Transradial Approach: Just Do It !TEJAS M. PATEL, MD, DM, FACC, FESC, FSCAI               PROFESSOR & HEAD    Department o...
DisclosureHonorarium from Terumo US
Historical perspective
Mason SonesBrachial cut-down
Melvin JudkinsPercutaneous femoral approach
CampeauTransradial coronary angiogram
KiemeneijTransradial coronary intervention
UL   LL
TRI        TFI Major Vascular Complications                      (n=1604)   (n=5211)   Kiemeneij F et al. 1996 J Am Coll C...
SUCCESS      Transradial PCI In Setting Of AMI                      96.6%      Tift Mann et al. J Am Coll Cardiol 1999 (n=...
TRI        TFI Procedural Success Final TIMI 3 Flow                                                   (n=665)   (n=1726)  ...
TRI      TFI   Major Vascular Complications                    (n=945) (n=2802)     Tift Mann et al. J Am Coll Cardiol 199...
TRI: Impact of Gp IIb / IIIa Blockers    Absence of Major Vascular Complications                                        TR...
TRI In AMI: No Delay In Reperfusion                                                                TRI      TFI        PRO...
J Am Coll Cardiol. 2004; 44 (2): 349-56 Radial versus femoral approach for percutaneouscoronary diagnostic and interventio...
Am Heart J. 2009; 157(1):132-40        Radial versus femoral access for coronary   angiography or intervention and the imp...
Catheter Cardiovasc Interv 2009;74: 408-415Effectiveness of the transradial approach to reduce bleedings   in patients und...
Catheter Cardiovasc Interv. 2010;75 (5): 695-9     Arterial access and door-to-balloon times forprimary percutaneous coron...
Catheter Cardiovasc Interv. 2010;75(7):991-5Comparison of door-to-balloon times for primary PCI   using transradial versus...
Impact ofbleeding & transfusion on the procedural outcome
Heart 2008;94:1530-1532                                     EDITORIALShould radial artery access be the "gold standard" fo...
Heart 2008;94:1019-1025       Association of the arterial access site at angioplasty with           transfusion and mortal...
CONCLUSION:• The MORTAL study ,which looked at a registry  of 33,000 Canadian patients, showed 50% less  blood transfusion...
JACC 2009
JACC 2009
JACC 2009
J Am Coll Cardiol Intv, 2008; 1:379-386Trends in the Prevalence and Outcomes of Radial and    Femoral Approaches to Percut...
RIVAL Study – ACC 2011                    Lancet 2011;377:1409–20 Radial versus femoral access for coronary angiography an...
Ostensible Reasons                                Blah…Blah…Blah• Small artery• RA spasm• Difficult to use bulky devices• ...
Experience• From Jan - 1992 to Nov - 2001   • 25,450 Transfemoral procedures   • 6,360 coronary interventions through TFA•...
Radial Artery Spasm
Working throughCalcified Radial Artery
Radial Artery Perforation
Higher puncture of   Radial artery
Very low radial loop & High puncture
High Puncture
Lateral Puncture
Addressing the    loops
Simple loop
Morechallenging   loop
Mostchallenging   loop
“Downsize the Catheter”   Diagnostic 5F  4F
Intervention     throughLoop & Perforation
Intervention through   Loop & Spasm
Practice makes you perfect…
Acute angle crossed   using a PTCA      catheter
Catheter Knot Reduction
Another exampleCatheter Knot Reduction
Axillo-Subclavian   Dissection
Working through Extreme Subclavian Tortuosity  “use of pigtail catheter”
Working throughSubclavian Tortuosity“use of PTCA catheter”
Another example   Balloon-assistedguide catheter tracking through a small RA
Working throughArteria Lusoria
Effect of dilatation and distortion of aorta
Schematic diagram of different loops     produced due to distortion of aorta•   Normal•   Z–loop•   Roller-coaster loop•  ...
Arteria Lusoria
Arteria LusoriaAnterior       Posterior     Oblique
Arteria Lusoria
Arteria Lusoria‘Roller-coaster loop’
Arteria Lusoria - Cath Maneuver
Arteria Lusoria ‘Cobra loop’
Cobra loopRCA stenting
Cobra loop coronarycannulation
Arteria lusoria withSubclavian tortuosity
Practice makes you perfect…
Again…Practice makes you     perfect…
Working throughRight Aortic Arch –    Right TRA
LIMA Cannulation using RRA
RCAAir Embolization
LMCA Bifurcation Rota-Stent
LMCA intervention… A real nightmare
RCA CTO
Unprotected LMCA StentingExtensive anterior wall MI-1 hour
Acute IWMI &Cardiogenic Shock
PeripheralInterventions
Our experience           Through TRARenal                      107Iliac                      36SFA                        ...
