Why not radial in 100% of the cases

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. DISCLOSURES
•
Scientific Director of International Chair in Interventional Cardiology and
Transradial Approach
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operates www.theradialist.org &
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organizes AIM-RADIAL congress
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Chair receives funding from multiple industry and other sources
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No salary or honorarium received from the chair

3. “Radialist” Feeling After
Radial Access Failure...

4. INTRODUCTION
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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. OBJECTIVES
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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. METHODS
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All comers Score:
•
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Consecutive patients who underwent PCI at Québec heart- lung
institute between January-June 2010, irrespective of the indication.
N=1654
STEMI Score:
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Consecutive STEMI patients 2006-2011- N=2020
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Exclusion criteria: None
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Baseline characteristics and, procedural data, and, if any, need and reason
for access site crossover, clinical outcomes.
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Operators: 6 fellows 12 interventional cardiologists

7. METHODS
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TRA-PCI failure was categorized 2 groups:
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Primary TRA-PCI failure when TFA was chosen as
initial access for any clinical reason (no radial puncture
attempted)
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Crossover TRA-PCI failure, due to inability to
complete the PCI procedure via TRA, requiring access site
crossover to TFA

8. METHODS
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Independent predictors of TRA-PCI failure from multivariate
model
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Risk score: each independent variable assigned a weighted
integer score
•
C-index and Bootstrapping (95% CI)

9. ACCESS SITE FLOW CHART, PRIMARY AND CROSSOVER
Primary
2.7%
Crossover
1.8%
E. Abdelaal et al. 2013 (submitted)

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. 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. ALL COMERS
TRA-PCI FAILURE RATE ACCORDING TO RISK SCORE (C-INDEX: 0.7658, 95% CI: 0.759-0.760)

13. CONCLUSIONS-1
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In a setting that promotes TRA as default access site, TRA-PCI can be
successfully performed in > 95% of all cases
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2.7% of all comers are excluded from TRA due to clinical reasons
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1.8% crossover rate- much lower than previously reported
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Principal cause of crossover failure = inability to gain radial access

14. TRA-PCI FAILURE RISK SCORE IN STEMI
The STEMI TRA-PCI Risk Score
From an idea of Eltigani Abdelaal

15. RESULTS
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Consecutive STEMI patients over 4 years= 2020 patients
(including cardiogenic shock)
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Primary TRA-PCI failure occurred in 111 (5%) patients
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Crossover TRA-PCI failure occurred in 44 (2.2%) patients.
E. Abdelaal et al. 2013 (submitted)

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. % 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. THE STEMI TRA-PCI RISK SCORE
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Shock
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Tube (inTubation)
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wEight (≤ 65 kg)
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balloon puMp
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creatInine >133 μmol/L
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hyperTension
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Radialist factor
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Age (≥ 75 years)
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prior PCI

19. The STEMI TRA-PCI Risk Score
RANGE FROM -1 TO 12
C-Index: 0.868, 95%CI: 0.866-0.869)

20. CONCLUSIONS
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Incidence of overall TRA-PCI failure in a default radial center is very low
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Overall < 10%
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A novel simplified risk score for TRA-PCI failure in STEMI consisting of 9
readily available variables has been developed and internally validated
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FAILURE score = female, CABG, shock
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STEMI-TRA PCI score = Shock, Tube, wEight, puMp, creatInine,
hyperTension, Radialist, Age, prior PCI.