Anticipating Failure:ROLE OF ARM IMAGING PRIOR TO ARTERIAL ACCESS Sanjay Chugh MD(Cal.),DM (AIIMS), MRCP(I), FACC, FSCAI(USA) Principal Consultant, Interventional Cardiology, Fortis Escorts Heart Institute, New Delhi, India
Conflict of Interest StatementWithin the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliationwith the organization(s) listed below.Physician Name Company/Relationship NONE NONE
There`s been a paradigm shift in interventional Cardiology to transradial access because of…. ↓ VASCULAR COMPLICATIONS ↑PATIENT COMFORT
BUT IF PATIENT INTEREST IS SUPREME THEN……• IS A TRIAL & ERROR APPROACH by operators on their Radial Learning Curve justified even at the expense of ↑ procedure failure, complications and patient inconvenience?
A SCIENTIFIC APPROACH TO ↓TRIAL & ERROR in THE LEARNING CURVE& HENCE CROSS-OVER, RADIATION TIME, PATIENT DISCOMFORT & PROCEDURE FAILURE Is therefore needed
So What`s the trial & error about ? In the `Learning Curve` which may lead to TR Procedure failure (~5%)• ACCESS RELATED 52.6%(Guedes et al, J INVASIVE CARDIOL 2010;22:391–7)• Inability to advance guide catheter to ascending aorta 51% ( Dehghani P et al(JACC Cardiovasc Interv. 2009 ;2(11):1057-64.)• RADIAL ARTERY SPASM 38% (Circ Cardiovasc Interv. Ball WT, et al2011e pub)
SIZE MATTERS……•PUNCTURING SMALL ARTERIES IS MORE DIFFICULT!•SPASM IS MORE IN SMALLER ARTERIES “ predictors of failure= "small radial artery" size (OR 2.6, 95% CI 1.4 to 5.0; p = 0.003) or a "difficult access" (OR 2.5, 95% CI 1.3-4.9; p = 0.006)”. Guedes et al, 1.7 mm Radial artery RA spasm J INVASIVE CARDIOL 2010;22:391–397
SHORT STATURE (OR:0.97; 95% CI: 0.95 to 0.99, p = 0.02) & AGE>75 (odds ratio [OR]: 3.86; 95% confidence interval [CI]: 2.33 to 6.40, p = 0.0006) = INDEPENDENT PREDICTORS OF FAILURE 142 cm 36 kg 1 mm; R Ao root 1.2 mm U 2.4cm 1.4 mm R; 1.5 mm U SCAI 2011 Dr Sanjay Chugh. Guide Cath selection for Transradial PCI
Is it okay to shove any size Guiding Catheter into any Radial artery ?eg A 7F GUIDE INTO A 1.7 mm ARTERY ?
Of course not! (SHEATH / GUIDING ) > 1:1 : (RA) initiates spasm SPASM MAKES CATHETER MANIPULATION DIFFICULT---> Saito et al.CCI 46, 1999:173 LEADS TO RADIAL OCCLUSION
HOW DO WE DECIDE IF THE ARTERY IS BIG ENOUGH TO SAFELY TAKE WHAT YOU WANT TO SHOVE INTO IT ? SIZE IT
RA Sizing ASE 2007SCAI 2011 Dr Sanjay Chugh. Guide Cath 13 selection for Transradial PCI
FAILURE: (1) SMALL ARTERY SIZE AND SPASM : (2) LOOPS / ANOMALIES/ STENOSIS •7% of procedural failure& CROSSOVER (Jolly SS, et alAm Heart J. 2009 Jan;157(1):132-40 in transradial intervention is due to radial artery tortuosity, loops, or stenosis (Dehghani P ,et al.JACC Cardiovasc Interv. 2009 BRACHIAL Nov;2(11):1057-64.) ULNAR RADIAL•Inability to advance the wire or catheter through the brachial artery accounts forup to 73% of procedural failure (Guedes et al, JIC 2010).
CAN WE ANTICIPATE FAILURE & HENCEENHANCE SUCCESS BY AVOIDING THESE BY PRE-PROCEDURE IMAGING?
