Benefit of pre-procedural radial angiography in STEMI patients, B Zafirovska

1. Benefit of Pre-procedural
Radial Angiography in
STEMI Patients
Biljana Zafirovska MD
University Clinic of Cardiology
Skopje, Macedonia

2. Disclosures
I do not have potential conflict of interest

3. The Advantages of
Transradial Artery Access (TRA)
 Decreased access site bleeding and major
vascular complications
 Decreased time to ambulation
 Decreased post-procedural cost
 Reduced hospital stay
 Allows same day discharge
 Easier vascular access and hemostasis for
obese patients

4. Disadvantages of Radial Access
 Associated with a physician learning curve
 Has limited compatibility with larger devices
 Procedure more challenging:
 Women and Elderly hypertensive due to
Increased tortuosity of the radial/brachial
and subclavian arteries, and/or High
degree spasm

5. Radial Access Site Complications
 Radial artery occlusion
 Mid forearm hematoma
 Radial artery pseudoaneurysm
 AV fistula
 Skin infection
 Dissection/Rupture
 Bleeding with resultant Compartment Syndrome

6. Preventing Radial Access Complications
 Patent hemostasis
 Efficient puncture (do more Radials!)
 “Know” the Radial Artery of every patient at
the beginning of the procedure

7. Rao, S. V. et al. J Am Coll Cardiol 2010;55:2187-2195
Radial Volume and Outcomes
Procedure duration
Procedure failure
Sheath insertion time

8. RADIAL ACCESSTECHNIQUE
CompleteTransitioning to the Radial Approach for
Primary PercutaneousCoronary Intervention:
A Real-World Single-Center Registry of
1808 Consecutive PatientsWith Acute
ST-Elevation Myocardial Infarction
Sasko Kedev, MD1
; Oliver Kalpak, MD1
; SuryaDharma, MD2
; Slobodan Antov, MD1
;
Jorgo Kostov, MD1
; Hristo Pejkov, MD1
; Igor Spiroski, MD1
rimary percutaneous coronary intervention (PPCI) is
an optimal strategy to re-open the occluded coronary
radial bone, which makeshemostasiseasier.10
The change of access-site strategy, from preferred femoral
ABSTRACT: Objectives. To compare the short- and long-term outcomes of transradial approach (TRA) versus transfemoral ap-
proach (TFA) for primary percutaneous coronary intervention (PPCI) during a complete institutional transition from TFA to TRA.
Methods and Results. An all-comer population of ST-elevation myocardial infarction (STEMI) patients (n=1808) who underwent
PPCI using TRA (n=1162) and TFA (n=646) from October 2007 to December 2010 were enrolled. TRA was used in 25% of PPCIs
by 2007 and in 96% of PPCIs in 2010. Primary endpoints were cardiovascular death and major adverse cardiac event (MACE),
defined as a composite of death, stroke, reinfarction, and target vessel revascularization at 30 days and 1year. At 30 days, TRA
compared to TFA was associated with a significant reduction of cardiovascular mortality (5.2% vs 10.5%; P<.001), significant
MACE reduction (7.3% vs 12.5%; P<.001), fewer access-site complications (0.9% vs 8.2%; P<.001), and lower TIMI major bleeding
(1.1% vs 4.3%; P<.001). At 1year, the cardiovascular mortality and MACE rates were also in favor of the TRA group (6.9% vs 11.5%;
P<.001and 11.6% vs 20.1%; P<.001), respectively. Conclusion. Complete transition from femoral access to a preferred radial ac-
cess is safe and ef ective for STEMI patients undergoing PPCI, with a favorable ef ect on short- and long-term outcomes.
JINVASIVE CARDIOL 2014;26(9):475-482
KEY WORDS: primary percutaneous coronary intervention, ST-elevation myocardial infarction; transradial approach
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9. Trends of TRA/TFA during study period
Temporal trends of transradial (TRA) and
transfemoral access (TFA) during the study period

10. Procedure Time
N=1808
TRA
n=1162
TFA
n=646
P value
Procedure Duration
minutes±SD (range)
40.2±16.9
(20-96)
37.0±10.4
(20-95)
0.34
PCI Time
minutes±SD (range)
21.4±7.5
(7-66)
22.8±5.9
(7-45)
0.42
Fluoro Time
minutes±SD (range)
9.2±6.2
(4-56)
9.8±6.4
(4-59)
0.30
D2B Time
minutes±SD (range)
56.9±49.5
(8-260)
51.8±34.4
(10-290)
0.46
Kedev S et al. J Invasive Cardiol 2014;26(9):475-482

