Patel TM 201111

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Transradial Primary PCI: Tips and Tricks for Success

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Patel TM 201111

  1. 1. Transradial Primary PCI: Tips and Tricks for SuccessTEJAS M. PATEL, MD, DM, FACC, FESC, FSCAI PROFESSOR & HEAD Department of Cardiovascular Sciences, Smt. N.H.L. Municipal Medical College, Sheth K.M. School of PG Studies & Research, Sheth V.S. Hospital, Ahmedabad, India. DIRECTOR Department of Cardiovascular Sciences, TCVS (Total Cardiovascular Solutions) Pvt. Ltd. Ahmedabad, India.
  2. 2. DisclosureI have no relevant disclosure related to this presentation
  3. 3. Am J Cardiol. 1999; 83 (6): 966-8, A10 Efficacy of Transradial Primary Stenting In Patients With Acute Myocardial Infarction Ochiai M, Isshiki T, Toyoizumi H et al. CONCLUSION:Fifty-six patients with Killip Class I or II were subjected to TRA for AMI interventions with 100% success in stent deployment and 97% success in normalization of distal coronary blood flow. No major vascular complications occurred in this experience
  4. 4. SUCCESSTransradial PCI in Setting of AMI 96.6% Tift Mann et al. J Am Coll Cardiol 1999 (n=68) 96% Delarche N et al. Am J Geritar Cardiol 1999 (n=46) 100% Kim MH et al. J Invasive Cardiol 2000 (n=30) 90% Mathias et al. J Invasive Cardiol 2000 (n=14) 100%Mulkutla SR et al. Catheter Cardiovasc Interv 2002 (n=41) 100%Hamon M et al. Catheter Cardiovasc Interv 2002 (n=119) 100%Louvard Y et al. Catheter Cardiovasc Interv 2002 (n=267) 98% Ziakas A et al. Am J Cardiol 1999 (n=100) 90% Saito S et al. Catheter Cardiovasc Interv 2002 (n=77) 96% Valsecchi O et al. Ital Heart J 2003 (n=163) 97%
  5. 5. Procedural Success Final TIMI 3 TRI TFI Flow (n=665) (n=1726) Tift Mann et al. J Am Coll Cardiol 1999 96 % 96 % Ziakas A et al. Am J Cardiol 1999 99% 97%Louvard Y et al. Cath Cardiovasc interv 2002 98% 97%Saito S et al. Catheter Cardiovasc Interv 2002 96 % 97 % Valsecchi O et. al Ital Heart J 2003 97% 96% Pooled data 97% 97%P = ns in all studies
  6. 6. TRI TFI Major Vascular Complications (n=1604) (n=5211) Kiemeneij F et al. 1996 J Am Coll Cardiol 0 2% Ziakas A et al. Am J Cardiol 1999 0 1.5% Tift Mann et al. J Am Coll Cardiol 1999 0 4% Choussat R et al. Eur Heart J 2000 0 4.5% Hildic S et al. 2000 0 6%Louvard Y et al. Catheter Cardiovasc Interv 2002 0 1.3% Saito S et al. Catheter Cardiovasc Interv 2002 0 3% Valsecchi O et al. Ital Heart J 2003 0 1.2% Lefevre T (TCT 2003) 0 2.3% Pooled data 0.0% 3.8%
  7. 7. TRI: Impact of Gp IIb / IIIa Blockers Absence of Major Vascular ComplicationsMajor vascular complications TRI TFI (n=244) (n=1953)Choussat R et al. Eur Heart J 2000 0 4.5%ESPRIT trial J Am Coll Cardiol 2003 0.7% 6.6% Pooled data 0.4% 6.5%
  8. 8. TRI in AMI: No Delay In Reperfusion TRI TFI PROCEDURAL TIME (min) (n=945) (n=2802) Ziakas A et al. Am J Cardiol 1999 43 ± 19 50 ± 28Louvard Y et al. (Centre A) Catheter Cardiovasc Interv 2002 45 ± 42 43 ± 32Louvard Y et al. (Centre B) Catheter Cardiovasc Interv 2002 67 ± 25 68 ± 21 Saito S et al. Catheter Cardiovasc Interv 2002 44 ± 18 51 ± 21 Valsecchi O et al. Ital Heart J 2003 62 ± 23 61 ± 22 Lefevre T (TCT 2003) 45 ± 50 48 ± 55 P=ns
  9. 9. Catheter Cardiovasc Interv. 2010;75 (5): 695-9 Arterial access and door-to-balloon times forprimary percutaneous coronary intervention in patientspresenting with acute ST-elevation myocardial infarction Weaver AN, Henderson RA, Gilchrist IC et al. CONCLUSION: Patients presenting with STEMI can undergo successful PCI via radial artery approach withoutcompromise in D2B times as compared to femoral artery approach
  10. 10. Catheter Cardiovasc Interv. 2010;75(7):991-5Comparison of door-to-balloon times for primary PCI using transradial versus transfemoral approach Pancholy S, Patel T, Sanghvi K et al. CONCLUSION:Transradial approach to primary PCI provides similardoor-to-balloon times to transfemoral approach, andsignificantly lowers access site related complications, in patients presenting with STEMI
  11. 11. Impact ofbleeding & transfusion on the procedural outcome
  12. 12. Heart 2008;94:1530-1532 EDITORIALShould radial artery access be the "gold standard" for PCI? Martial Hamon1, James Nolan2 1 University Hospital of Caen, Caen, France 2 University Hospital of North Staffordshire, Stoke-on-Trent, UK
  13. 13. Catheter Cardiovasc Interv. 2007; 69 (7): 961-6Access site hematoma requiring blood transfusion predicts mortality in patients undergoing percutaneous coronary intervention: data from the National Heart, Lung, and Blood Institute Dynamic Registry Yatskar L, Selzer F, Feit F et al. CONCLUSION:Access site complications, especially hematoma requiringtransfusion, remain a very important predictor of adverse procedural success and patient outcome
