Trans-Radial Approach in Overweight Patients

1. Trans-Radial approach in Overweight Patients Hakim Ben Amer, MD On behalf the TROP study group

3. Complications following diagnostic coronary angiography: Predicting factors Ammann CCVI 2003;59:13-18 7,412 consecutive diagnostic cardiac catheterizations between 1990 and 2000 0R 1.4; 95% CI 1.01-1.95; p= 0.04 0R 1.23; 95% CI 0.95-1.44; p= 0.1 Body weight (/10 kg) 0R 3.93; 95% CI 1.28-12.06; p= 0.01 0R 2.76; 95% CI 1.14-6.73; p= 0.02 Smoking 0R 2.54; 95% CI 0.93-7.02; p= 0.07 0R 2.35; 95% CI 1.0-5.51; p= 0.05 0R 2.6; 95% CI 1.53-4.41; p= 0.0004 French: <6, =6, >6 0R 0.58; 95% CI 0.34-0.98; p= 0.04 Senior physician (> 500) 0R 2.62; 95% CI 1.46-4.7; p= 0.003 Left / Right catheterization 0R 2.16; 95% CI 1.12-4.16; p= 0.03 Heart failure (Killip>1) Vascular complications Major complications All complications Factor

5. Clinical Significance of Bleeding Complications From Blankenship Am Heart J 1999; 138: S287-S296 - + 5896 $ + 4 Major Vascular Site Bleeding or Vascular Complication (Surgical) - + 1327 $ + 2 Major or Minor Vascular Site Bleeding or Vascular Complication (Surgical) Incapacitation (days-weeks) Return to normal activity delay + 1 Any Vascular Site Bleeding or Vascular Complication (Surgical) Others Extra Cost Median Length of Hospital Stay (Day)

6. Radial / Femoral Approach meta-analysis: Entry site complications Agostini P JACC

9. TROP Study Group N = 346

10. Clinical Datas Mean Age 61.2 +/- 10.9 years (30/83) Sexe (Male) 52.9 % Mean Weight 108 +/- 15 Kg (79/155) Mean Height 1.67 +/- 0.1 M (1.45/1.90) Mean BMI 38.7 +/- 3.4 Kg/m2 (35/56) Renal Insuf 7.8% TROP Study Group

11. Clinical Datas TROP Study Group %

12. Clinical Datas TROP Study Group P = .0006 25 (7.2) 59 (17.1) Angio/PCI (%) 21 (6.1) 19 (5.5) PCI (%) 52 (14.7) 171 (49.4) Angio (%) Femoral N = 97 Radial N = 249

13. Clinical Datas TROP Study Group %

14. Clinical Datas TROP Study Group %

15. Vascular Access Transradial approach IT: 249/346 ( 71.9% ) Transradial approach AC: 243/346 ( 70.2% ) Reasons for using Femoral access: 97/346 ( 28.1% ) - Physician choice (76): 78.4% - Dialysis (1): 1% - Need for 7F catheters (5): 5.2% - Abnormal Allen test (1): 1% - CABG (double Mam) (4): 4.1% - No or to small radial (4): 4.1% - Other (ring, prior rad failure…) (6): 6.2% TROP Study Group IT: Intention To Treat AC: After Cross over

16. Vascular Access Cross over: 17 (4.9%) - Radial to femoral: 9 (3.6%) - Radial to radial: 4 (1.6%) - Femoral to radial: 3 (3.1%) - Radial to Ulnar 1 (0.4%) TROP Study Group

17. Vascular Access: Size TROP Study Group N

18. INDICATIONS TROP Study Group %

19. Clinic Presentation TROP Study Group %

20. Documented Ischemia TROP Study Group %

21. Vascular Access Radial difficulties: 249 patients - Failure: 10 (4%) - No difficulty 210 (84.3%) - Catheterism diff. 10 (4%) - Spasm 6 (2.8%) - Loops 10 (4%) - Others 2 (0.8%) - TOTAL 29 (11.6%) TROP Study Group

22. CAD extension TROP Study Group %

24. Fem vs Rad access TROP Study Group 0.04 38 +/- 5 39 +/- 14 BMI (Kg/m2) NS 56 (54.4) 138 (56.7) Male (%) NS 60.5 +/- 10.1 61.2 +/- 11.3 Mean age (y) P Femoral (n=103) Radial (n=243)

25. Fem vs Rad access TROP Study Group P Femoral (n=103) Radial (n=243) NS 65 (63) 9 (9) 29 (28) 137 (56) 24 (10) 82 (34) Diabetes (%) No ID NID NS 60 (58) 17 (16) 26 (25) 137 (56) 30 (12) 60 (25) Smokers (%) No Current Past 0,001 40 (39) 41 (17) Family History (%) NS 72 (70) 165 (68) Hypercholesterolemia (%) NS 76 (70) 180 (70) Hypertension (%)

