Chevalier B

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Transradial Intervention in Chronic kidney Disease (CKD) Patients

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Chevalier B

  1. 1. TRI in Chronic KidneyDisease (CKD) Patients Bernard Chevalier ICPS Massy FRance Chamonix – Mont-Blanc 1-2 Avril 2011
  2. 2. SPECIFIC FEATURES OF CAD IN CKD PTSPCI IN CKD PTSRENAL PROTECTION FOR CKD PTS
  3. 3. CKD (GFR<60): A risk factor Insuffisance Rénale Dialysée•  HTN, LVH, CHF•  >35% of CKD pts have evidence of ischemic disease at the time of presentation to nephrologist•  Prognosis is mainly related to the severity of atheroma before End-Stage Renal Disease (ESRD)•  Importance of ischemia detection
  4. 4. Athérosclérose AccéléréeNot specific risk factors •  Age •  Male gender •  HTN •  Diabetes •  Dyslipidemia •  Smoking Specific risk factors: •  Hyperparathyroidism • Hyperphosphatemia •  Anemia • Hyperhomocystéinémy •  Oxidative stress • Inflammation • Renin-angiotensin activation
  5. 5. Inflammation-Thrombose 5888 pts > 65 ans, 647 pts(11%) Insuffisants rénaux M.G. Shlipak et al, Circulation 2003;107:87-92
  6. 6. CKD: a predictive factor for CAD outcome•  3 times higher 1y mortality in AMI (Shlipak et al)•  6 times higher 6 m mortality in GUSTO/ PURSUIT/PARAGON (Suwaidi et al.)•  Higher impact in young CKD patients•  Part of GRACE score with –  HR 2.09 for GFR between 30 & 60 (stage 3) –  HR 3.71 for GFR < 30 (stage 4&5)
  7. 7. CKD: impact on treatment•  In case of ACS, CKD pts –  Are underdiagnosed –  Receive less « guidelines » medications –  Have more limited access to angiography –  Get less PCI –  Have less secondary prevention medication•  However PCI pts have similar longterm decrease of renal function than medically treated pts
  8. 8. Coronary disease in ESRD•  Cardiovascular disease is the leading cause of mortality•  10 times risk than 5 Framingham RF pts!
  9. 9. Survie chez les patients dialysés Sarnak MJ. Circulation 2003;108:2154-69
  10. 10. Vascular calcification•  Consequence of bone mineral disorder•  Accelerated on dialysis patients•  Possible ways to limit: –  Dialysis protocol, low dose Vit D regimen, sevelamer•  Has direct impact on –  Quality of PCI (plaque modification/stent deployment) –  Quality of hemostasis at vascular access
  11. 11. ATHEROME de l’INSUFFISANT RENALPCI in CKD PatientsRISQUE et PREVENTION dud’INSUFFISANCE RENALE enCARDIOLOGIE INTERVENTIONNELLE
  12. 12. Higher number of PCI•  Severity of disease & crucial role of PCI•  Higher rate of recurrence after DES
  13. 13. Bleeding risk of PCI in CKD
  14. 14. Bleeding profile
  15. 15. Yatskar L, Catheterization and Cardiovascular Interventions 69:961–966 (2007)
  16. 16. Bleeding in all comers
  17. 17. Impact of In-Hospital Major Bleeding onEarly and Late Mortality in REPLACE-2 Stone GW J Invas Cardiol 2004, 16(suppl G): 12G-17G
  18. 18. Adverse effect of transfusion?
  19. 19. Pros TRI in CKDLess bleeding / Less renal event
  20. 20. P. Agostoni JACC 2004; 44:349-56
  21. 21. Cantor W, Catheterization and Cardiovascular Interventions 69:73–83 (2007)
  22. 22. Primary Angioplasty Moins de Complications Locales 20 p < 0.01Acces Site Complications (%) 15 p < 0.05 10 p < 0.05 5 0 TRA FA Perclose FA Manual Y. Louvard et al. CCVI 2002; 55: 206-211
  23. 23. Vuurmans T, Heart 2010;96:1538-1542.
  24. 24. Vuurmans T, Heart 2010;96:1538-1542.
  25. 25. Vuurmans T, Heart 2010;96:1538-1542.
  26. 26. Cons for TRI in CKD Radial occlusion
  27. 27. Radial in ESRD?•  Vascular access is the lifeline !•  Native AV Fistula > Prothetic graft > central venous catheter –  Impact on prognosis•  Non maturation 20 to 50% (artery diameter > 2 mm, more predictable in forearm)•  Venous neointimal hyperplasia (vein quality) alters patency: 12 to 18 months•  Forearm AV fistula are the best ones (?)
  28. 28. Sheath/artery ratio
  29. 29. COMPRESSION RADIALE-  300 patients-  Compression with elastic dressings as shorter as possible-  Doppler evaluation-  Early results: 4 radial occluded (1.3%) :-  Late results: about 270 patients •  any new occlusion after hospital discharge •  about 4 initial occlusions : 3 spontaneous recanalization and 1 persistent less than 1% radial occlusion rate Monségu Ann Cardiol Angeiol 2003; 52: 135-8
  30. 30. Relationship between compression and radial occlusion Radial patent Radial occlusion p 10.5%No flow before 49% 54% 0.41sheath removalNo flow after 63% 66% 0.49placingcompressionNo flow before 54% 90% 0.002compressionremoval Sanmartin Catheter Cardiovasc Interv 2007; 70: 185-9
  31. 31. Radial artery occlusion Pancholy J Invasive Cardiol 2009; 21: 101-4
  32. 32. Tips & tricks for TRI in severe CKD (stage 4 & 5 = GFR < 30)•  Vascular calcification + HTN = loops +++ –  Prefer left radial?•  Never use a sheath larger than radial artery –  5F PCI or sheathless 6F –  4F?•  Keep always one radial artery free of puncture –  If possible the one with best venous system•  Apply good hemostasis technique
  33. 33. ATHEROME de l’INSUFFISANT RENALRISQUE SAIGNEMENT etVOIE d’ABORD RADIALERENAL PROTECTION for CKD patients
  34. 34. 1. HYDRATION - 100 ml/h Nacl 0.9%/bicarbonate 14/1000 4 h avant examen - 1000 ml sérum 0.9%/bicarbonate 14/1000 24h après examen2. Low osmolarity contrast media3. Contrast load < 4 x GFR
  35. 35. CKD patients•  Are highly exposed to CAD•  Have a specific vascular atheroma•  With a higher risk of suboptimal result of PCI with more restenosis risk•  And higher bleeding complications related to access site•  Leading to a high number of coronary interventions
  36. 36. The choice of TRI•  Limits bleeding & renal events with significant impact on outcome•  Is possible in pts not yet on dialysis using very strict rules particularly for ESRD•  Could be considered with a lot of caution to avoid impairment of existing and future AV fistula•  Femoral route is a back-up choice using closure device

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