Incidence of radial artery injury after PCI for nonSTEMI ACS and 9-month follow-up re-catheterization assessed by optical coherence tomography (OCT)

1. INCIDENCE OF RADIAL ARTERY INJURY
AFTER PCI FOR NONSTEMI ACS AND 9-
MONTH FOLLOW-UP
RE-CATHETERIZATION ASSESSED BY
OPTICAL COHERENCE TOMOGRAPHY
Miklik R., Kanovsky J., Poloczek M., Bocek O.,
Jerabek P., Ondrus T., Spinar J., Kala P.
Department of Internal Medicine and Cardiology,
University Hospital Brno, Brno, Czech Republic

2. Disclosure: Roman Miklik, MD,
PhD
 Dr. Roman Miklik has no relevant financial interests
to disclose

3. Rationale for RA
investigations
 The number of transradial coronary
interventions (TRI) is increasing (our cathlab 95%)
 Injury of radial artery (RA) during previous TRI
affects graft patency in CABG pts (Kamiya 2003 )
 All-arterial revasc reduces long term mortality by
50% vs internal thoracic artery + venous grafts
in CABG patients (Zacharias 2009)
 First 2 studies reported high incidence of acute
radial injury with the use of 25cm and 16cm
sheath-length (Yonetsu 2010, di Vito 2014)

4. Methods
 Consecutive patients admitted for coronary
angiography (CAG) due to non-STEMI
diagnosis
 First myocardial lesion in patients’ history
 First transradial CAG, capable of scheduled
FU exam at 9months
 Informed consent
Exclusion: STEMI, previous MI, acute
heart failure, left main disease, renal
insufficiency

5. Methods
 6F 7cm sheath (Terumo), 6F guiding catheter
 Guiding off sheath
 Sheath pulled back 4-5cm
 FD-OCT recording of RA, starting 7cm from the sheath tip
(using X-ray contrast ruler)
 Manual injection of 10ml 100% contrast fluid
 Each patient both index and 9M FU OCT examination
Prox
Sheath in situ Sheath removed 5cm
Distal 40mm 14mm
OCT Recording 54mm
2 cm 7 cm

6. Methods
Acute injury:
1. Intimal tear
2. Dissection
3. Perforation
Index vs 9M FU
Proximal vs distal part

7. Results 1
 9M FU data available in 55 out of 106
pts
◦ Index OCT performed 100 pts
◦ 9M FU OCT performed in 49 pts
 Only 2 pts had lesions in both
proximal and distal segment
 No patient had acute injury during
both index and FU examination
 No radial occlusion at FU exam
 No clinical sequelae (1x hematoma)

8. Results 2
“the worst lesion counts” analysis
index vs 9M FU procedure
100 arteries 49 arteries
97
1
41
2
3
1
4
100%
95%
90%
85%
80%
75%
index procedure 9M FU procedure
P< 0,01
perforation
dissection
intimal tear
no injury
3 patients 8 patients

9. Results 3
Index vs 9M FU procedure and lesion location
N = 2 6 1 6
1
1 1
5
1
1
1
4
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
index
procedure
prox
9M FU
procedure
prox
index
procedure
distal
9M FU
procedure
distal
perforation
dissection
intimal tear
Proximal 14mm Distal 40mm

10. 4.7
0.7 0.7
1.3
2.7
0.7
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
intimal tear medial
dissection
perforation
proximal RA
distal RA
Results 4
Proximal vs distal RA and type of lesion
Analysis of 298 segments
%
P all NS

11. Discussion 1: Studies of radial injury
Yonetsu 2010
• 42pts with 1st time TRI,
31pts with repeat TRI,
%ACS unknown
• Sheath 16cm, 6F
• TD-OCT imaging
• high injury rate
• more intimal tears distal
than prox (43,8% vs
17,8%)
• same proportion of
medial dissections prox
and distal (20,5% vs
23,3%)
Di Vito 2014
• 25pts with 1st time
TRI, 26pts with repeat
TRI; 15pts
nonSTEMI, 1x STEMI
• Sheath 25cm, 6F
• FD-OCT imaging
• high injury rate
• more intimal tears
prox than distal
(31,4% vs 15,7%, NS)
• same proportion of
medial dissections
prox and distal (5,9%
vs 3,9%)
Our study 2014
• 100pts with 1st time
TRI, 49pts with repeat
TRI (9M FU), all
nonSTEMI
• Sheath 7cm, 6F
• FD-OCT imaging
• low injury rate
• more intimal tears
prox than distal (4,7%
vs 1,3%, NS)
• same proportion of
medial dissections
prox and distal (1,3%
vs 2,7%, NS)

12. Discussion 2: Potential explanations
 Low injury rate:
◦ experienced radial center
 More injuries during FU exams:
◦ Underestimation of the procedure
◦ Chronic arterial changes – intimal
hyperplasia
◦ Endothelial dysfunction – spasms,
constriction

13. Conclusion
 First study to investigate radial injury
with follow-up OCT examinations
 Very low incidence of radial injuries in a
radial center using short 6F sheaths
 Acute injuries are mostly limited to
intimal layer
 Repeat TR catheterizations have higher
prevalence of acute radial injury, very
likely due to chronic vessel
modifications
Supported by the Grant of the IGA Ministry
of Health of the Czech Republic no.
NT/13830
Thank you