Skvaril J - AIMRADIAL 2013 - Avoid radial occlusion

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Radial artery occlusion after catheterization. Can we effectively prevent it?

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Skvaril J - AIMRADIAL 2013 - Avoid radial occlusion

  1. 1. Radial artery occlusion after catheterization. Can we effectively prevent it? Škvařil J, Daníčková K, Broulíková K, Horáková S, Malý M Ústřední vojenská nemocnice Praha
  2. 2. Disclosure: Jan Škvařil, MD Dr. Škvařil has no relevant financial interests to disclose Ústřední vojenská nemocnice Praha
  3. 3. History Transradial selective coronarography. Campeau L. 1989 Transradial PCI . Kiemeneij, GJ. Laarman. 1992 Amsterdam Coronary stenting transradially. Kiemeneij, GJ. Laarman. 1993 Amsterdam. Outpatient PCI transradially. Kiemeneij, GJ. Laarman, 1994 Ústřední vojenská nemocnice Praha
  4. 4. Femoral x radial access Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157: 132– 40. Ústřední vojenská nemocnice Praha
  5. 5. Femoral x radial access Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J 2009;157: 132– 40. Ústřední vojenská nemocnice Praha
  6. 6. Radial access – drawbacks - Lower primary success rate. Cross-over more frequent - Radiation exposure - Iatrogenic radial artery occlusion (RAO) „asymptomatic loss of pulsation“ Ústřední vojenská nemocnice Praha
  7. 7. Radial access – drawbacks - Lower primary success rate. Cross-over more frequent - Radiation exposure - Iatrogenic radial artery occlusion (RAO) „asymptomatic loss of pulsation“ Ústřední vojenská nemocnice Praha
  8. 8. Hand vascular supply Arteria radialis, arteria ulnaris, arteria interossea Superficial and profound palmar arch Ústřední vojenská nemocnice Praha
  9. 9. Hand vascular supply Thanks to character of hand vascular supply RAO is asymptomatic as a rule. „Asymptomatic loss of pulsation “ Ústřední vojenská nemocnice Praha
  10. 10. RAO. Clinical course, significance Symptoms: painful forearm and thenar, loss of handgrip force and paresthesia critical limb ischemia extremely rare (individual cases, patients with end stage kidney disease. Systemic tissue disease). Symptom free: Repeated access, other access sites saving (radial artery harvest) Prevention of RAO x treatment of RAO Ústřední vojenská nemocnice Praha
  11. 11. RAO assessment 1) Physical exam. Palpation. Allen s test 2) Pletysmography 3) Point US 4) Duplex US Ústřední vojenská nemocnice Praha
  12. 12. RAO assessment 1) Physical exam. Palpation. Allen s test 2) Pletysmography 3) Point US 4) Duplex US Ústřední vojenská nemocnice Praha
  13. 13. Allen´s test ( palpation, event. with pletysmography) Ústřední vojenská nemocnice Praha
  14. 14. RAO assessment Total U.S.A. Europe Japan RAO assesment before hospital discharge (%) NO 52.5 51.9 59.0 36.0 Method (%), if YES Doppler 7.1 7.6 7.5 0.0 Oximetry/pletysmography 5.5 11.4 5.1 0.0 Palpation only 55.2 44.3 49.8 79.1 (source: Bertrand OF, Rao SV, Pancholy S, Jolly SS, Rodés-Cabau J, Larose E, Costerousse O, Hamon M, Mann T. Transradial approach for coronary angiography and interventions. Results of the first international transradial practice survey. JACC Cardiovasc Interv. 2010;10:1022-31)
  15. 15. RAO. „Asymptomatic loss of pulsation„ -Artery size. Artery/instrumentarium ratio (catether, sheath) -Instrumentarium properties (hydrophylic) -Primary x secondary punction. Haematoma. Dissection. Injury. -Heparin (2000 v.s. 5000 IU) or LMWH during and after procedure -Compression device. TR band -Time and technique of compression.(„non occlusive compression“) -Interruption of blood flow during compression. -Older patients, Females, lower body weight. Sanmartin M, Gomez M, Ramon JR, et al. Interruption of blood flow during compression and radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv 2007;70:185–189. Ústřední vojenská nemocnice Praha
