Transradial approach for complex coronary intervention The document discusses the transradial approach (TRA) for complex coronary interventions. Some key points: - TRA is the preferred access site due to lower risk of bleeding complications compared to transfemoral approach. - When performing complex interventions, the operator must balance complexity of the case with ability to advance necessary devices and manage thrombotic/bleeding risk. - Data from over 5,000 STEMI patients treated by the author over 10 years showed significantly lower rates of major bleeding, mortality, and MACE with TRA compared to transfemoral approach. - Crossover from TRA was low at 5.4%, mostly to alternative radial or ulnar arteries, demonstrating

1. Transradial approach for complex
coronary intervention
Docent Oliver Kalpak MD PhD
Univ. Klinika za Kardiologija
Medicinski Fakultet UKIM Skopje
Republika Severna Makedonija
oliver.kalpak@medf.ukim.edu.mk
kalpakoliver@gmail.com

2. Disclosure
• Nothing to disclose

3. EDUCATIONAL CONTENT ENDORSED BY EAPCI,
A REGISTERED BRANCH OF THE EUROPEAN SOCIETY OF CARDIOLOGY
©
2021
Europa
Digital
&
Publishing.
All
rights
reserved.
Percutaneous interventional cardiovascular medicine – The PCR-EAPCI Textbook
Risk stratification and risk models in revascularisation
Hironori Hara1, 2, Kuniaki Takahashi1, Vasim Farooq3, David R Holmes4, Yoshinobu Onuma2, Patrick W.
Serruys2

4. Complex coronary intervention
• Approach to plan complex coronary intervention requires
addressing multiple points in order to obtain procedural
success
• The arterial access, femoral or radial, might seems simple
to choose but we find it rather of substantial importance in
achieving best for the patient.
• Access site bleeding is avoidable simply by choosing radial
artery. We all are aware that bleeding force us to stop
those regiments we use to support our complex
intervention and we are aware that bleeder severely suffer.

5. The balance
• The balance between complexity and ability to
pass needed materials
• The balance between thrombotic and
bleeding risk
• The balance between operator and patient
preference

6. Points in radial access
• First of all is the operators experience regarding arterial
access for various interventions.
• Second is the bleeding associated with periprocedural
anticoagulation and anti aggregation support of
complex interventions.
• Third point is the ability to advance necessary material
trough radial artery when we plan complex
intervention, thus sometimes we must choose femoral.

7. TRA in my lab
• Trans-radial become our first choice for elective
procedures in 2007, (stages 1-3)
• for STEMI as well for other complex interventions TRA
become our first choice in 2009 and remain so trough
the past decade. (Stage 4 in TRA development)

8. Impact of TRA PCI over last 20 years
0
500
1000
1500
2000
2500
3000
3500
4000
elective PCI
STEMI PCI
TRA
first

9. my lab workload
• Close to 7 000 patients per year last decade
• All of them TRA as the first choice.
• Among them roughly 800 are STEMI interventions, and
about 3000 elective coronary and peripheral interventions.
• Regarding the complexity of those we have each year
• roughly 1000 bifurcation and multivessel PCI
• more than 100 LM interventions,
• 160 carotid stenting
• around 100 other peripheral interventions

10. We look back on 10 years of STEMI PCI
• In order to explore what we have accomplished we look back to our data of well-
defined group of over five thousand STEMI patients in 10 years.
• From total cohort of 5419 patients we find results that favor TRA approach.
• Out of 4048 TRA patients the Major access related bleeding was found in 28
patients or 0.7%,
• compared to 99 bleeders or 7.2% among 1371 TFA patients.

