Fischman AM - AIMRADIAL 2013 - Peripheral interventions

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Introduction of the transradial technique into a busy metropolitan interventional radiology practice: The first 300 cases

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Fischman AM - AIMRADIAL 2013 - Peripheral interventions

  1. 1. Introduction of the Transradial Technique into a Busy Metropolitan Interventional Radiology Practice: The First 300 Cases AM Fischman MD, RS Patel MD, JW Fung PA, NB Lamberson RN, M Ort RN, E Kim MD, FS Nowakowski MD FSIR, RA Lookstein MD FSIR Assistant Professor of Radiology and Surgery Division of Interventional Radiology Icahn School of Medicine at Mount Sinai New York, NY
  2. 2. Disclosures „  AM Fischman MD ®  Terumo Interventional Systems – Consultant, Speaker ®  Surefire Medical Inc. – Consultant ®  Philips Healthcare – Speaker „  E Kim MD ®  Philips Healthcare – Speaker „  RS Patel MD ®  Arstasis Inc – Consulting ®  Sirtex Medical Inc. - Consulting „  FS Nowakowski MD - None „  RA Lookstein MD ®  Cordis Corp. – Consultant ®  Bayer Healthcare – Consultant ®  Boston Scientific Corp. – Advisory Board, Speaker ®  WL Gore & Associates, Inc. – DSMB „  JW Fung PA, NB Lamberson RN, M Ort RN - None
  3. 3. TRA in IR „  Classic IR Textbook „  Published Sept 2013 „  What is going on here????
  4. 4. Introduction - Why Radial? „  Fewer vascular complications „  Lower rate of access site bleeding „  Greater patient satisfaction „  Immediate ambulation „  Procedure cost savings „  Long term cost savings? „  LESS INVASIVE! Bertrand et al. Comparison of transradial and femoral approaches for percutaneous coronary interventions: a systematic review and hierarchical Bayesian meta-analysis. American heart journal. Apr 2012;163(4):632-648. Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. Journal of the American College of Cardiology. Dec 18 2012;60(24):2481-2489. Mehta et al. Effects of Radial Versus Femoral Artery Access in Patients With Acute Coronary Syndromes With or Without ST-Segment Elevation. Journal of the American College of Cardiology. 10/12 2012. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. American heart journal. 09/01 1999;138(3 Pt 1):7-7.
  5. 5. Background „  177 cases via the radial artery ®  July 1999 to October 2002 „  65/70 patients (92.9%) replied that they would request transradial approach next time J Clin Gastroenterol 2003;37:412–417
  6. 6. Potential Advantages in Interventional Radiology Obese patients Patients with groin sensitivity Faster discharge times Immediate ambulation No closure device Many patients with coagulopathy from liver disease „  Nausea/vomiting patients not immobile „  Different approach for Replaced Right Hepatic Artery complex anatomy „  „  „  „  „  „  Chemoembolization
  7. 7. Radial vs. Femoral Approach
  8. 8. Materials and Methods – Endpoints „  18 month period, single center retrospective review Splenic Embolization with Onyx „  Technical Success „  Major and Minor Adverse Events „  Cost Hepatic Radioembolization Complex Renal Aneurysm Repair
  9. 9. Materials and Methods - Demographics „  300 procedures in 230 patients ®  180 male ®  50 female ®  mean age 65 (range 37-91) „  Procedures: ®  Hepatic Chemoembolization (n=143) ®  Hepatic Radioembolization Y90 (n=117) ®  Uterine Fibroid Embolization (n=13) ®  Renal/Visceral Angioplasty/Stenting (n=12) ®  Splenic Embolization (n=3) ®  Internal Iliac Artery Embolization (n=2) ®  Other Peripheral Embolization (n=6) ®  Iliofemoral Angioplasty/Stenting (n=2) ®  Subclavian Angioplasty/Stenting (n=1) ®  AAA Endoleak Embolization (n=1) Uterine Fibroid Embolization Hepatic Chemoembolization