26. Fem vs Rad access TROP Study Group NS 17 (16) 42 (18) Prior PCI (%) NS 8 (8) 11 (45) Prior CABG (%) NS 27 (26) 37 (15) Prior MI (%) P Femoral (n=103) Radial (n=243)

27. Fem vs Rad access TROP Study Group * With transfusion §: with 8 Closing Device 0.0001 55.6 +/- 23.3 35.3 +/- 25.4 Total Duration (min) 0.03 31.3 +/- 17.7 26.1 +/- 19.0 Angio Duration (min) NS 122 +/- 70 117 +/- 64 Contrast Angio (ml) 0.001 9 (8.7) § 4 (1.6) Hematoma (%) NS 3 (2.9) 3 (1.2) Vascular complication (%)* 0.02 2.7 +/- 4.3 1.7 +/- 2.2 Hosp stay after C (d) NS 4.4 +/- 4.6 3.7 +/- 4.1 Hosp stay (d) 0.01 189 +/- 102 159 +/- 95 Contrast Total (ml) 0,0005 2.3 +/- 0.7 1.9 +/- 0.8 Nb Cath used Angio (n) P Femoral (n=103) Radial (n=243)

28. Impact of Weight for in Hospital Outcome after PCI RM, Minuella Am J cardiol 2004;93:1229-32 <0,001 0,9 0,5 0,5 0,5 0,6 1,4 Vascular Injury (%) <0,001 2,4 1,8 2,0 2,1 2,6 5 MACE (%) <0,001 0,8 1,2 1,1 1,1 1,3 0,9 Emergent CABG (%) 0,227 0,3 0,3 0,4 0,3 0,3 0,5 Transmural MI (%) 0,001 1,4 0,6 0,7 0,8 1,1 3,8 Death (%) P >40 N=2745 35/39,9 N6252 30/34,9 N=19329 25/29,9 N=41175 18,5/24,9 N=25010 < 18,5 N=924 BMI (kg/m2) N=95435

32. Bleeding Complications F.V Aguirre et al, Circulation 1995;91:2882-90

33. Bleeding complications

34. Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients N Cox, Am J Cardiol 2004;94:1174–1177 Distribution of patients who underwent cardiac catheterization procedures by BMI

35. Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients N Cox, Am J Cardiol 2004;94:1174–1177

36. Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients N Cox, Am J Cardiol 2004;94:1174–1177

37. Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients N Cox, Am J Cardiol 2004;94:1174–1177 Vascular complications by BMI. The patients with the smallest BMIs experienced the highest rate of vascular complications

38. Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients N Cox, Am J Cardiol 2004;94:1174–1177 Overall vascular complication rate in nonobese and obese (BMI >30.0) patient subgroups stratified by vascular access approach

39. Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients N Cox, Am J Cardiol 2004;94:1174–1177

40. Low-Normal or Excessive Body Mass Index: Newly Identified and Powerful Risk Factors for Death and Other ComplicationsWith Percutaneous Coronary Intervention Stephen G. Ellis, Am J Cardiol 1996;78:642-64 Major Cardiac Outcomes and Complications

41. Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other Complications With Percutaneous Coronary Intervention Stephen G. Ellis, Am J Cardiol 1996;78:642-64 Peripheral Vascular Complications

42. Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other Complications With Percutaneous Coronary Intervention Stephen G. Ellis, Am J Cardiol 1996;78:642-64 Independent Correlates of Death With and Without BMI

43. Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other Complications With Percutaneous Coronary Intervention Causes of Death Stephen G. Ellis, Am J Cardiol 1996;78:642-64

44. Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other ComplicationsWith Percutaneous Coronary Intervention Stephen G. Ellis, Am J Cardiol 1996;78:642-64

45. Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox) H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

46. Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox) H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

47. Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox) H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

48. Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox) H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

49. Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI H. Gurm J Am Coll Cardiol 2002;39:834–40 Procedural Characteristics of Study Patients According to BMI

50. Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI Incidence and Odds Ratios of In-Hospital Events According to BMI: PTCA Group H. Gurm J Am Coll Cardiol 2002;39:834–40

51. Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI H. Gurm J Am Coll Cardiol 2002;39:834–40 Incidence and Odds Ratios of In-Hospital Events According to BMI: CABG Group

52. Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI H. Gurm J Am Coll Cardiol 2002;39:834–40 Incidence and OR of Long-Term Mortality According to BMI: PTCA Group (n=2,090)

53. Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI H. Gurm J Am Coll Cardiol 2002;39:834–40 Incidence and OR of In-Hospital Events According to BMI: CABG Group

54. Obesity a risk for CABG surgery N.J.O. Birkmeyer Circulation 1998;97:1689-94

55. Obesity a risk for CABG surgery N.J.O. Birkmeyer Circulation 1998;97:1689-94 CVA Cerebrovascular Accident SWI Sternal Wound infection