  14. 14. Heart 2008;94:1019-1025 Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg) A J Chase, E B Fretz, W P Warburton et al. Design, setting and patients: By data linkage of three prospectively collated provincial registries, 38 872 procedures in 32 822 patients in BritishColumbia were analysed. The association between access site,transfusion & outcomes was assessed. Main outcome measures: 30-Day and 1-year mortality
  15. 15. CONCLUSION:• The MORTAL study ,which looked at a registry of 33,000 Canadian patients, showed 50% less blood transfusions and accompanying reductions in mortality for patient done radially• By probit regression the absolute increase in risk of death at 1 year associated with receiving a transfusion was 6.78%
  16. 16. JACC 2009
  17. 17. JACC 2009
  18. 18. JACC 2009
  19. 19. J Am Coll Cardiol Intv, 2008; 1:379-386 Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention: A Report From the National Cardiovascular Data Registry Sunil V. Rao, Fang-Shu Ou, Tracy Y et al. CONCLUSION:Study looked at 593,094 U.S. patients and found that radial patients experienced 58% less bleeding complications
  20. 20. Experience• From Jan - 1992 to Nov - 2001 • 25,450 Transfemoral procedures • 6,360 coronary interventions through TFA• From Dec - 2001 to June - 2011 • 35,202 Transradial procedures • 9,152 coronary interventions through TRA • 291 Peripheral intervention through TRA • 98% procedures through TRA
  21. 21. Our Experience Percutaneous interventions in AMI (n=880) Retrospective analysisExclusion (n=26) Transradial Percutaneous Interventions in AMI (n=854)
  22. 22. Radial Access Major Vascular Complications Vascular Surgery 0 Hand Ischemia 0Transfusion (bleeding from puncture site) 0
  23. 23. Have there been challenges to performing transradial interventions in acute MI?Yes, of course….
  24. 24. UNPROTECTED LMCA STENTINGExtensive anterior wall MI-1 hour
  25. 25. LMCA total occlusion
  26. 26. Complex RCA lesionAnomalous origin Absence of „nipple‟
  27. 27. Deep Intubation in AMI
  28. 28. Arteria Lusoria
  29. 29. Evolving inferior wall MI:Challenges encountered
  30. 30. Anomalous origin of right subclavian artery from descending aorta
  31. 31. Real Challenge
  32. 32. Cobra Loop
  33. 33. Cobra Loop
  34. 34. Cobra Loop
  35. 35. Arteria lusoria withSubclavian tortuosity
  36. 36. Transfemoral RouteWe all have seen this happen often… Big hematoma with extravasation
  37. 37. Transfemoral RouteWe all have seen this happening at times…. Retroperitoneal hematoma
  38. 38. Advantage• TRA in acute MI situation gives an operator liberty of performing intervention even if patient has already received thrombolysis or GPIIbIIIa inhibitor• There is no retroperitoneal space …!
  39. 39. J Am Coll Cardiol Intv 2010;3:845-50Retroperitoneal Hematoma After Percutaneous Coronary Intervention: Prevalence, Risk factors, Management, Outcomes & Predictors of Mortality Santi Trimarchi, Dean E. Smith, David Share et al. CONCLUSION: Retroperitoneal hematoma is an uncommon complication ofcontemporary percutaneous coronary intervention associated with high morbidity & mortality. Independent predictors of mortality in patients with RPH include female sex, history of MI, cardiogenic shock, renal impairment & LVEF < 50%
  40. 40. Clear Choice We don’t need to wrestle with this question any longerTransradial route is the clear option for Virtually all patients of AMI
  41. 41. A word of caution Treat AMI patients via Trans-Radial route onlyafter your “new learning curve” is over
  42. 42. TRI in setting of AMI• Safe• Feasible• Procedural Success and Time are similar to TFI when performed by experienced radialists……..
  43. 43. TR STEMI Intervention program is animportant off-shoot of an elective TRI program
  44. 44. No formalized guidelines
  45. 45. Our Recommendation• 250 elective coronary angiograms• 75 elective PCI through TRA in stable cases… Why ???
  46. 46. Our Recommendation• 25 hemodynamically stable AMI cases Over-coming a “new learning curve” without delay in reperfusion…
  47. 47. • Simultaneous wrist and groin preparation Why ???
  48. 48. • Inject contrast through puncture cannula before introducing the sheath Why ???
  49. 49. I am scared ofBleeding & Major vascular complications…!!!
  50. 50. The Story would have been different if….
  51. 51. Major advantage Major vascularcomplication rate is nearly 0% ...
  52. 52. Achilles heel„A new learning curve‟ & “Mental block”
  53. 53. Thank Youwww.transradialWORLD.org

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