Yeh RW 2016 Transradial access and intervention
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This document provides guidance on performing percutaneous coronary interventions (PCIs) using the transradial approach. It discusses: 1) Evidence from clinical trials showing lower mortality, lower bleeding rates, and shorter hospital stays with transradial compared to transfemoral access. 2) Tips for patient selection, accessing the radial artery, engaging coronary arteries, and successfully completing interventions. 3) How to manage complications like bleeding and spasm. The overall recommendation is that transradial should become the default access approach, especially for higher risk cases, if the operator takes time to learn the technique.
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Yeh RW 2016 Transradial access and intervention
- 1. Beth Israel Deaconess Medical Center HARVARD MEDICAL SCHOOL A Step by Step Approach Transradial Access and Intervention Robert W. Yeh, MD MSc Beth Israel Deaconess Medical Center Harvard Medical School
- 2. Overview • Know the Evidence • Patient Selection • Tips for Access • Tips for Engaging Coronaries • Tips for Successfully Completing Interventions • Specific Scenarios
- 3. Registry Data: Transradial PCI in the UK 3 Katib et al. JACC Intv 2015.
- 4. Transradial PCI in the US 4 Feldman. Circulation 2013.
- 5. Large Associated Benefit 5Katib et al. JACC Intv 2015.
- 6. RIVAL 7021 pts randomized to radial vs. femoral access. Negative Trial for primary endpoint of death, MI, stroke, nonCABG bleeding Significantly decrease in vascular complications Subgroups showed benefit 6 3.7% vs. 4.0% Jolly et al. Lancet 2011.
- 7. MATRIX Primary endpoints Death, MI, Stroke: 8.8% rad vs. 10.3% fem HR 0.85 (0.74-0.99) p= 0.0307 Death, MI, Stroke, BARC 3 or 5 bleeding 9.8% rad vs. 11.7% fem HR 0.83 (0.73-0.96) P=0.0092 Valgimigli et al. Lancet 2015.
- 8. RCT Data - Mortality Karrowni, et al. JACC Cardiovascular Intv. 2013.
- 9. Integrating Transradial Access in Your Practice Increasing magnitude of benefit for radial!
- 10. Learning Curve • Hess et al: New radial operators in US
- 11. Patient Selection • Radial should be a default approach • Right radial approach is ergonomically more favorable, associated with lower radiation. • Left radial may be preferable for post-CABG patients, challenging RCA interventions. • Poor Allen’s test may not be prohibitive.
- 13. Access technique - 1 cm above styloid process
- 15. • Stick through back wall. • use a shallower angle for a thin person, when you are hitting bone. • Pull back slowly • Tension-releasing technique. • Don’t be too eager to wire • Spin the wire and advance, stop with any resistance
- 17. Getting Catheters to Coronaries • Anticoagulate, Vasodilator • Ask pt to take deep breaths if having difficulty getting into ascending aorta • use LAO projection • Can use traditional JL and JR or radial-specific catheters (e.g. Jacky, Ikari…)
- 18. Getting Catheters to Coronaries • Anticoagulate • Ask pt to take deep breaths if having difficulty getting into ascending aorta • use LAO projection • Can use traditional JL and JR or radial-specific catheters (e.g. Jacky, Ikari…)
- 19. Successfully and Efficiently Completing Interventions • Don’t choose a weak guide • Weak guides • Left: XB3, EBU3, CLS 3, XBLAD • Right: JR, Ikari right • Intermediate guides • Left: 3.5 guides, Ikari 3.5 • Right: Ikari left, Hockey stick • Strong guides • Left: XB4, EBU4 Voda4 • Right: AL 0.75 and greater
- 20. • Use techniques to give you more support • Exchange for supportive wires • Guide extension • Anchoring • Use a bigger guide if needed
- 22. Guide Extension Co-Axial Anchor to get Guide Extension Down - lead with a balloon - follow with Guide Extension - Inflate balloon and pull to take out slack - Push down Guide Extension
- 27. Hemostasis • Patent hemostasis • Band in place • Occlude ulnar • Check plethysmography. Pancholy et al. CCI. 2008
- 28. Complications Ounce of prevention worth a pound of cure. Bleeding • BP cuff up on arm to get control. • Ace bandage over forearm can help with compression. • Go to a different access site for loops. Spasm • Sedate the patient. Take your time.
- 29. Summary • Learn to use it as a default, particularly in higher risk cases • Set yourself up to succeed • Do it the same way every time and don’t cut corners.