Published data by our group   Patel T, Kuladhipati I, Shah S. et al.    Successful percutaneous endovascular management o...
Renal Artery Stenting
Bilateral iliac      &SFA Stenting
SuperiorMesenteric Artery    Stenting
Subclavian  Artery Stenting
Vertebral Artery    Stenting Ostial Lesion
Vertebral Artery    Stenting Intra-cranial
Chronic Basilar    Artery  Occlusion
Left Carotid Stenting      through Right Radial Route
What is the limitation ?
Anterior Tibial PTA
It is the limitation of hardware…
Thank Youwww.transradialWORLD.org
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Transradial Approach: Just Do It !

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Patel TM 201110

  1. 1. Transradial Approach: Just Do It !TEJAS M. PATEL, MD, DM, FACC, FESC, FSCAI PROFESSOR & HEAD Department of Cardiovascular Sciences, Smt. N.H.L. Municipal Medical College, Sheth K.M. School of PG Studies & Research, Sheth V. S. Hospital, Ahmedabad, India. DIRECTOR Department of Cardiovascular Sciences, TCVS (Total Cardiovascular Solutions) Pvt. Ltd. Ahmedabad, India.
  2. 2. DisclosureHonorarium from Terumo US
  3. 3. Historical perspective
  4. 4. Mason SonesBrachial cut-down
  5. 5. Melvin JudkinsPercutaneous femoral approach
  6. 6. CampeauTransradial coronary angiogram
  7. 7. KiemeneijTransradial coronary intervention
  8. 8. UL LL
  9. 9. TRI TFI Major Vascular Complications (n=1604) (n=5211) Kiemeneij F et al. 1996 J Am Coll Cardiol 0 2% Ziakas A et al. Am J Cardiol 1999 0 1.5% Tift Mann et al. J Am Coll Cardiol 1999 0 4% Choussat R et al. Eur Heart J 2000 0 4.5% Hildic S et al. 2000 0 6%Louvard Y et al. Catheter Cardiovasc Interv 2002 0 1.3% Saito S et al. Catheter Cardiovasc Interv 2002 0 3% Valsecchi O et al. Ital Heart J 2003 0 1.2% Lefevre T (TCT 2003) 0 2.3% Pooled data 0.0% 3.8%
  10. 10. SUCCESS Transradial PCI In Setting Of AMI 96.6% Tift Mann et al. J Am Coll Cardiol 1999 (n=68) 96% Delarche N et al. Am J Geritar Cardiol 1999 (n=46) 100% Kim MH et al. J Invasive Cardiol 2000 (n=30) 90% Mathias et al. J Invasive Cardiol 2000 (n=14) 100%Mulkutla SR et al. Catheter Cardiovasc Interv 2002 (n=41) 100%Hamon M et al. Catheter Cardiovasc Interv 2002 (n=119) 100%Louvard Y et al. Catheter Cardiovasc Interv 2002 (n=267) 98% Ziakas A et al. Am J Cardiol 1999 (n=100) 90% Saito S et al. Catheter Cardiovasc Interv 2002 (n=77) 96% Valsecchi O et al. Ital Heart J 2003 (n=163) 97%
  11. 11. TRI TFI Procedural Success Final TIMI 3 Flow (n=665) (n=1726) Tift Mann et al. J Am Coll Cardiol 1999 96 % 96 % Ziakas A et al. Am J Cardiol 1999 99% 97%Louvard Y et al. Catheter Cardiovasc interv 2002 98% 97% Saito S et al. Catheter Cardiovasc Interv 2002 96 % 97 % Valsecchi O et al. Ital Heart J 2003 97% 96% Pooled data 97% 97%p= ns in all studies
  12. 12. TRI TFI Major Vascular Complications (n=945) (n=2802) Tift Mann et al. J Am Coll Cardiol 1999 0 4% Ziakas A et al. Am J Cardiol 1999 0 1.5%Louvard Y et al. Catheter Cardiovasc Interv 2002 0 1.3% Saito S et al. Catheter Cardiovasc Interv 2002 0 3% Valsecchi O et. al Ital Heart J 2003 0 1.2% Lefevre T (TCT 2003) 0 2.3% Pooled data 0 1.8%
  13. 13. TRI: Impact of Gp IIb / IIIa Blockers Absence of Major Vascular Complications TRI TFIMajor vascular complications (n=244) (n=1953)Choussat R et al. Eur Heart J 2000 0 4.5%ESPRIT trial J Am Coll Cardiol 2003 0.7% 6.6% Pooled data 0.4% 6.5%
  14. 14. TRI In AMI: No Delay In Reperfusion TRI TFI PROCEDURAL TIME (minutes) (n=945) (n=2802) Ziakas A et al. Am J Cardiol 1999 43 19 50 28Louvard Y et al. (Centre A) Catheter Cardiovasc Interv 2002 45 42 43 32Louvard Y et al. (Centre B) Catheter Cardiovasc Interv 2002 67 25 68 21 Saito S et al. Catheter Cardiovasc Interv 2002 44 18 51 21 Valsecchi O et al. Ital Heart J 2003 62 23 61 22 Lefevre T (TCT 2003) 45 50 48 55 P=ns
  15. 15. J Am Coll Cardiol. 2004; 44 (2): 349-56 Radial versus femoral approach for percutaneouscoronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials Agostoni P, Biondi-Zoccai GG, de Benedictis ML et al. CONCLUSION:The radial approach for coronary procedures appears as asafe alternative to femoral access. Moreover, radial access virtually eliminates local vascular complications