11. Inerventional caracteristics N = 5419 STEMI
TRA
4048
TFA
1371
P
Infarct related artery
LAD 1935 (47.8%) 664 (48.4%) 0.441
Cx 619 (15.3%) 203 (14.8%) 0.517
RCA 1380 (34.1%) 483 (35.2%) 0.489
LM 45 (1.7%) 17 (1.2%) 0.384
multivessel 1675 (41.4%) 537 (39.2%) 0.378
LM involved 332 (8.2%) 78 (5.7%) 0.141
Flow
TIMI 0
before 3287 (81.2%) 1089 (79.4%) 0.254
TIMI 3
before 453 (11.3%) 166 (12.1%) 0.387
TIMI 3
after PCI 3757 (92.7%) 1254 (91.5%) 0.203
PCI success 3971 (98.1%) 1343 (97.8%) 0.841

12. Bleeding N = 5419
TRA
4048
TFA
1371
OR
(95% CI)
p
Major Bleeding
Access related
28
(0.7%)
99
(7.2%)
0.11
(0.03-0.41)
0.001
Major Bleeding
Non-access related
77
(1.9%)
28
(2.0%)
0.91
(0.43-2.41)
0.317
Major bleeding (all) 105
(2.6%)
127
(9.3%)
0.29
(0.13-0.72)
0.014
Minor bleeding 304
(7.5%)
112
(8.2%)
0.59
(0.37-3.12)
0.414
Any Bleeding 409
(10.1%)
239
(17.4%)
0.64
(0.16-0.89)
0.021

13. Primary points N = 5419
TRA
4048
TFA
1371
OR
(95% CI)
P
30 d MACE 308
(7.6%)
148
(10.8%)
0.61
(0.32-0.85)
0.001
1 y MACE 467
(11.6%)
229
(16.7%)
0.52
(0.24-0.74)
0.001
30 d mortality 158
(3.9%)
115
(8.4%)
0.70
(0.22-0.86)
0.001
1 y mortality 251
(6.2%)
155
(11.3%)
0.49
(0.21-0.75)
0.001

14. NNT of 22 patients to prevent 1 mortality event

15. Clinical Outcome favors TRA
30-day mortality of
• 3.9 % for TRA STEMI intervention
compared to
• 8.4% for TFA STEMI intervention group
with OR 0.11(0.03-0.41) (95% CI) and p < 0.001.
• We also find less than 0.2% of mortality for all other
interventions by using TRA.

16. Decision to cross over from TRA
• Crossover from default radial was low 5.4%
• towards left radial in 2.6 % ,ulnar 1.6 %
• and towards TFA only 1.3% of the patients

17. Presentation of cases
• To illustrate our practice, we present couple of cases
of complex coronary interventions including recent
crossover to femoral when it was warranted.
• Fundamentalism has no place in interventional
cardiology

18. Case 1
• 62 years, female
• Acute Coronary Syndrome / Non-STEMI
• Presentation with Severe persistent chest pain, ECG with 3mm deep ST depression
on precordial leads, TA 110/70 previously hypertensive
• Previous several years old stents on LAD and Cx, diag , received in several sessions
for treating AP
• DM i.d. more than 10 years, HTA more than 20 y

19. Case 1

20. Case 1 –
was there a place for second thoughts?

21. Case 1

22. Case 1
NC balloon 3,5 on 28 atm

23. Case 1- second stent and final
10 months follow up-OK

24. Case 2
• 50 years, male
• APNS after 6 months of CABG
• First diagnostic TRA, last patient of the busy day
• Next day- planed complex intervention via TFA
• Big gear
• Kiss with big NC balloons

25. Case 2

26. Case 2 – 1,25 balloon,3 wires

27. Case 2-NC 3,0

28. Case 2 after first stent

29. Case 2
Kiss two big baloons 3,5 NC on still image and final result on cine

30. Hurdles of TRA
• Stage 1- to puncture radial.
• Stage 2 – to navigate trough limb arteries
• Stage 3 - to engage coronaries and obtain
support for the intervention
• Stage 4 – to do LM,CTO,Bifurcation, peripheral
• Stage 5 – to avoid fundamentalism and crossover
when it is necessary for better outcome

31. Take home message
• TRA first choice - for all procedures-
• TRA can boost your numbers of procedures in the same time
with your self-confidence and ability to overcome hurdles
• TRA is opportunity when facing complex PCI
• Fundamentalism avoidance strategy is in the high stages of
TRA development

32. Thank you for your time
Хвала на пажњи
Благодарам на вниманието