Bertrand OF - AIMRADIAL 2013 - Radial in 100%?

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Why not radial in 100% of the cases

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Bertrand OF - AIMRADIAL 2013 - Radial in 100%?

  1. 1. WHY NOT RADIAL IN 100% OF THE CASES? Olivier F. Bertrand, MD, PhD Associate-Professor of Medicine, Laval University Adjunct-Professor, Department of Mechanical Engineering, McGill University Quebec Heart-Lung Institute AIM-RADIAL 2, NYC, Sep 2013
  2. 2. DISCLOSURES • Scientific Director of International Chair in Interventional Cardiology and Transradial Approach • operates www.theradialist.org & • organizes AIM-RADIAL congress • Chair receives funding from multiple industry and other sources • No salary or honorarium received from the chair
  3. 3. “Radialist” Feeling After Radial Access Failure...
  4. 4. INTRODUCTION • Although transradial approach (TRA) is increasingly used worldwide, it might not be possible in all cases • Studies have reported crossover rate to TFA from 5 to 10% • Considerable variability in radial experience, and selected cohorts
  5. 5. OBJECTIVES • To describe the incidence, mechanisms and predictors of TRA-PCI failure in a high volume tertiary radial center • • • Among all comers In STEMI population To derive a simple clinical scoring system predictive of TRA-PCI failure
  6. 6. METHODS • All comers Score: • • Consecutive patients who underwent PCI at Québec heart- lung institute between January-June 2010, irrespective of the indication. N=1654 STEMI Score: • Consecutive STEMI patients 2006-2011- N=2020 • Exclusion criteria: None • Baseline characteristics and, procedural data, and, if any, need and reason for access site crossover, clinical outcomes. • Operators: 6 fellows 12 interventional cardiologists
  7. 7. METHODS • TRA-PCI failure was categorized 2 groups: • Primary TRA-PCI failure when TFA was chosen as initial access for any clinical reason (no radial puncture attempted) • Crossover TRA-PCI failure, due to inability to complete the PCI procedure via TRA, requiring access site crossover to TFA
  8. 8. METHODS • Independent predictors of TRA-PCI failure from multivariate model • Risk score: each independent variable assigned a weighted integer score • C-index and Bootstrapping (95% CI)
  9. 9. ACCESS SITE FLOW CHART, PRIMARY AND CROSSOVER Primary 2.7% Crossover 1.8% E. Abdelaal et al. 2013 (submitted)
  10. 10. Causes of TRA-PCI Failure Reason N (%) Cardiogenic Shock Prior CABG – operator preference 6 (13) RAO 5 (11) Prior CABG - Bilateral Mammary Grafts 4 (9) Prior CABG with LIMA - LRA harvested for conduit 2 (4) Need to Preserve RA as future conduit - young patient aged 16 1 (2) Fixed Flexion Deformity of Forearm 1 (2) Takayasu Arteritis 1 (2) Undetermined 8 (18) Inadequate Puncture 17 (57) Radial Spasm Crossover Failure (N =30) 8 (18) Prior TRA-PCI Failure Primary Failure - Primary TFA (N =45) 9 (20) 5 (17) Radial Loop/Tortuosity 4 (13) Subclavian Tortuosity 2 (7) Inadequate Guiding Catheter Support 2 (7)
  11. 11. Multivariate Predictors of TRA-PCI Failure in All Comers and Risk Score Variable Model Coefficient rounded Clinical Risk Score OR 95% CI P-value Female gender 1 1 3.2 1.95-5.26 <0.0001 Prior CABG 2 2 6.1 3.63-10.05 <0.0001 Cardiogenic shock 3 3 11.2 2.78-41.2 0.0011 Clinical risk score assigned to each of the 3 variables represents model coefficient (rounded to whole unit).
  12. 12. ALL COMERS TRA-PCI FAILURE RATE ACCORDING TO RISK SCORE (C-INDEX: 0.7658, 95% CI: 0.759-0.760)
  13. 13. CONCLUSIONS-1 • In a setting that promotes TRA as default access site, TRA-PCI can be successfully performed in > 95% of all cases • 2.7% of all comers are excluded from TRA due to clinical reasons • 1.8% crossover rate- much lower than previously reported • Principal cause of crossover failure = inability to gain radial access
  14. 14. TRA-PCI FAILURE RISK SCORE IN STEMI The STEMI TRA-PCI Risk Score From an idea of Eltigani Abdelaal
  15. 15. RESULTS • Consecutive STEMI patients over 4 years= 2020 patients (including cardiogenic shock) • Primary TRA-PCI failure occurred in 111 (5%) patients • Crossover TRA-PCI failure occurred in 44 (2.2%) patients. E. Abdelaal et al. 2013 (submitted)
  16. 16. Independent predictors of TR-PCI failure in STEMI patients Integer Score Model coefficient OR 95% CI P-value Age ≥ 75 years 1 0.551 1.7 1.0 - 2.9 0.031 Weight ≤ 65 kg 1 1.0963 3 1.9 - 4.8 <0.0001 Creatinine > 133 μmol/L 1 1.29 3.6 1.9 - 6.8 <0.0001 Hypertension 1 0.6112 1.8 1.2 -2.9 0.0094 Prior PCI 1 0.9515 2.6 1.5 - 4.5 0.0009 Cardiogenic shock 1 1.0445 2.8 1.4 - 5.6 0.004 IABP 1 0.7107 2 0.9 - 4.3 0.06 Physician with ≤5% rate of TFA -1 -0.7955 0.45 0.21 - 0.90 0.03 Physician with ≥10% rate of TFA +1 0.7785 2.2 1.2 -3.7 0.005 5 4.6764 107 41.6 -339 <0.0001 Variable Intubation Integer score assigned according to coefficient
  17. 17. % of TRA and TFA in STEMI for 12 operators during study period 100 % TRA % TFA 15.2 13.6 9.8 9.5 8.4 1 2 3 4 5 7.2 6.7 6.6 5.9 5.7 4.8 2.6 8 9 10 11 12 90 80 70 60 % 50 40 30 20 10 0 6 7 Operator
  18. 18. THE STEMI TRA-PCI RISK SCORE • Shock • Tube (inTubation) • wEight (≤ 65 kg) • balloon puMp • creatInine >133 μmol/L • hyperTension • Radialist factor • Age (≥ 75 years) • prior PCI
  19. 19. The STEMI TRA-PCI Risk Score RANGE FROM -1 TO 12 C-Index: 0.868, 95%CI: 0.866-0.869)
  20. 20. CONCLUSIONS • Incidence of overall TRA-PCI failure in a default radial center is very low • Overall < 10% • A novel simplified risk score for TRA-PCI failure in STEMI consisting of 9 readily available variables has been developed and internally validated • FAILURE score = female, CABG, shock • STEMI-TRA PCI score = Shock, Tube, wEight, puMp, creatInine, hyperTension, Radialist, Age, prior PCI.

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