Acute radial artery occlusion (RAO): best practices to reduce it - Samir B Pancholy

1. Acute Radial Artery Occlusion
Samir B. Pancholy, MD, FAHA, FACC, FSCAI
Program Director, Cardiology Fellowship,
Wright Center for Graduate Medical Center
Professor of Medicine,
Geisinger Commonwealth School of Medicine, Scranton, PA , USA

2. Disclosures
• No conflict of interest related to this presentation

3. Proprietary and Confidential
2
RAO Incidence
3.90%
8.90%
14.90%
9.20%
5.50%
14%
Rotterdam AJULAR Edris et al. HANGAR Degirmencioglu Hahalis et al.
2015 PubMed RAO Rates
Proprietary and Confidential
9.40% - Mean Reported
RAO Incidence
RAO Happens !!!!!!!

4. Mechanism of RAO
• Thrombosis (acute)
• Rapid organization with fibrotic lumen
obliteration

5. Mechanism of RAO

6. Mechanism of RAO

7. Mechanism of RAO

8. Mechanism of RAO

9. Mechanism of RAO

10. Aminian A et al Eurointervention 2017

11. Aminian A et al Eurointervention 2017

12. Aminian A et al Eurointervention 2017

13. Aminian A et al Eurointervention 2017

14. Aminian A et al Eurointervention 2017

15. SheathlessTechnique
Horie K et al. Eurointervention 2017

16. SheathlessTechnique
Horie K et al. Eurointervention 2017

17. UFH Dose and RAO
Spaulding C et al, CCI 1996

18. Heparin Dose matters!
Bernat I et al Am J Cardiol

19. UFH Dose and RAO
Hahalis G et al, Int J Cardiol 2015

20. Can we get away without Heparin?
Bossard M et al Can J Cardiol 2017

21. Bossard M et al Can J Cardiol 2017

22. Hahalis G et al JAHA 2017

23. Bossard M et al Can J Cardiol 2017

24. Bossard M et al Can J Cardiol 2017

25. Warfarin is not enough!!!!
Pancholy S et al, Am J Cardiol 2014

26. RAO: Flow cessation
0
10
20
30
40
50
60
70
80
90
100
RAO No RAO
Sanmartin et al CCI 2007; 70: 185-9

27. Patent Hemostasis
Pancholy S et al. Catheter Cardiovasc Interv. 2008;72(3):335-40.

28. Wilson SJ et al Int J Cardiol 2017

29. Dangoisse V et al Am J Cardiol 2017

30. Dangoisse V et al Am J Cardiol 2017

31. Beware of Rebound Bleeding
0
10
20
30
40
50
60
70
80
90
100
15 min + QuickClot 15 min 2 Hours
RAO (%)
Politi L et al, J Interv Cardiol 2011:24(1);65-72
Rebound Bleeding (%)

32. Rebound Bleeding = Revengeful Pressure

33. RAO
Rebound Bleeding = Revengeful Pressure

34. How to compress?
0
50
100
150
200
250
300
350
Dressing Balloon Band Pad Band
Duration in Minutes
P < 0.0001
Cong X et al, J Cardiov Nurs, 2016
P < 0.0001
1650 patients RANDOMIZED to 3 groups

35. How to compress?
0
2
4
6
8
10
12
14
16
18
Dressing Balloon Band Pad Band
RAO %
P < 0.0001P < 0.0001
Cong X et al, J Cardiov Nurs, 2016
1650 patients RANDOMIZED to 3 groups

36. Eliminate residual spasm
Dharma S, Kedev S, Patel T et al, CCI 2014

37. Radio-Ulnar circuit
UA
RA

38. Radio-Ulnar circuit
UA
RA

39. Radio-Ulnar circuit
UA
RA

40. Ulnar compression
UA
compressed
UA
released

41. RadialVTI with Ulnar compression
0
2
4
6
8
10
12
14
Baseline Ulnar compression
VTI(m.s2)
P < 0.0001
8.4
12.8*
N = 150
Pancholy S et al, J Inv Cardiol (in press)

42. Figure 2: CONSORT Diagram
Assessed for eligibility (n=4238)
Randomized (n=3000)
Excluded (n=1238)
• Ad-hoc PCI (n=818)
• Previous ipsilateral TRA (n=80)
• Barbeau pattern D (n=211)
• Warfarin therapy (n=110)
• No ulnar pulse (n=19)
Group I (n=1497)
Patent hemostasis
Lost to follow-up (n=35)
4 mortalities, 31 unreachable
Group II (n=1503)
Patent hemostasis
with ulnar compression
Lost to follow-up (n=34)
2 mortalities, 32 unreachable
Analyzed (n=1462) Analyzed (n=1469)
Enrollment
Allocation
Follow-up
Analysis
Pancholy S et al, JACC Interv (In press)
PROPHET-II
(Prevention of Radial Artery Occlusion – Prophylactic Hyperperfusion Evaluation Trial)

43. Pancholy S et al, JACC Interv (In press)
PROPHET-II
(Prevention of Radial Artery Occlusion – Prophylactic Hyperperfusion Evaluation Trial)

44. • Prophylactic Ulnar compression lowers RAO
PROPHET-II
(Prevention of Radial Artery Occlusion – Prophylactic Hyperperfusion Evaluation Trial)

45. Figure 1: Ipsilateral Ulnar Compression During Radial Artery Hemostasis
PROPHET-II
(Prevention of Radial Artery Occlusion – Prophylactic Hyperperfusion Evaluation Trial)

47. Koutouzis et al, J Inv Cardiol 2016: August

48. Have we made a difference?

49. 0
2
4
6
8
10
12
Sanmartin Rathore Plante Pancholy
Early Late
NR NR

50. 0
2
4
6
8
10
12
Sanmartin Rathore Plante Pancholy
Early Late
Patent
Hemostasis
Patent Hemostasis
With
Ulnar Compression
Cubero Bernat PROPHET-II ULTRA
Early Late
NR NR NR NR 0 0

51. 0
2
4
6
8
10
12
Sanmartin Rathore Plante Pancholy
Early Late
Patent
Hemostasis
Patent Hemostasis
With
Ulnar Compression
Cubero Bernat PROPHET-II ULTRA
Early Late
NR NR NR NR 0 0

52. Thank you