This document compares the risk of microembolization during diagnostic coronary angiography between single catheter and double catheter strategies. In the first study, a left radial approach was found to have a lower rate of microembolization than a right radial approach, likely due to less catheter manipulation and exchanges. Independent predictors of high microembolization included a greater number of catheters used. A second study found that using a single "Tiger" catheter halved the rate of microembolization compared to using a double catheter "Judkins" strategy, mainly by reducing catheter exchanges. Minimizing catheter exchanges may help reduce the risk of air embolism and microembolization during coronary angiography procedures.

1. Risk
of
microemboliza0on
during
diagnos0c
coronary
angiography:
comparison
between
single
and
double
catheter
strategy
Andrea Pacchioni, Bernhard Reimers
Cardiology Department, Ospedale Civile, Mirano, Venice
AIMRADIAL 2014 - Chicago

2. Is
there
a
risk
of
microemboliza0on
during
diagnos0c
coronary
angiography?
Andrea Pacchioni, Bernhard Reimers
Cardiology Department, Ospedale Civile, Mirano, Venice
AIMRADIAL 2014 - Chicago

3. right radial
BACKGROUND
Stroke in PCI < 0.5%
New silent lesions @ DW-MRI: 2-25%
Silent microemboli @ TCD: 100%
Correlation with cognitive dysfunction
femoral
right radial
right radial
Omran et al, Lancet 2003
Hamon et al, Stroke 2006
30%
23%
15%
8%
0%
Omran Hamon

8. Bertrand OF et al, JACC Intv 2010

9. BACKGROUND
• Right radial vs femoral
• 43 patients with stable CAD
• Judkins catheters
• 35% reduction of cerebral
microembolization with
femoral approach
• High incidence in RMCA
during right radial
Jurga et al, Stroke 2011

10. HYPOTHESIS:
Left radial do it better?
•Same advantages of right radial (reduction of bleeding, fast
mobilization, reduced discomfort)
•Better catheter manipulation (Judkins catheters are still 1st
choice!)
•Avoids abdominal and thoracic descending aorta
•Origin of left CCA from aortic arch
Randomized comparison
LEFT RADIAL vs RIGHT RADIAL
Primary endpoint: silent microemboli @ TCD
Pacchioni A et al, Int J Cardiol 2013

11. METHODS:
TRANSCRANIAL
DOPPLER

12. MICROEMBOLUS
sloping high power
tracks with progression
across depth as time
changes

13. METHODS:
paBents
Referring for suspected CAD (stable angina or NSTEACS)
Exclusion criteria:
Ischemic Allen test
Previous CABG
Hemodynamic instability
Atrial fibrillation
Insufficient temporal bone window for TCD monitoring
Severe carotid stenosis

14. METHODS:
catheterizaBon
Right or left radial puncture (Seldinger technique)
Introducer: Terumo 11 cm 6 Fr
2500 U of UFH + verapamil
Guidewire: Cordis Emerald 0.035” – Terumo Glidewire 0.035” if
needed
Catheters: 6 Fr Cordis Judkins left and right as first choice, then
Amplatz left and right
Over-the-wire catheter exchange
Closed automatic injector: ACIST

15. METHODS:
the
MES…
definiBon
Microemboli assigned to different coronary angiography steps:
*cath manipulation, further distinguished in
- exchange (advancement and retrieve) = advancement
and over-the-wire removal of catheters and insertion of the
wire to overcome tortuosity
- coronary engagement = manipulation in aortic arch and
coronary ostia engagement
*contrast injection= injection of contrast medium and cath flush
MES tot = MES cor + MES exch + MES inj

16. METHODS:
staBsBcal
analysis
• MES: 75 + 28 in right radial (pilot group)
Expected reduction with left radial: 35%
Sample size (power 0.8, significance 0.05): 20 patients for each
group
randomization to right or left radial artery by sealed envelopes
• Bivariate analysis: Student T-test, Fisher exact test, chi2, Mann-
Whitney, Kruskal Wallis with Bonferroni correction
• 66th percentile: cut-off for high incidence of microemboli
Simple and multiple logistic regression analysis to assess
independent predictors of high incidence of microemboli

