Nolan J - AIMRADIAL 2014 - Radialists and femoral access
- A study of 1352 PCI procedures at a radial center found that while 25.2% used femoral access, these cases had fewer complications (12.5% hematomas vs 6.25% requiring intervention) than expected given reduced femoral experience. - Analysis of UK PCI data found radial use increased from 12-49% for PPCI, with no increase in femoral complications at radial centers and a possible reduction in 30-day mortality for femoral cases at radial centers. - While radial access is safer, some patients still require femoral, and data suggests radial operators have good outcomes for these cases as well.
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Nolan J - AIMRADIAL 2014 - Radialists and femoral access
- 1. RADIALISTS PERFORM BETTER FEMORAL PCI Jim Nolan University Hospital of North Staffordshire
- 2. WHY DOESN’T EVERYBODYUSE RADIAL ACCESS • Learning curve • Extended Procedural duration • Increased nursing input • Patient preference • Impaired Procedural success and applicability • Increased cost of radial specific kit • Radiation exposure • If they do they will lose the ability to do safe TFA
- 3. RADIAL ENVIRONMENT •Small calibre vessel • Spasm risk • Anatomical variation • Advanced guide catheter techniques • Skilled high volume TRA operators are highly proficient interventionists ( as are their teams )
- 4.
- 5. FACTORS THAT MAYACT TO INCREASE TFA COMPLICATIONS IN RADIAL CENTERS • Fewer TFA procedures • Reduced exposure to technique for operators in training and daily practice • Reduced institutional experience with post TFA care
- 6. EVOLOUTION OF PRACTICE TFA CASES ARE NOW UNCOMMON
- 7. FACTORS THAT MAYACT TO REDUCE TFA COMPLICATIONS IN A RADIAL CENTER •When a TRA operator has to perform a TFA case it is done with maximum attention to puncture, haemostasis and aftercare •TRA operators performing TFA frequently use guidance for the puncture •Limited use of VCDs
- 8. VACD – DEVICEFAILURE RATE (Sesana et-al, JIC 2000, n = 827) (%) RATE 9 FAILURE COLLAGEN PLUG SUTURE 11 12 10 8 6 4 2 0
- 9. VCD META ANALYSIS– RANDOMISED + OBSERVATIONAL (Nikolsky et-al, JACC 2004, n = 37,066)
- 10. 2010 META-ANALYSIS OFRCT COMPSRING VCD TO MANUAL COMPRESSION (Biancari et-al,Am Heart J 2010,n=7528)
- 11. HOW CAN WEINVESTIGATE THE SAFETY OF TFA IN RADIAL CENTERS
- 12. PATIENTS UNDERGOING PCIFROM THE FEMORAL ROUTE BY DEFAULT RADIAL OPERATORS Ihsan M. Rafie, MD; Muez M. Uddin, MD; Nicholas Ossei-Gerning, MD; Richard A. Anderson, MD; Timothy D. Kinnaird*, MD Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom Eurointervention 2014
- 13. CARDIFF STUDY •1352 PCI procedures performed by default radial operators over 12 month period • TFA used when operator felt it to be technically and clinically appropriate ( skilled TFA operators) • ACUITY based definition of TFA related complications ( included haematomas that were not associated with Hb fall and required no intervention) • TFA utilised in 351 (25.2%) cases
- 14. WHAT TYPE OFPATIENT HAD TFA IN THE CARDIFF STUDY • Female gender (41% v 21%) • Older (65 v 63) • Lower BMI (80% v 84%) • Shorter stature (167 v 171) p < 0.001 for all comparisons
- 15. WHAT TYPE OFPROCEDURE WAS DONE VIA TFA IN THE CARDIFF STUDY?