YES, BY KNOWING THE HAND BEFORE-HAND ! ENHANCE SUCCESS BY ANTICIPATING FAILURE
Feasibility and Utility of Pre-procedure Ultrasound Imaging ofthe Arm to facilitate Trans-Radial Coronary Diagnostic and Interventional Procedures. TCT 2011 (In Press)
• Pre-procedure ultrasound assessment of the Right and Left Radial, Ulnar, andBrachial arteries, using a linear probe in all patients.• Endpoints: Incidence and Correlates of : * Arterial anomalies * Procedure success * Crossover to alternate access * Fluoroscopy time * Ultrasound assessment time.• Patient Demographics, Medical history, and Procedural characteristics , angiographic assessment of arm arteries were recorded
• Prospective Single center Registry• Consecutive patients undergoing diagnostic and interventional procedures (2006 to 2011).• Institutions: Fortis Escorts Heart Institute New Delhi, (including Fortis Escorts Kalyani Heart Centre, Gurgaon) India,
While radial artery loops and tortuosity may beeasily traversed with 0.014” guidewires, doing soincreases procedure time and radiation exposureto the patient and operator, and also may result insignificant spasm and discomfort for the patient.
Stenosis in upstream RA can cause procedural delay or failure & crossover (CAN BE PICKED UP BY DOPPLER PRE-PROCEDURE)PLETHYSMOGRAPHY MAYNOT PICK THIS UP! Stenosis in Radial artery------------------ Why diversify ?
NEVER NEEDED TO LOOK FOR UPSTREAM OBSTACLES EXCEPT ONCEBECAUSE WE WERE IN AN ACCESSORY SMALL RADIAL INSTEAD OF ULNAR ARTERY
Access Artery (Radial/Ulnar) Selection for Angiogram or PCI (BRACHIAL NEVER USED)• 5F in ≥ 1.6mm for angio; 6F≥1.8 mm for PCIKnowledge of the arm anatomy allowed us to choose :• The Biggest artery• Without anomaly/abnormality
PREFERENCE ORDER FOR ACCESS SIDE• RIGHT SIDE PREFERRED IN MOST• LEFT ACCESS PREFERRED in PCI to Shepherd crook/ tortuous/ calcific RCA• Access opposite to arm with previous injuryscar/fracture /Venous cannula/phlebitis
PREFERENCE ORDER FOR CHOICE OF ACCESS ARTERY (RRA >LRA>RUA>LUA)• RADIAL OVER ULNAR• ULNAR PREFERRED only IF *LOOP OR PARALLEL RADIAL & ULNAR *IF BOTH RADIALS WERE SMALL (PROVIDED ULNAR CONSIDERED EASY TO COMPRESS MANUALLY FOR HEMOSTASIS)• Groin was used if both arteries in both arms were unsuitable because of small size or anomaly.
Aortic root 3.8 cm LT RADIAL 1.8 Cm ULNAR 2.1 CmRt Radial 1.8 cmUlnar 1.7 cm
Spasm was recorded as per the following grades:• Grade-4: Severe pain and spasm disallowing any catheter movement necessitating crossover.• Grade-3: Moderate pain and spasm restricting catheter movement & necessitating a pause in procedure and > 2 doses of additional intra- arterial Diltiazem or Verapamil> 5mg and/ or > 1 mg of intravenous Midazolam .• Grade-2: Mild pain and spasm not restricting catheter movement ; no pause in procedure but > 1 dose of (additional) intra-arterial Diltiazem (or Verapamil) of 5mg and / or 0.5 mg of intravenous Midazolam .• Grade-1: Mild pain and spasm not restricting catheter movement ; no pause in procedure and only 1 dose of either or both intra-arterial Diltiazem (or Verapamil) of 5mg and/or > 0.5 mg of intravenous Midazolam.
