Cardiogenic shock is a leading cause of death in AMI patients, with mortality rates between 30-60%. While radial access has been shown to reduce bleeding complications, patients presenting with cardiogenic shock are often treated via transfemoral access. Recent studies have demonstrated that radial access PCI is feasible in cardiogenic shock patients, with one study showing a reduction in in-hospital mortality for radial versus transfemoral access. However, experienced radial centers only use the radial approach in around 50% of cardiogenic shock cases, indicating radial access is still underutilized despite potential benefits in this high-risk group.

1. Cardiogenic shock and radial
approach
Dr Mamas Mamas
Senior Lecturer, Honorary Consultant
Cardiologist
University of Manchester

2. Cardiogenic shock
• Cardiogenic shock (CS) a leading cause of mortality in
patients with AMI
• Mortality rates significant. 30-day mortality between 30-60%
• Major bleeding complications occur in upto 10% of patients
with CS
• Many studies of access site related outcomes have excluded
CS (eg RIVAL, STEMI-Radial etc)
• Even in experienced radial centers, patients presenting in CS
are often treated via TFA
• Commentators suggested that CS remains the final frontier
giving experienced radial operators pause for thought

3. Cardiogenic shock
• Most data derived from small series
• Bernat / Bertrand (2013): 2 centre study
– 197 PPCI patients with CS (7.4%). PCI through TRA 55%
– TFA patients: more likely to be intubated (66% vs 42%), have IABP (55% vs
36%)
– Similar 30 day mortality (TRA:41%VS TFA 53%; p=0.11). Decrease non
CABG related bleeding and access site related bleeding in TRA group.

4. Cardiogenic shock
• Rodriguez-Leor (2013) single centre 122 emergency PCI CS
patients, 80 TRA (65%)
– Mechanical ventilation (TFA 66.7% vs TRA 41.2%, P=0.008);
inotropic drugs (TFA 88.1 vs TRA 63.7%, 0.004)
– Mean BP lower in TFA group, % IABP greater in TFA, mean EF
lower in TFA
Independent predictors for in
hospital mortality:
TRA OR 0.39 95% CI (0.15-
0.97)

5. Change in UK cardiogenic shock rates
and access site practice

6. % Radial 2005
Unpublished data

7. % Radial 2006
Unpublished data

8. % Radial 2007
Unpublished data

9. % Radial 2008
Unpublished data

10. % Radial 2009
Unpublished data

11. % Radial 2010
Unpublished data

12. % Radial 2011
Unpublished data

13. % Radial 2012
Unpublished data

14. Utilisation (%) and no. of cases of the radial and femoral
access site during PCI in patients presenting with cardiogenic
shock (2006-2012)
41
638
154
640
777
% Access site utilisation
894
Test for trend across ordered categorical groups P<0.0001 for both cohorts over
time

15. Relationship between access site utilisation and TRA
centre experience based on % of cases undertaken
through TRA approach.

16. 483,381 PCIs in UK from 2006-2012
8,222 PCIs with cardiogenic shock (1.7%)
991 (12.0%) access site
unknown
7,231 PCIs with cardiogenic shock (1.7%)
Mamas et al Am H Journal 2014;167(6):900-908

17. Baseline characteristics

18. Independent predictors of TFA use

19. Outcomes

20. Outcomes: Bleeding

21. Outcomes
• Outcomes relate to centre experience
– In centres where TRA < 25%, HR (for TRA) for 30 day mortality:
HR=0.68 95%CI 0.45-1.03, P=0.06
– In centres where TRA 75-100%, , HR (for TRA) for 30 day mortality:
HR=0.50 95%CI 0.35-0.33, P<0.0001
against proportion of procedures performed radially in centre,
.4 .6 .8 1
OR
Odds ratio of 30-day mortality
for radial access versus femoral access
with 95% CI
adjusted for covariates
0 .2 .4 .6 .8 1
proportion of procedures performed radially
OR NoEffect
UpperBound LowerBound

22. Radial access and outcomes in CS
Gandhi et al. J Thrombosis Thrombolysis 2014

23. • Cardiogenic shock patients at
highest risk of sustaining bleeding
complications
• 45% independent reduction in 30-
day mortality from BCIS dataset
• ? Large magnitude of mortality
benefit associated with TRA use
relates to big bleeding risk in CS

24. Magnitude of access site related bleeding and mortality
reduction relates to baseline bleeding risk
Mamas et al. J Am Coll Cardiol. 2014;64(15):1565-7.

25. Patients at highest risk of bleeding complications
less likely to have PCI through TRA

26. Conclusion
• CS PCI feasible through TRA approach in a
significant proportion of cases
• Even in high volume TRA centres (>75%) only 50%
of CS undertaken TR in UK
• CS PCI represents amongst the highest bleeding risk
PCI cases
• TRA utilisation may be associated with decreased
30d mortality outcomes (in experienced centres)
• Magnitude of mortality benefit relates to baseline
bleeding risk
• Cases most likely to benefit from TRA undertaken
femorally!