- 16. RESULTS IN TFACASES • 44 patients (12.5%) had femoral vascular complication (ACUITY definition) • 22 of these ( 6.25%) were haematomas with no intervention required • 22 (6,25%) had TFA complication that required some form of intervention
- 17. The use ofradial access decreases the risk of vascular access-site-related complications at a patient level but is associated with an increased risk at a population level: the radial paradox Lorenzo Azzalini, MD, MSc; E. Marc Jolicoeur*, MD, MSc, MHS Interventional Cardiology Division, Dept. of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
- 18. INFLUENCE OF RADIALACCESS ON BLEEDING AND VASCULAR COMPLICATIONS – META ANALYSIS OF RANDOMISED TRIALS (Jolly et-al,lancet,2011, n=10,000+)
- 19. META-ANALYSIS OF RCTCOPARING RADIAL v FEMORAL ACCESS IN STEMI PATIENTS UPDATED TO INCLUDE RIFLE (Mamas et-al,Heart 2011,n=3978) OR for mortality = 0.53 (95% CI 0.38-75); P<0.001 for radial
- 20. BRITISH CARDIOVASCULAR INTERVENTIONSOCIETY • BCIS established in 1998 to promote and monitor PCI activity in UK • Collects data on all PCI performed in UK via central electronic database ( 113 patient ,procedural and outcome variables ) • Robust mortality data using NHS number • Linked to NHS central register • Legal requirement for every death in UK to be recorded
- 21. ACCESS SITE PRACTICE EVOLUTION IN THE UK
- 22. UK BCIS PPCI N=46,128 PPCI 39% TRA TRA for PPCI increased from 12% to 49% Mamas M, JACC Cardiovasc Interv. 2013; 6: 698-706 TRM 2013
- 23. ACCES SITE RELATEDOUTCOMES IN CARDIOGENIC SHOCK (AHJ,2014, n=7,231)
- 24. WHO STILL DOESTFA IN UK ?
- 25. GEOGRAPHICAL DISTRIBUTION OF TRA IN UK
- 26. WHAT TYPE OFOPERATORS DO TFA IN UK? Kinnaird T et al, O Heart 2014
- 27. CLOPIDOGREL USE INSTEMI PCI
- 28. PCI OUTCOMES ACCORDINGTO CLINICAL SYNDROME AND ACCESS SITE (n=433,000 JACCI 2014,in press) 0.1 1 Favours TRA Favours TFA STABLE 30-Day Mortality 0.78 (0.57-1.03) p=0.77 MACE 1.04 (0.92-1.18) p=0.53 Bleed 0.24 (0.15-0.39) p<0.001 Access site complication 0.22 (0.17-0.29) p<0.001 URGENT 30-Day Mortality 0.85 (0.76-0.96) p=0.01 MACE 0.85 (0.77-0.94) p<0.001 Bleed 0.40 (0.31-0.52) p<0.001 Access site complication 0.24 (0.19-0.30 p<0.001 EMERGENCY 30-Day Mortality 0.69 (0.62-0.77) MACE 0.71 (0.65-0.78) p<0.001 Bleed 0.53 (0.43-0.66) p<0.001 Access site complication 0.20 (0.13-0.29) p<0.001 Figure 3. Forest plot of log odds ratio of outcomes following multivariate logistic regression
- 29. EVALUATION OF TFAACCESS SITE PRACTICE IN MAJORITY RADIAL CENTERS • Years 2006 to 2010 • Single access site recorded • TRA or TFA
- 30.
- 31. ARE RADIAL CENTERSBETTER AT EVERYTHING?
- 32. WHAT DOES BCISTELL US • TRA benefits seen in RCT translate into clinical practice • Radial centers do better radial PCI • No increase in TFA complications in radial centers • TFA procedures performed in a TRA center were associated with an observed reduction in mortality at 30 days • In MVA OR 0.86, 95% CI 0.76-0.99, p=0.032
- 33. Limitations • Observationaldata • Unmeasured confounders • Data collected in an evolutionary period (operators have TFA background) • May not apply to TFA cases in very high volume TRA centers ( case mix effects )
- 34. CONCLUSIONS • Radialcentres do better femoral PCI • Radial centres do better radial PCI • Radial centres do better PCI
Editor's Notes
- #23 over 46 thousand PPCI procedures with a documented single access site overall 39% TRA....Increased from 12 % to almost 50% over 4 years Those done radially had better MACE free survival as illustrated in the unadjusted kaplan meier curve here