This document discusses TRI (transradial intervention) in patients with chronic kidney disease (CKD). It notes that CKD patients have accelerated atherosclerosis and are at high risk for coronary artery disease. While PCI can help treat CAD, CKD patients face higher risks of bleeding complications and renal impairment from the procedures. The document recommends hydration, low-osmolar contrast agents, and limiting contrast load when performing PCI in CKD patients to protect kidney function. It argues that TRI may reduce bleeding risks compared to transfemoral approaches but must be used cautiously in end-stage renal disease to avoid compromising existing or future arteriovenous fistulas needed for hemodialysis access.

1. TRI in Chronic Kidney
Disease (CKD) Patients
Bernard Chevalier
ICPS Massy
FRance
Chamonix – Mont-Blanc 1-2 Avril 2011

2. SPECIFIC FEATURES OF CAD IN CKD PTS
PCI IN CKD PTS
RENAL PROTECTION FOR CKD PTS

3. CKD (GFR<60): A risk factor
Insuffisance Rénale Dialysée
• HTN, LVH, CHF
• >35% of CKD pts have evidence of
ischemic disease at the time of
presentation to nephrologist
• Prognosis is mainly related to the severity
of atheroma before End-Stage Renal
Disease (ESRD)
• Importance of ischemia detection

4. Athérosclérose Accélérée
Not specific risk factors
• Age
• Male gender
• HTN
• Diabetes
• Dyslipidemia
• Smoking
Specific risk factors:
• Hyperparathyroidism
• Hyperphosphatemia
• Anemia
• Hyperhomocystéinémy
• Oxidative stress
• Inflammation
• Renin-angiotensin activation

5. Inflammation-Thrombose
5888 pts > 65 ans, 647 pts(11%) Insuffisants rénaux
M.G. Shlipak et al, Circulation 2003;107:87-92

6. CKD: a predictive factor for CAD
outcome
• 3 times higher 1y mortality in AMI (Shlipak
et al)
• 6 times higher 6 m mortality in GUSTO/
PURSUIT/PARAGON (Suwaidi et al.)
• Higher impact in young CKD patients
• Part of GRACE score with
– HR 2.09 for GFR between 30 & 60 (stage 3)
– HR 3.71 for GFR < 30 (stage 4&5)

7. CKD: impact on treatment
• In case of ACS, CKD pts
– Are underdiagnosed
– Receive less « guidelines » medications
– Have more limited access to angiography
– Get less PCI
– Have less secondary prevention medication
• However PCI pts have similar longterm
decrease of renal function than medically
treated pts

8. Coronary disease in ESRD
• Cardiovascular disease is the leading
cause of mortality
• 10 times risk than 5 Framingham RF pts!

9. Survie chez les patients dialysés
Sarnak MJ. Circulation 2003;108:2154-69

10. Vascular calcification
• Consequence of bone mineral disorder
• Accelerated on dialysis patients
• Possible ways to limit:
– Dialysis protocol, low dose Vit D regimen,
sevelamer
• Has direct impact on
– Quality of PCI (plaque modification/stent
deployment)
– Quality of hemostasis at vascular access

11. ATHEROME de l’INSUFFISANT RENAL
PCI in CKD Patients
RISQUE et PREVENTION du
d’INSUFFISANCE RENALE en
CARDIOLOGIE INTERVENTIONNELLE

12. Higher number of PCI
• Severity of disease &
crucial role of PCI
• Higher rate of recurrence
after DES

13. Bleeding risk of PCI in CKD

15. Bleeding
profile

16. Yatskar L, Catheterization and Cardiovascular Interventions 69:961–966 (2007)

17. Bleeding in all comers

18. Impact of In-Hospital Major Bleeding on
Early and Late Mortality in REPLACE-2
Stone GW J Invas Cardiol 2004, 16(suppl G): 12G-17G

19. Adverse effect of transfusion?

20. Pros TRI in CKD
Less bleeding / Less renal event

21. P. Agostoni JACC 2004; 44:349-56

22. Cantor W, Catheterization and Cardiovascular Interventions 69:73–83 (2007)

23. Primary Angioplasty
Moins de Complications Locales
20
p < 0.01
Acces Site Complications (%)
15
p < 0.05
10 p < 0.05
5
0
TRA FA Perclose FA Manual
Y. Louvard et al. CCVI 2002; 55: 206-211

24. Vuurmans T, Heart 2010;96:1538-1542.

25. Vuurmans T, Heart 2010;96:1538-1542.

26. Vuurmans T, Heart 2010;96:1538-1542.

27. Cons for TRI in CKD
Radial occlusion

28. Radial in ESRD?
• Vascular access is the lifeline !
• Native AV Fistula > Prothetic graft > central
venous catheter
– Impact on prognosis
• Non maturation 20 to 50% (artery diameter
> 2 mm, more predictable in forearm)
• Venous neointimal hyperplasia (vein
quality) alters patency: 12 to 18 months
• Forearm AV fistula are the best ones (?)

29. Sheath/artery ratio

30. COMPRESSION RADIALE
- 300 patients
- Compression with elastic dressings as
shorter as possible
- Doppler evaluation
- Early results: 4 radial occluded (1.3%) :
- Late results: about 270 patients
• any new occlusion after hospital discharge
• about 4 initial occlusions : 3 spontaneous
recanalization and 1 persistent
less than 1% radial occlusion rate
Monségu Ann Cardiol Angeiol 2003; 52: 135-8

31. Relationship between compression and
radial occlusion
Radial patent Radial occlusion p
10.5%
No flow before 49% 54% 0.41
sheath removal
No flow after 63% 66% 0.49
placing
compression
No flow before 54% 90% 0.002
compression
removal
Sanmartin Catheter Cardiovasc Interv 2007; 70: 185-9

32. Radial artery occlusion
Pancholy J Invasive Cardiol 2009; 21: 101-4

33. Tips & tricks for TRI in severe CKD
(stage 4 & 5 = GFR < 30)
• Vascular calcification + HTN = loops +++
– Prefer left radial?
• Never use a sheath larger than radial
artery
– 5F PCI or sheathless 6F
– 4F?
• Keep always one radial artery free of
puncture
– If possible the one with best venous system
• Apply good hemostasis technique

34. ATHEROME de l’INSUFFISANT RENAL
RISQUE SAIGNEMENT et
VOIE d’ABORD RADIALE
RENAL PROTECTION for CKD patients

35. 1. HYDRATION
- 100 ml/h Nacl 0.9%/bicarbonate 14/1000 4 h avant
examen
- 1000 ml sérum 0.9%/bicarbonate 14/1000 24h
après examen
2. Low osmolarity contrast media
3. Contrast load < 4 x GFR

36. CKD patients
• Are highly exposed to CAD
• Have a specific vascular atheroma
• With a higher risk of suboptimal result of
PCI with more restenosis risk
• And higher bleeding complications related
to access site
• Leading to a high number of coronary
interventions

37. The choice of TRI
• Limits bleeding & renal events with
significant impact on outcome
• Is possible in pts not yet on dialysis using
very strict rules particularly for ESRD
• Could be considered with a lot of caution
to avoid impairment of existing and future
AV fistula
• Femoral route is a back-up choice using
closure device