Vaknin-Assa H
•
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Octogenarian - Radial Artery Coronary Catheterization Approach
![Why
Radial
Approach
and
why
in
the
elderly?
§ Fewer
vascular
complication
In
an
analysis
of
the
National
6 Radial
N=4074
P=0.69
5.11
Femoral
N=301351
Cardiovascular
Data
Registry
5
4.17
investigators
reported
a
4
P<0.001
significantly
lower
risk
for
%3 2.38
Radial
Femoral
bleeding
complications
in
the
2 P<0.0001
0.96
transradial
group
(OR:
0.42
1 0.15
1.06
[95%
confidence
interval:
0
0.31-‐0.56],
p<0.01)
Bleeding
Vascular
Procedure
Rao
SV,
et
al.
J
Am
Coll
Cardiol
Intv
failure
2008;1:379-‐86
§
Earlier
patient
mobilization
compared
with
the
transfemoral
§ Shorter
hospital
stays
§ Lower
hospital
costs](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Vaknin-Assa H
- 1. Brachial artery Radial artery Ulnar artery Interosseous artery OCTOGENARIAN -‐RADIAL ARTERY CORONARY CATHETERIZATION APPROACH Hana Vaknin Assa, Abid Assali Ran Kornowski Rabin Medical Center
- 2. Why Radial Approach and why in the elderly? § Fewer vascular complication In an analysis of the National 6 Radial N=4074 P=0.69 5.11 Femoral N=301351 Cardiovascular Data Registry 5 4.17 investigators reported a 4 P<0.001 significantly lower risk for %3 2.38 Radial Femoral bleeding complications in the 2 P<0.0001 0.96 transradial group (OR: 0.42 1 0.15 1.06 [95% confidence interval: 0 0.31-‐0.56], p<0.01) Bleeding Vascular Procedure Rao SV, et al. J Am Coll Cardiol Intv failure 2008;1:379-‐86 § Earlier patient mobilization compared with the transfemoral § Shorter hospital stays § Lower hospital costs
- 3. Effect on pts age on the association of rPCI with procedural succeess and bleeding complication Rao SV, et al. J Am Coll Cardiol Intv 2008;1:379-‐86
- 4. What are the technical difficulties and how to overcome? § Access -‐ Spasm -‐ Lt vs Rt Radial Approach § Vessel Tortuosity -‐ Technique to overcome § Complex procedures (Left main, CTO, Calcified vessel, Bifurcation, Vein grafts Angioplasty) § Pts Comorbidities – Renal failure.
- 5. Transradial approach-‐left vs right TALENT study-‐ Sciahbasi et al. Am Heart J 2011;161:172-‐9.)
- 6. TALENT study -‐Results Sciahbasi et al. Am Heart J 2011;161:172-‐9)
- 7. The problem of arteria lusoria in right transradial coronary angiography and angioplasty The aberrant right subclavian artery arises from the aorta distal to the origin of the left subclavian artery Rajpal K CCI 2001;54:196-‐201
- 8. Variation of the Radial Artery Alpha shape radial S shape radial Omega shape Brachial alpha artery (A). artery (B) radial artery (C) loop(D) High origin radial artery (E). Subclavian artery Subclavian artery tortuosity (E). tortuosity (F).
- 9. Transradial approach for coronary angioplasty in Chinese elderly patients The incidence of radial and brachiocephalic trunk anatomical tortuosity is higher in elderly patients, transradial coronary intervention can be performed with similar safety and procedural success in these patients as compared with non-‐ elderly patients Zheng et al.Chin Med J 2008;121(12):1126-‐1129
- 10. Case Presentation #1-‐ W.A. 84 yr old male,DM-‐Insulin Tx, HTN, S/P PCI of LAD 1994,Ischemic CMP-‐Severe LV Dysfunction, Effort Angina & Positive Thalium Scan
- 12. Technique to overcome Radial Tortuosity § Never push the guide wire and take a radial angiogram via a radial sheath. § Under the fluoroscopic guidance, 0.035-‐inch hydrophilic guide wire (Terumo, Japan) rather than Teflon coating conventional guide wire is advanced carefully toward the brachial artery. § In some case, 0.014-‐inch coronary guide wire is more helpful to pass the angulated lesion.
- 13. Technique to overcome Subclavian Tortuosity § Deep inspiration during the advancement of guide wire, the guide wire can be easily introduced toward the ascending aorta § The use of Stiff Wire (Amplaz Extrastiff)
- 14. Complex procedure (Left main, CTO, Calcified vessel, Bifurcation,Vein grafts Angioplasty) § Need for large 7F catheter (Sheathless Guiding Catheter-‐Hadi et al.A feasibility study CCC 2010 Abstract 198 ) § Bypass Grafts § Need for IABP
- 15. Case#2-‐ F.M.83 yr, male,HTN,Dyslipidemia S/P CABG-‐1997,AAA,CRF, S/P CVA,NSTEMI and Pulminar Congestion, LV Function preserved, Left Radial Approach-‐ PCI of VG/RCA & VG/OM Xience prime 3.5/15 Endeavor Resolute 2.75/12
- 16. PCI of VG/OM Using DES Xience prime 3/15
- 17. Case #3: E.A. 85 yr old,HTN, Transient Inferior STEMI Left Radial Approach Anomalous origin of RCA
- 18. Left transradial approach – PCI of RCA Sheathless JR Guideliner Whisper wire BMS 3.5/15 Prokinetic stent
- 19. Final Results
- 20. Multivariate Predictors of TR-‐PCI Failure Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-‐1064
- 21. Predictors of Mortality and Long-‐Term Outcomes of Octogenarians Undergoing Transradial PCI – Dery et al. § Retrospective analysis of Consecutive 988 Octogenarians (mean age=84±3.2 yr, Mortality Rate(%) 48% females) 28 § 5 yr F/U § 87% successful radial 13 Access 4.5 § 9% Major and minor Bleeding In Hospital 1 year 5 year § Transradial access was inversely correlated with 1yr mortality (HR 0.49,CI 0.29-‐0.8,p=0.0048) Jean-‐Pierre Dery et al. J. Am. Coll. Cardiol. 2010;55;A209.E1975
- 24. Take home message § Transradial approach is associated with fewer vascular complications § The procedure is safe and feasible (new equipment) § A select group of octogenarians
- 25. Rabin Medical Center-‐ Radial Approach 21.8% 8.0% 6.7% 1.6% 1.5% 2.3% 2006 2007 2008 2009 2010 2011