with longer fluoroscopy times

  20. 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…..

  21. The Anatomy

  22. The Anatomy

  23. 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.

  24. 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

  25. 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

  26. Radial Access: proximal to styloid process – Not really the wrist!

  27. Technical Tips for Successful TransradialCannulation • 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

  28. Sedation and Verapamil / Nitro Virtually Eliminate the Spasm Problem After Before

  29. Radial Loop and Radial Recurrent Artery

  30. 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

  31. 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 maneuvers • Need for TF conversion • Catheter shape selection for cannulation • Catheter control and backup support • “Patent Haemostasis” after pulling out the sheath

  32. Commonly Used Guiding Catheter Shapes

  33. Sheathless Catheters

  34. Patent Haemostasis

  35. Developments with trans-radial equipment • Dedicated and better TR access tools • hydrophilic sheaths • Sheathless guiding catheters • Single catheter diagnostics (e.g. Tiger) • 5 French compatible PCI equipment • Ability to perform complex interventions • STEMI, bifurcations, CTO, LM, long lesions etc. N=57

  36. 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%)

  37. 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

  38. Radial Artery Complications • 1372 Procedures Asymptomatic 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)

  39. 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

  40. 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

  41. Thank you

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