  10. 10. Materials and Methods – Embolization Devices ®  ®  ®  ®  ®  ®  ®  ®  N-BCA Glue Onyx Liquid Embolic System Calibrated Microspheres Drug-eluting Microspheres Yttrium-90 Microspheres Gelfoam Microcoils Amplatzer Plug Embolization of Breast AVM with Onyx
  11. 11. Materials and Methods - Procedure Details „  Sheath size: ®  6F – 8.3% (25/300) ®  5F – 86.3% (259/300) ®  4F – 5.3% (16/300) „  Bands Used: ®  ®  ®  ®  TR Band (297) R Band (1) Bengal Band (1) RADAR (1)
  12. 12. Technique - Barbeau Test (Pulse Oximetry) Barbeau et al. Am Heart J 2004;147:489–93
  13. 13. PRE-DILATE PROTOCOL „  40mg of lidocaine cream (EMLA) PLUS „  30mg of nitroglycerin ointment
  14. 14. Technique - Arm Positioning „  Left wrist used for all interventions below diaphragm „  Prop arm above left groin „  Use towel roll and arm board if necessary
  15. 15. Technique - Vessel Access „  Puncture ®  Micropuncture single wall technique ®  US guidance in ALL cases! ®  .018 wire
  16. 16. Technique - Vessel Access „  Hydrophilic sheath „  IA cocktail: ®  ®  ®  3000 U Heparin 2.5 mg Verapamil 200 mcg Nitroglycerin
  17. 17. Technique - Celiac/SMA Catheterization 5F Sarah Radial 110cm (Terumo)
  18. 18. Technique - Catheters Used „  „  „  „  „  „  „  „  „  „  „  „  5F 5F 5F 4F 4F 5F 5F 5F 5F 5F 5F 5F Sarah Radial 110cm (Terumo) Cobra 100cm (Terumo) Jacky Radial 110cm (Terumo) Aqua 125cm (Cordis) Cobra 100cm (Cordis) Envoy 100 Guidecath (Cordis) JR4 100cm (Cordis) MPA 100cm (Cordis) Bern 120cm (Penumbra) Sherpa AL1 Guide (Medtronic) Sherpa HS1 Guide (Medtronic) Launcher Guide (Medtronic) „  Other shapes (Champ, MP1, RDC, MAC, IMA, SCR, SCL) Longest Lengths in our lab: Guiding sheath: 110cm Guiding catheter: 110cm Diagnostic catheter: 150cm
  19. 19. Technique - Patent Hemostasis „  Maintain “nonocclusive pressure! „  Should be able to feel a distal RA Pulse 5F – 2 hours until band removal 4F – 1.5 hours until band removal Samir Pancholy, et al Catheterization and Cardiovascular Interventions 72:335–340 (2008)
  20. 20. Results – Technical Success „  97% Technical success (291/300) ®  ®  ®  ®  ®  4 cases radial artery too small for cannulation 2 case Barbeau D waveform 1/9 radial loops unable to be navigated 1 subclavian occlusion 1 case radial occluded from prior intervention (unable to access) 9 Radial Loops Encountered - 3% Loop reduced with 4F Glidecath (Terumo) and . 016 Fathom wire (BSC)
  21. 21. Results – Adverse Events „  No major adverse events „  20 Grade I access site hematomas (6.7%) „  6 cases of RAO (2%) ®  All asymptomatic ®  4 were reaccessed for repeat procedure „  1 mild hand pain/weakness (0.3%) „  2 microperforation of branch vessel (0.6%) ®  Causing pain <= 24 hours „  1 radial artery pseudoaneurysm (0.3%) ®  Treated with thrombin injection
  22. 22. Results - Cost Comparison FEMORAL „  5F standard sheath „  19g needle „  5F Sos 80cm „  Closure Device RADIAL „  5F Glidesheath „  Microneedle „  5F glide cobra 100cm (or 110 Sarah radial) „  TR Band Approx. $230 Approx. $130 Estimated direct cost savings during study – $30,000 Indirect costs were not measured
  23. 23. What are the limitations in IR? „  Limited catheter shape and length „  Balloon and stent systems don’t reach below the iliac arteries „  Lack of training programs PTA Renal FMD
  24. 24. Conclusion TRA for peripheral interventions and embolization is: „  Feasible in majority of patients „  Safe and well tolerated with low complication rates „  Less costly than TFA
  25. 25. Where are we headed in 2014? „  Randomized studies specific to IR (particularly in Interventional Oncology) „  Quality of life surveys (IPAD and SMS) „  Training programs for IR docs Glue Embolization of bleeding renal mass „  Catheter and Guide design underway…..

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