This document presents a study on total wrist access for primary PCI in 2624 consecutive patients with acute ST elevation myocardial infarction, highlighting the effectiveness and safety of the transradial access (TRA) strategy. The study demonstrates a high success rate in utilizing TRA, associated with low mortality and major adverse cardiac events (MACE) rates. Conclusions indicate that total wrist access is feasible, associated with low crossover rates, and results in favorable patient outcomes.

1. TOTAL WRIST ACCESS FOR
PRIMARY PCI
SINGLE CENTER REGISTRY OF 2624 CONSECUTIVE
PATIENTS WITH ACUTE ST ELEVATION
MYOCARDIAL INFARCTION
OLIVER KALPAK
UNIVERSITY CLINIC FOR CARDIOLOGY
SKOPJE
MACEDONIA

2. Disclosures: Nothing to disclose
• Authors:
• Oliver Kalpak (presenting )
• Antov S., Kostov J., Pejkov H., Spiroski I., Boshev M., Vasilev I.,
Zafirovska B., Kedev S.
• University Clinic of Cardiology
• Medical Faculty -Univ. St Cyril And Methodius
• Skopje
• Macedonia

3. Background: Why TRA for STEMI
• TRA is associated with significant clinical benefit in STEMI
patients
• TRA is associated with lower Mortality and MACE rates in High
volume STEMI PCI Center
• Primary PCI in STEMI Patients A Meta-Analysis of RCT Karrowni (JACC2013)
• RIFLE STEACS Romagnoli et all (JACC 2012)
• RIVAL Jolly et al (Lancet 2011)
• STEMI RADIAL Bernat (JACC 2014)
• Operator volume RIVAL Jolly et al (JACC 2014)
• TRA for STEMI and Shock Pancholy TCT 2014

4. Meta analysis RA vs FA for STEMI

5. Transferred Access strategy for STEMI
2007 2008 2009 2010 2011 2012 2013
800
700
600
500
400
300
200
100
0
TRA+TUA 25 170 358 609 581 567 745
TFA 72 310 241 23 8 2 1
N 97 480 599 632 589 569 746
Number of patients

6. Completely transferred Access for STEMI PCI
74.5%
64.9%
25.5% 35.1%
59.6%
95.3% 98.50% 99.70% 99.9%
40.4%
4.7%
1.50% 0.30% 0.1%
5.7% 5.8% 4.4% 1.6% 0.1% 0.1% 0.0%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2007 2008 2009 2010 2011 2012 2013
crossover to TFA TRA + TUA TFA

7. TRANSITIONING TO THE RADIAL APPROACH FOR PRIMARY PCI
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
Single Center Registry of 1808 STEMI patients
TRA TFA
OR 0.55 (0.39-0.76)
OR 0.46 (0.32-0.66) p<0.001
p<0.001
OR 0.11 (0.05-0.20)
p<0.000
30Days mortality Major Vascular Bleeding 30 Days MACE
KEDEV ,et al. J INVASIVE CARDIOL 2014;26(9):475-482

8. Total Wrist Access for STEMI in our Center
• 2624 consecutive STEMI PCI patients during 4 years (2010 to 2013)
• 7 operators with high volume TRA experience
• Default TRA access strategy for all interventions
• 98.7% Wrist ( TRA +TUA) and 1.3% TFA
• Second choice was ipsilateral Ulnar or left Radial or Ulnar artery
and last choice Femoral artery

9. Mortality and MACE at 30 days and 6 months
20
15
10
5
0
6,6%
8,6%
5,0% 5,6%
30 Days 6 months
MACE Mortality
N=2624 n %
30 d Mortality 131 5.0
30 d MACE 174 6.6
6 m Mortality 147 5.6
6m MACE 226 8.6

10. Total Wrist Access for STEMI
98,7%
1,3%
Wrist (TRA+TUA) 2589 patients TFA 35 patients

11. Crossover from Default Right Radial Access Strategy
144 out of 2624 patients
48%
28%
24%
L Radial Ulnar Femoral

12. Artery Access in 2624 STEMI PCI
94,5 %
2,6% 1,6% 1,3%
R Radial L Radial Ulnar Femoral

13. Radial for STEMI and Crossover rates in literature
Center/Author N % Radial
% Crossover to
TFA
Macedonia/Kalpak
AIM Radial 2014 2624 94.5 1.3
UK/Mammas
JACC BCIS database 2013 48603 39.1 5.1
UK/Hetherington
Heart 2009 1051 54.2 7.7
Holland/ Vink
Heart 2011 2209 96.1 3.8
Belgium/Dangoisse
Eurointervention 2013 3600 46.4 1.3
Italy /Valgimigli
JACC REAL reg. 2012 11068 27.7 7.7-3.5

14. Conclusions
• TotalWrist Access was achieved in our high volume dedicated
TRA Center
• Total Wrist Access is safe and feasible for STEMI and it was
linked with low mortality and cardiovascular events rates in
unselected all-comers cohort
• Default TRA strategy was associated with low crossover rate
• Crossover towards femoral access was lower than crossover
towards left radial and ulnar

15. THANK YOU