  16. 16. RAO. „Asymptomatic loss of pulsation„ -Artery size. Artery/instrumentarium ratio (catether, sheath) -Instrumentarium properties (hydrophylic) -Primary x secondary punction. Haematoma. Dissection. Injury. -Heparin (2000 v.s. 5000 IU) or LMWH during and after procedure -Compression device. TR band -Time and technique of compression.(„non occlusive compression“) -Interruption of blood flow during compression. -Patients age, Females, lower body weight. Sanmartin M, Gomez M, Ramon JR, et al. Interruption of blood flow during compression and radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv 2007;70:185–189. Ústřední vojenská nemocnice Praha
  17. 17. Treatment (compression) after procedure TR Band (TERUMO) Selective and measurable compression Ústřední vojenská nemocnice Praha
  18. 18. Patent hemostasis Barbeau test (modified Allen´s test) inflation 10 ml ulnar compression pulse absence partial deflation Ústřední vojenská nemocnice Praha ulnar compression pulse present
  19. 19. Patent hemostasis Barbeau test (modified Allen´s test) inflation 10 ml ulnar compression pulse absence partial deflation Radial artery patent Ústřední vojenská nemocnice Praha ulnar compression pulse present
  20. 20. Treatment (compression) after procedure. RAO prevention Patent hemostasis (perfusion h., non-occlusive h.) Objective: 1) Prevention of bleeding 2) Maintenance of blood flow. Ústřední vojenská nemocnice Praha
  21. 21. Patent hemostasis and TR band importance -Patent hemostasis + TR band = 60% decrease of RAO occurance. -Recanalization of ~ 50% cases within 1 month regardless of compression method used. -Patent hemostasis > heparin admin. -3-10% after TRA, 30-40% after prolonged monitoring CCU Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of Radial Artery Occlusion—Patent Hemostasis Evaluation Trial (PROPHET Study): A randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv 2008:72:335–340. Pancholy S. Impact of Two Different Hemostatic Devices on Radial Artery Outcomes after Transradial Catheterization, J Invasive Cardiol 2009; 21:101-104 Ústřední vojenská nemocnice Praha
  22. 22. Treatment (compression) after procedure Protocol of observation - Before procedure. Pletysmogrpahy- pulse oxymetry - 30 minutes after procedure. - 1. day after proc./before discharge. Pletysmography (false positivity possible – a.interossea) Duplex ultrasonography (DUS) (gold standard) -before hospital discharge -after 30 days Ústřední vojenská nemocnice Praha
  23. 23. Results 1. period (6/084/09) Age (11/10-5/11) n = 804 Men /Women 2. period n = 532 514 (63,9%) / 290 314 (59%) / 218 66.9 (9,5) 67.2 (10.1) p NS NS % of PCI 35.9 28 % of F5 15.2 45.1 Hydroph. sheath ~ < 30% ~ > 90 % dif TR band ~ 75 – 80% = 100% dif Ústřední vojenská nemocnice Praha p < 0,05 p < 0,001
  24. 24. Results Procedures DUS RAO %RAO RAO %RAO Undetected total discharge discharge day 30 day 30 after 30 days discharge 1. period (6/08-4/09) 906 804 87 10.82 46 5.79 9 2. period (11/10-5/11) 672 532 29 5.45 15 2.85 5 Ústřední vojenská nemocnice Praha
  25. 25. Results 12.00 10.00 p<0,001 8.00 p=0,001 6.00 1 .období p=0,015 4.00 P<0,001 2.00 0.00 prop 30. den % RAO Ústřední vojenská nemocnice Praha 2. období
  26. 26. Questions Further systematic follow up: - furhter decrease of RAO in time ? - late RAO (intimal proliferation) ? Medication after RA and medical treatment in case of RAO (if any): - UFH, ASA, LMWH, DAPT Ústřední vojenská nemocnice Praha
  27. 27. Conclusion -Asymptomatic loss of pulsation (RAO) represents a specific complication of TRA -It has benign character as a rule. We have not noted any relevant case. -Prevention of RAO is important for the possible repeated use of a given access site. -This saves other eventual vascular access sites ( HD, arterial grafts etc..) -To estimate vessel patency exactly, DUS is the most suitable. (x routine) - Patent hemostasis + TR band = RAO incidence < 6% (24 h) and <3% (30d) respectively -Further decrease is possible mainly due to size reduction of devices used Ústřední vojenská nemocnice Praha

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