11. Mortality and MACE at 30 Days
5.2%
0.9%
7.3%
10.5%
8.2%
12.5%
Mortality 30 D MajorVascularBleeding 30 Days MACE
TRA TFA
RRR 50%
RRR 42%
RRR 89%
NNT 18
NNT 14
NNT 19
MACE : All-cause death, Any Re-intervention, Re-infarction, Stroke, Major bleeding non-vascular, Major Bleeding vascular
RRR: Risk Reduction Ratio, NNT : Number of patients Needed to Treat
Kedev S et al. J Invasive Cardiol 2014;26(9):475-482

12. Mortality and MACE at 1 year Follow up
6.9%
11.6%11.5%
20.1%
Mortality at 1year MACE at 1year
TRA TFA
RRR 40%
RRR 42%
NNT 23
NNT 12
Kedev S et al. J Invasive Cardiol 2014;26(9):475-482

13. ESC Recommendations on TRA
 Considering the recognition given by the
European Society of Cardiology (ESC) panel
consensus document that the TransRadial
Approach should be the default approach for
PCI in experienced transradial centers, more
attention should be paid to strategies for
achieving successful transradial arterial access.

14. New study 2016
Abdelaal E, et al. Heart 2016;0:1–7. doi:10.1136/heartjnl-2015-308371

15. Causes of TRA PCI failure
Abdelaal E, et al. Heart 2016;0:1–7. doi:10.1136/heartjnl-2015-308371
Inadequate or difficult puncture: 64%
Difficulty passing guidewire or catheter: 27%
Cardiogenic shock: 36%

16. Predictors of TRA failure in STEMI
Abdelaal E, et al. Heart 2016;0:1–7. doi:10.1136/heartjnl-2015-308371
Variable Odds Ratio 95% CI
Age ≥75 yrs 1.7 [1.0, 2.9]
Weight 65 kg 3.0 [1.9, 4.8]
Creatinine >133 μmol/L 3.6 [1.9, 6.8]
Hypertension 1.8 [1.2, 2.9]
Prior PCI 2.6 [1.5, 4.5]
Cardiogenic shock 2.8 [1.4, 5.6]
IABP 2.0 [0.9, 4.3]
Physician with ≤5% rate of TFA 0.5 [0.2, 0.9]
Physician with ≥10% rate of TFA 2.2 [1.2, 3.7]
Intubation 107 [42, 339]

17. Retrograde radial artery angiography
Why?

18. RA Pitfalls and Technical Considerations
Lo T.S. et al. Heart 2009; 95: 410–415.
Technical failure for RA procedures is between 1–5%
 Difficult puncture/cannulation
 Radial artery spasm
 Anatomical variations
 Curves & Loops: Radial, Brachial

19. RA angiography
 In our center implemented as a routine
procedure before every wrist artery access in
March 2011
 Since then 30,000 RA angiographies have
been performed

20. How to perform RA angiography
 A solution of 3 ml of contrast diluted with 7 ml
of blood is injected through the cannula or
through the side arm of the sheath under
fluoroscopy in PA projection
 Purpose: To define the radial artery anatomy
from mid forearm to ulnobrachial
anastomosis and to delineate ulnar artery
anatomy as well, generating a roadmap for
the procedure.

21. Data from our database
 Total number of 26 806 consecutive
patients and RA angiographies were
analysed over a period of 5 years in this
study
 Separate analysis was done on the 3659
STEMI patients in that period and their RA
angiographies

22. Total wrist access in 99% of all patients
25100
93.64%
425, 1.6%
1157, 4.3%
94, 0.4%
30, 0.1%
Total N Pts 26806
RRA
LRA
TUA
TFA
TBA

23. STEMI patients
STEMI patients n 3569 (%)
TRA 3579 (97,6%)
LRA 37 (1%)
TUA 67 (1,9%)
TFA 8 (0,2%)
TBA 5 (0,06%)

24. Baseline characteristics of STEMI Patients
Clinical Variables All STEMI Patients
(N=3659)
Age (years) 62 (20-89)
Male 2708 (74%)
BMI (kg/m2) 25(19 - 47)
CAD risk factor
Hypertension 1480 (40%)
Diabetes mellitus 475 (13%)
Dyslipidemia 613 (16,7%)
Smoking 1058 (29%)
Positive Family History for CAD 350 (10%)
Prior TRA 297 (8,1%)
Fluoroscopy time 9 (0-88)
Procedure time 33(5-300 min)

25. Procedural characteristics of STEMI Patients
Sheath Size
6F 3643 (99%)
5F 15 (0.4%)
7F 1 (0.02%)
2 sheaths RA and UA 10 (0.3%)
RA occlusion (on angiography) 41 (1.1%)

