Access site-related outcomes: relationship with operator and center volume, J Nolan

1. ACCESS SITE RELATED
OUTCOMES:RELATIONSHIP WITH
OPERATOR AND CENTER
VOLUME
Professor Jim Nolan
University Hospital of North Midlands, UK

2. Disclosures
• I have no conflict of interest to declare

3. WHY DO WE BOTHER WITH
RADIAL ACCESS?

4. YOU USE RADIAL ACCESS
TO REDUCE
• Vascular complications
• Bleeding/transfusion
• MACE
• Death

5. ARE ALL OPERATORS AND
CENTERS THE SAME?

6. EFFECT OF CENTER
VOLUME ON RIVAL CPE
(Lancet 2011,n=7021)

7. MVA OF RADIAL PCI CENTER
VOLUME IN RIVAL
(Per 50 additional cases, JACC 2014)

8. MVA OF RADIAL OPERATOR
VOLUME IN RIVAL
(Per 50 additional cases, JACC 2014)

9. WHAT ABOUT THE MOST RECENT
DATA – MATRIX CPE
(Lancet 2015, n=8,404)

10. There is a volume effect in
highly selected populations
enrolled in RCTs, but what
about the real world?

11. BRITISH CARDIOVASCULAR
INTERVENTION SOCIETY
• 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 PCI
variables )
• Robust mortality data using NHS number
• Linked to NHS central register
• Legal requirement for every death in UK
to be recorded

12. ACCESS SITE PRACTICE
EVOLUTION IN THE UK

13. WHAT IS THE PATTERN OF TRA
IN UK CENTERS?

14. WHAT ABOUT INDIVIDUAL
OPERATORS?

15. EFFECT OF OPERATOR RADIAL
PRACTICE IN UK?
• (Mamas/nolan et al,Cir Int 2016, n=164,359)

16. INSTITUTIONAL PRACTICE IS
LESS IMPORTANT IN UK

17. IN MULTIPLE RCTs AND LARGE
OBSERVATIONAL STUDIES
• TRA outcomes are linked to institutional
and individual practice patterns
• Best outcomes are achieved by high
volume TRA operators/institutions
• Need to do more than 30% of cases via
TRA to favourably impact on adverse
events
• High proportion TRA operators achieve a
50% mortality reduction v TFA

18. WHAT ARE THE
MECHANISMS FOR THIS
EFFECT?

19. TR APPROACHTR APPROACH
THE LEARNING CURVE FORTHE LEARNING CURVE FOR
EARLLY ADOPTERS WAS LONGEARLLY ADOPTERS WAS LONG
 Lefevre TCT 2003Lefevre TCT 2003
 Puncture failure, spasm, different guide manipulationPuncture failure, spasm, different guide manipulation

20. LEARNING CURVE EFFECTS
MAY HAVE A NEGATIVE IMPACT
(Fluoro time,Hess/Rao Circ 2014,n=54,561)

21. Contrast volume,Hess/Rao

22. TR LEARNING CURVE IN CONTEMPORARY
PRACTICE
(Ball et al,CircI,2011,n=1672)

23. TRANSRADIAL LEARNING CURVE IN
CONTEMPORARY PRACTICE
(Looi et-al,Am J Cardiol 2011,n=1001)
FluoroscopyTime(min)

24. CASE SELECTION EFFECTS
(Rajani et el,JIC 2015,n=10,231)

25. IMPACT OF RADIAL ACCESS IS
MAXIMUM IN HIGH RISK PATIENTS
(Mamas/Nolan,JACC 2014,n=348,689)

26. CONCLUSIONS
• TRA is better for patients
• But only if you switch to a high volume
TRA practice
• Mediated by learning curve/case selection
effects
• Powerful reason to move your
interventional practice to mostly TRA ( as
in UK )

27. SHOULD RADIAL APPROACH ONLY
BE USED IN HIGH VOLUME RADIAL
CENTRES?