Anticoagulation Strategies for Transradial Diagnostic and Interventional Cases Tift Mann, MD, FACC
Disclosure Statement of Financial InterestI, Tift Mann, DO NOT have a financialinterest/arrangement or affiliation withone or more organizations that could beperceived as a real or apparent conflict ofinterest in the context of the subject ofthis presentation.
Heparin must be administered for all transradial procedures 1002mo radial occlusion 80 71% 60 40 24% 20 4% 0 No Heparin UFH 2000-3000 UFH 5000 Spaulding et al CCVD 39:365 (1996)
IA vs IV heparin:No difference in incidence of RAO Pancholy. Am J Cardiol 2009; 104: 1083
Bivalirudin vs heparin:No difference in RAO Plante et al. CCVI 2010; 76:654
What anticoagulation strategy should be used for ad hoc TRI? 1. Increase the total heparin dose to 80-100 units/kg 2. Switch to bivalirudin
Transitioning to bivalirudin in ad hoc transradial procedures: divide the heparin dose• Divided dosing with unfractionated heparin should provide the same protection against post- procedure radial occlusion as the standard 5000 unit single dose if diagnostic only procedure .• The safety profile of bivalirudin should not be altered if it is given after an initial reduced heparin dose should PCI be required.
Transitioning to bivalirudin in ad hoc transradial procedures Venkatesh K et al. JIC 2006;18:120
Does TRI and Bivalirudin combination reduce all procedure-related bleeding?
Site of Bleeding Complications in Patients Undergoing PCI Rao, et al. J Am Coll Cardiol 2010;55:2187-2195
R I V A L Site of Non-CABG Major Bleeds (RIVAL definition) *Sites of Non Access site Bleed: Gastrointestinal (most common site), ICH, Pericardial Tamponade and Other
Eurovision: Bivalirudin monotherapy in PCI Bleeding Outcomes Femoral Radial P-value (n=1353) (n=580) Major Bleeding 1.7% 1.2% 0.4216 Minor Bleeding 4.8% 1.9% 0.0026 Thrombocytopenia 0 0 Any bleeding 8.0% 4.5% 0.0055 Access Site Bleed 3.6% 1.0% 0.0017 Non-Access Site Bleed 1.6% 0.9 0.1897 Hamon et al, TCT 2011
EArly Discharge After Transradial Stenting of CoronarY Arteries inHigh–Bleeding-Risk Patients Using Bivalirudin to Reduce Bleeding EASY-B2B Study Pts with increased bleeding risk undergoing TR PCI randomized to Heparin vs Bivalirudin Bertrand et al
R I V A L Definition: Major Bleeding Fatal > 2 units of Blood transfusion Hypotension requiring inotropes Requiring surgical intervention ICH or Intraocular bleeding leading to significant vision loss
R I V A L Definition: Major Vascular Access Site Complications •Large hematoma • Pseudoaneurysm requiring closure • AV fistula • Other vascular surgery related to the access site • Blood txf 1 unit
R I V A L “Other” Outcomes Radial Femoral (n=3507) (n=3514) HR 95% CI P % %Major VascularAccess Site 1.4 3.7 0.37 0.27-0.52 <0.0001ComplicationsACUITY Non-CABG 1.9 4.5 0.43 0.32-0.57 <0.0001Major Bleeding
R I V A L Results stratified by High*, Medium* and Low* Volume Radial Centres *High (>146 radial PCI/year/ median operator at centre), Medium (61-146), Low (≤60)Tertiles of Radial PCI Centre Volume/yr HR (95% CI) p-value Primary Outcome Interaction High 0.021 Medium Low Death, MI or stroke High 0.013 Medium Low Non CABG Major Bleed High Medium 0.538 Low Major Vascular Complications High 0.019 Medium Low Access site Cross-over High 0.003 Medium Low 0.25 1.00 4.00 16.00 Radial better Femoral better
Risk of death for up to 1 year:transfemoral vs. transradial access site Adjusted OR (95% CI) 0.78 (0.64-0.96) P= 0.018 From SCAAR registry, EuroPCR, 2011
What is the strategy for patients oncoumadin undergoing TR procedures?
Transradial access in the fully anticoagulated patient N=66 No major bleeding Hildick-Smith et al CCVI 58:8,2003
TR Access in pts receiving coumadin INR 2.4 INR 1.4 Sanmartin et al. Rev Esp Cardiol. 2007;60:988
CONCLUSION: Transradial access provides asafety margin for interventional procedures
Radial vs. Femoral AccessMAJOR BLEEDING DEATH / MI / STROKE Jolly et al. Am Heart J 2009
Abciximab in pts with transradial access N=504 N=501 Bertrand et al. Circ 2006;114:2636
Risk of death for up to 30 days:transradial vs. transfemoral access site (male vs. female) Favors Radial Favors Femoral OR 95% CI 0.66 (0.51-0.86), p=0.002 0.78 (0.64-0.97), p=0.022
Risk of death for up to 30 days:transradial vs. transfemoral access site (by age) Favors Radial Favors Femoral OR 95% CI 0.59 [ 0.45-0.78] 0.70 [0.53-0.93] 1.12 [0.78- 1.61] 0.84 [0.50-1.42]