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Chevalier B
 

Transradial Intervention in Chronic kidney Disease (CKD) Patients

Transradial Intervention in Chronic kidney Disease (CKD) Patients

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    Chevalier B Chevalier B Presentation Transcript

    • TRI in Chronic KidneyDisease (CKD) Patients Bernard Chevalier ICPS Massy FRance Chamonix – Mont-Blanc 1-2 Avril 2011
    • SPECIFIC FEATURES OF CAD IN CKD PTSPCI IN CKD PTSRENAL PROTECTION FOR CKD PTS
    • CKD (GFR<60): A risk factor Insuffisance Rénale Dialysée•  HTN, LVH, CHF•  >35% of CKD pts have evidence of ischemic disease at the time of presentation to nephrologist•  Prognosis is mainly related to the severity of atheroma before End-Stage Renal Disease (ESRD)•  Importance of ischemia detection
    • Athérosclérose AccéléréeNot specific risk factors •  Age •  Male gender •  HTN •  Diabetes •  Dyslipidemia •  Smoking Specific risk factors: •  Hyperparathyroidism • Hyperphosphatemia •  Anemia • Hyperhomocystéinémy •  Oxidative stress • Inflammation • Renin-angiotensin activation
    • Inflammation-Thrombose 5888 pts > 65 ans, 647 pts(11%) Insuffisants rénaux M.G. Shlipak et al, Circulation 2003;107:87-92
    • CKD: a predictive factor for CAD outcome•  3 times higher 1y mortality in AMI (Shlipak et al)•  6 times higher 6 m mortality in GUSTO/ PURSUIT/PARAGON (Suwaidi et al.)•  Higher impact in young CKD patients•  Part of GRACE score with –  HR 2.09 for GFR between 30 & 60 (stage 3) –  HR 3.71 for GFR < 30 (stage 4&5)
    • CKD: impact on treatment•  In case of ACS, CKD pts –  Are underdiagnosed –  Receive less « guidelines » medications –  Have more limited access to angiography –  Get less PCI –  Have less secondary prevention medication•  However PCI pts have similar longterm decrease of renal function than medically treated pts
    • Coronary disease in ESRD•  Cardiovascular disease is the leading cause of mortality•  10 times risk than 5 Framingham RF pts!
    • Survie chez les patients dialysés Sarnak MJ. Circulation 2003;108:2154-69
    • Vascular calcification•  Consequence of bone mineral disorder•  Accelerated on dialysis patients•  Possible ways to limit: –  Dialysis protocol, low dose Vit D regimen, sevelamer•  Has direct impact on –  Quality of PCI (plaque modification/stent deployment) –  Quality of hemostasis at vascular access
    • ATHEROME de l’INSUFFISANT RENALPCI in CKD PatientsRISQUE et PREVENTION dud’INSUFFISANCE RENALE enCARDIOLOGIE INTERVENTIONNELLE
    • Higher number of PCI•  Severity of disease & crucial role of PCI•  Higher rate of recurrence after DES
    • Bleeding risk of PCI in CKD
    • Bleeding profile
    • Yatskar L, Catheterization and Cardiovascular Interventions 69:961–966 (2007)
    • Bleeding in all comers
    • Impact of In-Hospital Major Bleeding onEarly and Late Mortality in REPLACE-2 Stone GW J Invas Cardiol 2004, 16(suppl G): 12G-17G
    • Adverse effect of transfusion?
    • Pros TRI in CKDLess bleeding / Less renal event
    • P. Agostoni JACC 2004; 44:349-56
    • Cantor W, Catheterization and Cardiovascular Interventions 69:73–83 (2007)
    • Primary Angioplasty Moins de Complications Locales 20 p < 0.01Acces Site Complications (%) 15 p < 0.05 10 p < 0.05 5 0 TRA FA Perclose FA Manual Y. Louvard et al. CCVI 2002; 55: 206-211
    • Vuurmans T, Heart 2010;96:1538-1542.
    • Vuurmans T, Heart 2010;96:1538-1542.
    • Vuurmans T, Heart 2010;96:1538-1542.
    • Cons for TRI in CKD Radial occlusion
    • Radial in ESRD?•  Vascular access is the lifeline !•  Native AV Fistula > Prothetic graft > central venous catheter –  Impact on prognosis•  Non maturation 20 to 50% (artery diameter > 2 mm, more predictable in forearm)•  Venous neointimal hyperplasia (vein quality) alters patency: 12 to 18 months•  Forearm AV fistula are the best ones (?)
    • Sheath/artery ratio
    • COMPRESSION RADIALE-  300 patients-  Compression with elastic dressings as shorter as possible-  Doppler evaluation-  Early results: 4 radial occluded (1.3%) :-  Late results: about 270 patients •  any new occlusion after hospital discharge •  about 4 initial occlusions : 3 spontaneous recanalization and 1 persistent less than 1% radial occlusion rate Monségu Ann Cardiol Angeiol 2003; 52: 135-8
    • Relationship between compression and radial occlusion Radial patent Radial occlusion p 10.5%No flow before 49% 54% 0.41sheath removalNo flow after 63% 66% 0.49placingcompressionNo flow before 54% 90% 0.002compressionremoval Sanmartin Catheter Cardiovasc Interv 2007; 70: 185-9
    • Radial artery occlusion Pancholy J Invasive Cardiol 2009; 21: 101-4
    • Tips & tricks for TRI in severe CKD (stage 4 & 5 = GFR < 30)•  Vascular calcification + HTN = loops +++ –  Prefer left radial?•  Never use a sheath larger than radial artery –  5F PCI or sheathless 6F –  4F?•  Keep always one radial artery free of puncture –  If possible the one with best venous system•  Apply good hemostasis technique
    • ATHEROME de l’INSUFFISANT RENALRISQUE SAIGNEMENT etVOIE d’ABORD RADIALERENAL PROTECTION for CKD patients
    • 1. HYDRATION - 100 ml/h Nacl 0.9%/bicarbonate 14/1000 4 h avant examen - 1000 ml sérum 0.9%/bicarbonate 14/1000 24h après examen2. Low osmolarity contrast media3. Contrast load < 4 x GFR
    • CKD patients•  Are highly exposed to CAD•  Have a specific vascular atheroma•  With a higher risk of suboptimal result of PCI with more restenosis risk•  And higher bleeding complications related to access site•  Leading to a high number of coronary interventions
    • The choice of TRI•  Limits bleeding & renal events with significant impact on outcome•  Is possible in pts not yet on dialysis using very strict rules particularly for ESRD•  Could be considered with a lot of caution to avoid impairment of existing and future AV fistula•  Femoral route is a back-up choice using closure device