Mann T 201111

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Anticoagulation Strategies for Transradial Diagnostic and Interventional Cases

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Mann T 201111

  1. 1. Anticoagulation Strategies for Transradial Diagnostic and Interventional Cases Tift Mann, MD, FACC
  2. 2. 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.
  3. 3. 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)
  4. 4. Bernat et al, AJC 2011
  5. 5. IA vs IV heparin:No difference in incidence of RAO Pancholy. Am J Cardiol 2009; 104: 1083
  6. 6. Bivalirudin vs heparin:No difference in RAO Plante et al. CCVI 2010; 76:654
  7. 7. 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
  8. 8. 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.
  9. 9. Transitioning to bivalirudin in ad hoc transradial procedures Venkatesh K et al. JIC 2006;18:120
  10. 10. Does TRI and Bivalirudin combination reduce all procedure-related bleeding?
  11. 11. Site of Bleeding Complications in Patients Undergoing PCI Rao, et al. J Am Coll Cardiol 2010;55:2187-2195
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. What is the strategy for patients oncoumadin undergoing TR procedures?
  21. 21. Transradial access in the fully anticoagulated patient N=66 No major bleeding Hildick-Smith et al CCVI 58:8,2003
  22. 22. TR Access in pts receiving coumadin INR 2.4 INR 1.4 Sanmartin et al. Rev Esp Cardiol. 2007;60:988
  23. 23. CONCLUSION: Transradial access provides asafety margin for interventional procedures
  24. 24. Radial vs. Femoral AccessMAJOR BLEEDING DEATH / MI / STROKE Jolly et al. Am Heart J 2009
  25. 25. Abciximab in pts with transradial access N=504 N=501 Bertrand et al. Circ 2006;114:2636
  26. 26. 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
  27. 27. 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]
  28. 28. Results Outcome Transfemoral Transradial P value OR Adjusted OR (%) (%) (95 % CI) (95 % CI)N = 21 339Measured Variable:30 day mortality event/N (%) 667/15290 (4.4) 193/6049 (3.2) <0.001 0.72 (0.61-0.85) 0.57 (0.46-0.72)1 year mortality event/N (%) 982/13446 (7.3) 260/4175 (6.2) 0.018 0.84 (0.73-0.97) 0.78 (0.64-0.96)Male: 30 day mortality/N (%) 120/4396 (2.7) 373/10797 (3.5) 0.022 0.78 (0.64-0.97)Female: 30 day mortality/N(%) 73/1653 (4.4) 294/4493 (6.5) 0.002 0.66 (0.51-0.86)Any reported bleeding event/N(%) 495/14953 (3.3) 88/5866 (1.5) <0.001 0.45 (0.35-0.56) 0.43 (0.31-0.61)Serious bleeding event/N (%) 335/14953 ( 2.2) 58/5866 (1.0) <0.001 0.44 (0.33-0.58) 0.43 (0.32-0.57)Hospital stay Days mean(SD) 5.2 (6.3) 4.8 (5.1) <0.001 From SCAAR registry, EuroPCR, 2011
  29. 29. Anticoagulation Strategies for Transradial Diagnostic and Interventional Cases Tift Mann, MD, FACC TCT 2011

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