Illustration-5 N=6125 Presented for Angiogram/PCI* (2006- 2011) 2344 Complete ultrasound data on arm arteries 12.9% (n=279) unsuitable 8.9% (n=193) unsuitable for trans- radial / trans- for even for an angiogram Remaining 1872 patientsulnar PCI*(because of small underwent a transradial / because of small radial &diameter of bilateral radial transulnar procedure Ulnar arteries and ulnar arteries) *PCI=Percutaneous Coronary Intervention
PATIENT DEMOGRAPHICS1.Sex 1179(63%) M; 693(37%) F2.Mean age (yrs) 51.6 (±23.7)RISK FACTORS1.Diabetic 569(30.4%)2.Tobacco abuse 624(33%)3.Hypertensive 649(34.6%)4.Dyslipidemia 702(37.5%)•
CLINICAL DIAGNOSISStable Angina including 711(38%)Post MI *& patients with positiveStress testUnstable Angina/ACS 1161(52%)
ARM IMAGING (ULTRASOUND) TIME• The mean time (bilateral forearm )= 6.4 min ± 1.8min(95% confidence interval).
Our ultrasound strategy only required a minimum of effort and time• 62% in the inpatient setting (Coronary care Unit and Wards);• in 33% patients our protocol could be implemented on the day of the procedure in the pre-procedure area.• 5% of the ultrasound studies were performed in the clinic setting
Doppler assessment of anomaly was accurate in all cases onCOMPARISON WITH ANGIOGRAPHIC ASSESSMENT
SIZE OF RADIAL & ULNAR ARTERY ON THE 2 SIDESSIZE OF RADIAL & ULNAR ARTERY MEANON THE 2 SIDES Diameter (mm)Left Radial Artery Male 1.8±0.29 Female 1.7±0.26Left Ulnar Artery Male 1.8±0.30 Female 1.7±0.3Right Radial Artery Male 1.9±1.12 Female 1.7±0.29Right Ulnar Artery Male 1.8±0.30 Female 1.6±0.28
Table-II: +ve Correlations of Radial artery with Ulnar artery size Left Radial Artery Left Ulnar ArteryLeft Radial Artery Pearson Correlation 1 .404(**) Sig. (2-tailed) 0.000Left Ulnar Artery Pearson Correlation .404(**) 1 Sig. (2-tailed) 0.000 **. Correlation is significant at the 0.01 level (2-tailed). Right Radial Artery Right Ulnar Artery Right Radial Artery Pearson Correlation 1 .416(**) Sig. (2-tailed) 0.000 Right Ulnar Artery Pearson Correlation .416(**) 1 Sig. (2-tailed) 0.000
Table III- 9.8 % Incidence of Anomalies in Radial Artery in the study populationAnomalies Radial ArteryIntimal thickness 3.6%Parallel Radial and Ulnar suggesting 4.7%possibility of high origin of radialfrom Brachial or Radioulnar loop orsimilar anomalyLoop seen at Cubital Fossa 0.9%Blocked artery 0.6%
LIMITATION-1• We did not randomize patients to an ultrasound-based strategy or usual care; therefore, our comparisons of radiation times , procedure success and access site crossover are with the published literature rather than direct comparison
A journey of a 1000 miles begins with the 1st step…..• The purpose of our study was to describe our experience, which is the first using a routine pre-procedure ultrasound evaluation of the arm arterial structures.
LIMITATION-2• One operator performed all of the ultrasound procedures, and• One separate operator performed all of the coronary procedures.• It is difficult to generalize our results to other operators who may have varying levels of experience with ultrasound imaging or radial procedures.
COST IMPLICATIONS• Cost -effectiveness OF PRE-PROCEDURE ARM IMAGING was not studied.• THE COST OF PRE PROCEDURE ULTRASOUND MAY BE OFFSET BY REDUCTION IN RADIATION TIME, PROCEDURAL COMPLICATIONS & FAILURE
Impact on RA /UA Occlusion• not tested in our study,• is being done as a part of an on going study at our Institution..
This single center prospective registry showsPRE-PROCEDURE ULTRASOUND IMAGING OF ARM ARTERIAL STRUCTURES IS *FEASIBLE, **REQUIRES MINIMUM TIME AND EFFORT, ***PROVIDES INFORMATION ON ARTERIAL SIZE AND ANATOMICAL VARIANTS ****THUS FACILITATING TR & TU PROCEDURES & REDUCING SPASM, CROSSOVER, PROCEDURE FAILURE & PT .DISCOMFORT
RANDOMIZED STUDY NEEDED BUT…. WOULD I EVER DO A TRANSRADIAL WITHOUT PRE-PROCEDURE ARM IMAGING; NEVER !