The radial sheath is pulled-out at the CathLab immediately at the end of the procedureboth diagnostic or therapeutic Radial Sheath
The patient is mobile and canleave the Cath Lab walking
Radial entry site several hoursafter the end of the procedure
Radial VS Femoral approach MACEAgostoni P Et Al:Radial versus femoral approach for percutaneous coronarydiagnostic and interventional procedures; Systematic overview and meta-analysisof randomized trials.J Am Coll Cardiol. 2004 Jul 21;44(2):349-56.
Radial VS Femoral approach Entry site complicationsAgostoni P Et Al:Radial versus femoral approach for percutaneous coronarydiagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials.J Am Coll Cardiol. 2004 Jul 21;44(2):349-56.
PRIMARY PCI, is a Bleeding Prone ScenarioAnti aggregation therapy during PPCI:Aspirin, Plavix, Prasogrel, Anti 2b3a(ReoPro, Integrilin, Aggrastat).• Anti coagulation therapy during PPCI:Heparin, Clexane, Bivalirudin,• Sometimes thrombolytic therapy on board!• Sometimes the patient is on Coumadin
Mortality closely tied to major bleeds at primary PCI HORIZONS-AMI (9/08): >3600 patients getting PCI for acute ST-segment- elevation MI (STEMI) randomized to get bivalirudin or unfractionated heparin (UFH) plus a glycoprotein IIb/IIIa inhibitor Hazard ratiosa (HR) for primary-end point components as predictors of 30-day mortality in HORIZONS-AMI multivariate analysis Major non-CABG-related bleedingEnd point HR (95% CI) p as well as reinfarction were both significant predictors of 30-day all-Reinfarction 9.13 (2.62-31.85) <0.001 cause mortality in the trial,Stroke 2.65 (0.74-9.43) 0.13 independent of baseline features and all other clinical events. AIschemia- 1.15 (0.31-4.20) 0.83 major bleeding event, on its own,driven TVR raised the mortality risk by a factor of up to five (p<0.001), dependingMajor 5.08 (3.10-8.35) <0.001 on the analysis.bleedingb
Mortality closely tied to major bleeds at primary PCI Pooled analysis from three major bivalirudin trials— REPLACE-2, ACUITY, and HORIZONS: PCI during ACS-STEMI (from the last four years) Independent hazard ratio of non-CABG-related major bleeding and MI within 30 days on mortality within one yearEvent Hazard ratio Deaths within 1 y, n p (95% CI) Non-CABG 3.1 (2.4-3.9) 104 <0.001 major bleed MI 2.8 (2.2-3.6) 77 <0.001 Data presented at the European Society of Cardiology 9/09 Congress-Barcelona
Studies of the Impact of Blood Transfusion on Mortality After PCI Impact of Transfusion on Frequency of Mortality [95% Patient STEMI Blood Confidence Author (Ref. #) Patients (n) Population Included? Transfusion (%) Interval] p Value Jani et al. (12) 4,623 Anemic patients Yes 22.3 In-hospital, <0.0001 with MI adjusted OR: 2.02 [1.47– 2.79] Doyle et al. (6) 17,901 Unselected Yes 6.8 30 days, 1–2 U <0.0001 adjusted HR: 8.9 [6.3–12.6] 3+ U adjusted <0.0001 HR: 18.1 [13.7– 24] Kinnaird et al. 10,974 Unselected Yes 5.4 1 year, OR per <0.0001 (1) unit transfused: 1.47 [1.36– 1.55] Kim et al. (5)* 567* Severe bleeding Yes 25.7 1 year, RR: 2.03 0.0028 Chase et al. (13) 38,872 Unselected Yes 3.5 30-day adjusted <0.0001 OR: 4.01 [3.08– 5.22]Doyle, B. J. et al. J Am Coll Cardiol 2009;53:2019-2027 1-year adjusted <0.0001 OR: 3.58 [2.94– 4.36]
The Hillel Yaffe Medical Center Experience withTrans-Radial Approach for Primary PCI
Trans-Radial Approach for Primary PCIMethods: More than 90% of the procedures in ourCath Lab are done as trans-radial approach. SinceJanuary 2007 we adopted the radial approach for allnew patients with STEMI referred to primary PCI.Patients with weak radial pulse, severedysrhythmias, CHF or hypotension were excluded.We used published world data on primary PCI fortime table, fluoroscopy time and contrast volumereference.
Trans-Radial Approach for Primary PCIResults: 98 STEMI patients, 88 males, 10females, mean age 58±12 years, underwentprimary PCI/TRA as a routine procedure (rightradial all).IRA were: LAD: 42, LCX: 15, RCA: 41.Full patency restoration of the IRA was achievedin 100% of the patients.
Trans-Radial Approach for Primary PCI In 32 cases we used thrombus aspirationdevices. In 5 patients a bifurcation PCI with kissingballoon was performed successfully. Ten patients had slow reflow phenomenonresolved after IC Adenosine injection. In 4 cases IABP was inserted trough thefemoral artery due to low blood pressureand slow reflow.
Trans-Radial Approach for Primary PCIThere were no major bleeding, pseudo-aneurysmor fistula. There was no need for blood transfusionIn one case (treated by Integrilin Heparin andPlavix) there was a large hematoma in groin (IABPinsertion site) and small one in the forearm. Therewere 5 more cases with minor hematoma in theforearm.There was no cerebral ischemic event.
Time Table, Fluoroscopy time, Contrast volume World data Our experience in PCI/ TRASymptom onset Median 218 min 90-840 (median 267)to Balloon minHospital door to 83-120 (median 116) 45-180 (median 72) minBalloon minCath Lab door to 20-53 min 20-35 (median 27) minBalloonFluoroscopy time 18.3 ± 12.2 min 8±5 minContrast volume 265±130 ml 161±63 ml PCI/TRA: Primary PCI using trans-radial approach
Trans-Radial Approach for Primary PCIConclusions: Following a meticulouslearning curve, the trans-radial approachcan be applied for primary PCI with highsuccess rate, short door to ballooninterval, and low complication rate. Thisapproach improves patient’s convenienceand well being.
Trans-Radial Approach for Primary PCIThe very low bleeding and vascularcomplication rate increases the safety marginfor this procedure that involves intense use ofanti-coagulation/aggregation medications andcan improves long term survival.We are now in a process of assessing thelong term outcome of these patients.