26. Total crossover in STEMI

27. Crossover direction
TR Access site crossover direction N=113 (3%)
Right Transulnar access 67/113 (60%)
Left Transradial access 33/113 (29%)
Right Transfemoral access 8/113 (7%)
Right Brachial access 5/113 (4,4%)

28. RA Anomalies

29. RA Anomalies
 Published data about the presence of
RA anomalies reported percentages
ranging from 7%-22%
 The exact influence of these anomalies
on TR success is uncertain

30. RA Anomalies in STEMI patients

31. High take off RA from BA
 Usually takes off
from the BA or AxA
 Most common
anomaly of the
radial artery
 5,9% according to
our data

32. High take off RA from AxA

33. Radial artery loop
 Defined as 360 degree
loop
 1% according our data

34. Radial artery loop
 Sometimes
remnant/reccurent RA is
present
 In STEMI access the RA
loop and the diameter of
the remnant artery

35. Complex loop with remnant artery and
high degree spasm

36. Reason for transfer to TUA
2 sheaths RA and UA

37. Tortuosities of RA
 1,4% according to
our data
 Most prone to
spasm

38. Tortuous RA with severe spasm

39. Tortuous RA with severe spasm

40. TR Access site crossover due
to RA anomalies
TR Access site crossover N
TR crossover/unable to cross anomaly 19/313 (6%)
High bifurcating origin of the radial artery from the
brachial or axillary arteries
3/19 (15,7%)
Radial artery loop (360°) 14/19 (73%)
Radial artery tortuosity 2/19 (10%)
Hypoplastic radial artery 0/19 (0 %)
Crossover due to significant clinical spasm 0 (0%)

41. Crossover direction due to RA anomalies
TR Access site crossover direction N=19 patients
Right Transulnar access 11
Left Transradial access 6
Right Transfemoral access 2

42. Effect of presence of RA anomalies on
procedural factors and clinical outcomes
Anomalous RA
STEMI
N=313 (8.6%)
Non anomalous RA
STEMI
N= 3346 (91.4%)
P value
Fluoroscopy time (mins) 10±9 9±8
Procedure time (mins) 34±18 32±20
Clinical radial artery spasm 44 (14%) 102 (3.0%) <0.001
Access site bleeding complications 24 (7.6%) 147 (4.3%) <0.001
Successful access to central aorta 278 (89%) 3268 (98%)
Values expressed as mean±SD

43. Access site complications
N
Access site bleeding
complications EASY score
171 (4.6%)
Hematoma grade 1 111 (3.0%)
Hematoma grade 2 52 (1.4%)
Hematoma grade 3 6 (0.16%)
Hematoma grade 4 2 (0.05%)
Hematoma grade 5 0 (0%)
Major vascular complication 0 (0%)
Signs of hand ischemia 0 (0%)
N
Clinical RA spasm
Grade I
Grade II
Grade III
Grade IV
105 (2.8%)
96 (2.6%)
6 (0.2%)
3 (0.1%)
0 (0%)

44. Case 1
 Pt MK
 Presented with an Anterior STEMI
 Before routine RA angiography at our center

45. If you don’t do angiography before trying
something …

46. Perforation of RA with lead wire

47. Crossover to LRA

48. Routine RA angiography on the
same patient 1 year later prior to
another procedure

49. Small RA loop in upper segment of RA

50. PCI wire crossing

51. Microcatheter crossing and exchange
with Ironman wire

52. Straightening of RA loop

53. Catheter crossing

54. Case 3
 Pt ND
 RA angiography performed through cannula

55. One of 8 STEMI patients in the last 5
years that required change to TFA

56. Crossover to TFA

57. Case 3
Pt ND
RA angiography with cannula

61. Ulnar access with ipsilateral RA Occlusion

62. Another Ulnar access with
ipsilateral RA occlusion

63. Little preview of our future study!
Comparison between patients before and
after routine RA angiography at our
center
STEMI patients
2010-03.2011
N=637
STEMI patients
03.2011-03.2016
N= 3659
P value
Fluoroscopy time (mins) 9±5 9±8.4
Procedure time (mins) 40±18 32±20 <0.001
Major Access site bleeding
complications grade 4/5
4 (0,6%) 2 (0,05%) <0.001
Successful TRA access to central aorta 607 (95%) 3546 (97%)
Values expressed as mean±SD

64. Conclusions
Routine pre-procedural radial artery angiography
 Gives the operator a chance to successfully
plan the strategy for the STEMI procedure,
access the RA and predict future situations
during intervention
 Is easy, quick and safe
 Helps less experienced operators advance
more quickly along the learning curve
 Can prevent complications
 Helps YOU take optimal care of the Radial
Artery!

65. THANK YOU !