Adoption of transradial approach in Italy: current practice - Stefano Rigattieri

1. Adoption of TRA in Italy:
current practice
Stefano Rigattieri, MD, PhD
Interventional Cardiology Unit
«Sandro Pertini» Hospital, Rome, Italy

2. • None related to this presentation
Disclosures

3. GISE activity data; www.gise.it
Vascular access in Italy 2010-2016
(all interventional cardiology procedures)
TRA rate 75%

4. Vascular access in Italy 2013-2016
(PCI)
GISE activity data; www.gise.it

5. • The survey was endorsed by the Italian
Society of Invasive Cardiology (SICI-
GISE) and the Italian Radial Club, an
association of interventional
cardiologists devoted to the practice of
TRA
• Time frame: July to September 2016
• Web-based (SurveyMonkey platform)
• Invited participants: SICI-GISE members
(invitation by mailing list)
• Respondents: 508 (out of about 1500)
• Question number: 35
• Average rate of response: 97% (range
87-100)
The Italian Survey on TRA for coronary procedures
51%
22%
27%

6. 0 10 20 30 40 50 60
<50
50-99
100-150
>150
%
Number of PCI/operator/year
0 10 20 30 40 50 60 70
<10
10-49
50-80
81-90
>90
%
%
Rate of transradial procedures
0 20 40 60 80 100
>10%
5-10%
1-4%
<1%
%
Rate of transulnar procedures

7. 81%
12%
7%
Preferred side for TRA
right left left in elderly, right in young
27%
4%
69%
Evaluation for TRA
Allen test Barbeau test Only palpation of the pulse
77%
23%
How to stick the radial
Needle Cannula over needle

8. 1%
16%
83%
Sheath size for diagnostic angio
4 French 5 French 6 French
0 10 20 30 40 50 60 70 80
non hydrophilic < 10 cm
non hydrophilic > 10 cm
hydrophilic < 10 cm
hydrophilic > 10 cm
%
Preferred sheath type
8%
47%
45%
Heparin dose for diagnostic angio
no heparin 2500 IU 5000 IU
0 10 20 30 40 50
cocktail (N+V, other)
nitrates
verapamil
no
%
Use of spasmolytic drugs

9. 11%
4%
85%
Choice of diagnostic catheters
single dedicated TRA
catheter (e.g. Tiger,
Jacky)
single non-dedicated
catheter (e.g. Amplatz
left, MP)
Judkins catheters
0 20 40 60 80 100
Sheathless 7,5 French
Sheathless 6,5 French
5 French
6 French
%
Default sheath for PCI
0 20 40 60 80 100
Dedicated TRA
other (e.g. Amplatz)
Judkins
Extra backup
%
Preferred guiding catheter for left
coronary PCI
0 20 40 60 80 100
dedicated TRA
Other (Hockey stick, 3DRC)
Amplatz
Judkins
%
Preferred guiding catheter for
right coronary PCI

10. 0 10 20 30 40 50 60
acute coronary syndrome
primary PCI
frail patients, elderly, low BMI
severe CKD/haemodialysis
shock/hemodinamic instability
TRA no limits
%
When not to use TRA
0 10 20 30 40 50 60 70
ipsilateral brachial
ipsilateral ulnar
femoral
contralateral TRA
%
Second preferred access if need for
crossover
0 20 40 60 80 100
Right TRA
Bilateral TRA
Left TRA
Femoral
%
Preferred access in the case of
bilateral ITA grafts

11. 0 5 10 15 20 25 30
Sheathless 6,5 Fr
Sheathless 7,5 Fr
Slender 7-in-6 system
>6 Fr system
shift to femoral
6 Fr system
%
How to manage complex PCI (left
main, rota, 2-stent bif)
0 5 10 15 20 25 30 35 40 45
bilateral TRA also for retrograde PCI
bilateral TRA but only for antegrade PCI
femoral
femoral + ancillary radial (contralateral injection)
%
TRA and CTO

12. 42%
40%
18%
Vascular access and perceived
patient RX exposure
right TRA left TRA femoral
23%
75%
2%
Vascular access and perceived
operator RX exposure
right TRA left TRA femoral
65%
16%
19%
Use of additional protective drapes
(e.g. RADPAD®)
never occasionally routinely

13. 0 10 20 30 40 50 60 70
Quik Clot®
other
RadiStop™
Compression bandage
TR band®
%
Preferred techniques for hemostasis
0 10 20 30 40 50 60
Reverse Allen
echo-doppler
none
palpation
%
Check of radial artery patency post-cath
13%
21%
66%
Coronary procedures and same-day
discharge
both diagnostic and PCI
only diagnostic
no
8%
92%
Patent hemostasis
yes
no

14. Bertrand et al. 2010 Rigattieri et al. 2017
N of respondents 1107 508
Countries 75 1
Right TRA (%) 90 81
Puncture with bare needle 60 77
Assessment of dual hand
circulation (%)
77 31
Crossover to contralateral
radial (%)
31 57
Crossover to femoral (%) 54 41
Use of spasmolytics (%) 86 59
Sheath size Mostly 6 Fr Mostly 6 Fr
Routine assessment of RA
occlusion (%)
69 58
Same-day discharge (%) 48 34
Bertrand et al. JACC Intv 2010;3:1022-31
Rigattieri et al. Cardiovasc Revasc Med 2017;18:154-9

15. CONCLUSIONS:
• TRA for coronary procedures is widely adopted in Italy, whereas transulnar approach is rarely
used
• The majority of operators do not perform assessment of dual-hand circulation (Valgimigli et
al. JACC 2014)
• Heparin anticoagulation is suboptimal (Rashid et al. JAHA 2016)
• Patent hemostasis using Barbeau’s test (Pancholy et al. CCI 2008) is rarely used
• Complex PCI is managed by TRA especially using new devices allowing larger working lumen
(sheathless and slender systems)
• Complex CTO procedures (especially retrograde) still represent an issue for TRA (conflicting
data reported by Tanaka et al. JACC Intv 2017 and RECHARGE registry, Circ Cardiovasc Interv
2017)
• Most operators are concerned about radiation exposure with TRA (Sciahbasi et al. JACC 2017)
yet only a minority of them use additional protections
• TRA in severe kidney disease is an issue for about 1/5 of respondents and must be addressed;
in US the National Kidney Foundation strongly recommends against the use of TRA in this
subset of patients in order to avoid risk to arteries which may be needed for future
arteriovenous dialysis access (K/DOQI clinical practide guidelines for vascular access, Am J
Kidney Dis 2006)