17. Characteris0cs
Value,
n/total
(%) Right
radial
approach
(n=20) LeH
radial
approach
(n=20) P
value
Age
-­‐
yrs
* 64.5
+
7.6 66.7
+
11.9 0.493
Male 12
(60%) 12
(60%) 1
BMI,
Kg/m2* 26.4
+
4.2 26
+
2.9 0.737
Hypertension 14
(70%) 16
(80%) 0.465
Diabetes 3
(15%) 5
(25%) 0.429
Current
smoking 7
(40%) 6
(30%) 0.736
Dyslipidemia 16
(80%) 12
(60%) 0.168
Chronic
renal
failure
† 4
(20%) 4
(20%) 1
Previous
myocardial
infarcBon 4
(20%) 5
(25%) 0.705
Previous
stroke/TIA 0
(0%) 1
(5%) 0.311
Previous
PCI 9
(45%) 10
(50%) 0.752
Acute
coronary
syndrome 15
(75%) 17
(85%) 0.429
Clopidogrel
12
(60%) 12
(60%) 1
StaBn
18
(90%) 16
(80%) 0.376
Beta-­‐blocker
12
(60%) 9
(45%) 0.342
ACE
inhbitor
12
(60%) 15
(75%) 0.311
Leb
ventricle
ejecBon
fracBon 53
+
11.9 58.3
+
5.7 0.082

18. Characteristics Value
Right radial approach
(n=20)
Left radial approach
(n=20)
P value
Absence
of
CAD 3
(15%) 3
(15%) 1
CAD
1
vessel 2
(10%) 5
(25%) 0.212
CAD 2 vessel 10 (50%) 8 (40%) 0.52
CAD 3 vessel 5 (25%) 4 (20%) 0.7
Subsequent
PCI 14
(70%) 15
(75%) 0.744
Procedural
Bme 10.75
+
3 10.5
+
3.4 0.8
Fluoroscopic
Bme
(sec) 234
+
76 193
+
59 0.06
Contrast
medium
amount
(ml) 49
+
17 33
+
5 0.001*
Number
of
injecBons 7.8
+
1.2 7.2
+
1.9 0.25
Number
of
catheters 2.35
+
0.6 2.2
+
0.6 0.435
Number
of
catheters
for
LCA 1.1
+
0.36 1.1
+
0.4 0.701
Number
of
catheters
for
RCA 1.25
+
0.5 1.1
+
0.4 0.35
> 1 catheter exchange 6 (30%) 2 (10%) 0.114

19. RESULTS (3)
Overall MICROEMBOLI

20. RESULTS (4)
MICROEMBOLI during cath manipulation

21. RESULTS (5)
MICROEMBOLI during cath exchange

22. RESULTS (6)
MICROEMBOLI during coronary ostia engagement

23. RESULTS (7)
MICROEMBOLI during contrast injections

24. RESULTS (8)
MICROEMBOLI in each MCA

25. RESULTS (9)
MICROEMBOLI according to number of catheters employed

26. RESULTS (10)
MICROEMBOLI according to coronary angiography stage

27. RESULTS (11)
Independent predictors of HIGH MICROEMBOLI: > 62
OR 95%
CI p
Vascular
access 21.3 0.84-­‐541 0.07
Number
of
catheter
16.47 1.23-­‐219.9 0.034
Acute
coronary
syndrome
1,1 0.057-­‐21.5 0.94
Pretreatment
with:
clopidogrel 5.2 0.19-­‐136.5 0.32
staBn 0.17 0.006-­‐4.7 0.29
ACE-­‐I 0.03 0.001-­‐1.01 0.07
costant 0.001 0.07

28. CONCLUSIONS:
part
1
• Right radial has a higher incidence of silent cerebral
embolization compared to left radial
• This is explained by higher mechanical manipulation
(higher catheter exchanges)
• When Judkins catheters are employed, left radial works
better
• Catheter exchanges should be minimized

29. TERUMO OPTITORQUE TIGER
Pacchioni A et al, Int J Cardiol 2013

30. METHODS:
• Single cath (Terumo Tiger) vs Double cath (Judkins Left and Right)
• Primary endpoint: MES tot
• MES: 71 + 28 in right radial (70 pts, unselected)
Expected reduction with single cath: 50%
Sample size (power 0.8, significance 0.05): 9 patients for each
group
randomization to single or double cath strategy by sealed envelopes
• Procedural success: diagnostic coronary angiography with 1 cath in SC
and 2 cath in DC

31. RESULTS (1)

32. RESULTS (2)

33. RESULTS (3)
MICROEMBOLI in each MCA

34. RESULTS (4)
MICROEMBOLI in each MCA

35. RESULTS (5)
MICROEMBOLI in each MCA

36. CONCLUSIONS:
part
2
• Single cath strategy halved incidence of cerebral
microembolization
• Most of advantage because of reduction of cath exchange
• probably air embolism (microcavitation during exchange)

37. LIMITATIONS:
• No info about posterior circulation
• High incidence of microemboli compared to other studies (high
prevalence of ACS and multivessel CAD)
• Microemboli are clinically silent, not all microemboli result in
MRI lesions (fortunately!), weak correlation with clinical events
• However, microemboli have been used as surrogate for
cerebral embolism to compare protection systems in CAS trial
• Extremely useful as model for mechanisms of cerebral
embolism
• Larger sample to be an exhaustive model