  16. 16. Am Heart J. 2009; 157(1):132-40 Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events:A systematic review and meta-analysis of randomized trials Jolly SS, Amlani S, Hamon M et al. CONCLUSION: Radial access reduced major bleeding and there was a corresponding trend for reduction in ischemic events compared to femoral access
  17. 17. Catheter Cardiovasc Interv 2009;74: 408-415Effectiveness of the transradial approach to reduce bleedings in patients undergoing urgent coronary angioplasty with GPIIb / IIIa inhibitors for acute coronary syndromes Marco De Carlo, Gabriele Borelli, Roberto Gistri et al. CONCLUSION: The transradial approach dramatically reduces access site bleedings, including TIMI major and minor bleedings, and transfusion rate, while preserving procedural success and clinical outcome. The transradial approach is an attractive solution to reduce bleeding complications in patients treated with GPIs
  18. 18. Catheter Cardiovasc Interv. 2010;75 (5): 695-9 Arterial access and door-to-balloon times forprimary percutaneous coronary intervention in patientspresenting with acute ST-elevation myocardial infarction Weaver AN, Henderson RA, Gilchrist IC et al. CONCLUSION: Patients presenting with STEMI can undergo successful PCI via radial artery approach withoutcompromise in D2B times as compared to femoral artery approach
  19. 19. Catheter Cardiovasc Interv. 2010;75(7):991-5Comparison of door-to-balloon times for primary PCI using transradial versus transfemoral approach Pancholy S, Patel T, Sanghvi K et al. CONCLUSION:Transradial approach to primary PCI provides similardoor-to-balloon times to transfemoral approach, andsignificantly lowers access site related complications, in patients presenting with STEMI
  20. 20. Impact ofbleeding & transfusion on the procedural outcome
  21. 21. Heart 2008;94:1530-1532 EDITORIALShould radial artery access be the "gold standard" for PCI? Martial Hamon1, James Nolan2 1 University Hospital of Caen, Caen, France 2 University Hospital of North Staffordshire, Stoke-on-Trent, UK
  22. 22. Heart 2008;94:1019-1025 Association of the arterial access site at angioplasty with transfusion and mortality: the M.O.R.T.A.L study (Mortality benefit of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg) A J Chase, E B Fretz, W P Warburton et al. Design, setting and patients: By data linkage of three prospectively collated provincial registries, 38 872 procedures in 32 822 patients in British Columbia were analysedThe association between access site, transfusion & outcomes was assessed Main outcome measures: 30-Day and 1-year mortality
  23. 23. CONCLUSION:• The MORTAL study ,which looked at a registry of 33,000 Canadian patients, showed 50% less blood transfusions and accompanying reductions in mortality for patient done radially• By probit regression the absolute increase in risk of death at 1 year associated with receiving a transfusion was 6.78%
  24. 24. JACC 2009
  25. 25. JACC 2009
  26. 26. JACC 2009
  27. 27. J Am Coll Cardiol Intv, 2008; 1:379-386Trends in the Prevalence and Outcomes of Radial and Femoral Approaches to Percutaneous Coronary Intervention A Report From the National Cardiovascular Data Registry Sunil V. Rao, Fang-Shu Ou, Tracy Y et al. CONCLUSION: Study looked at 593,094 U.S. patients and found that radial patients experienced 58% less bleeding complications
  28. 28. RIVAL Study – ACC 2011 Lancet 2011;377:1409–20 Radial versus femoral access for coronary angiography andintervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial Jolly SS, Yusuf S, Cairns J et al. CONCLUSION: Radial access was associated with a reduction in access-related complications There was a trend towards survival benefit in patients with STEMI
  29. 29. Ostensible Reasons Blah…Blah…Blah• Small artery• RA spasm• Difficult to use bulky devices• Inadequate guide catheter backup• Not so good for difficult coronary anatomy• Not safe for complex anatomy• RA occlusion• Radiation exposure
  30. 30. Experience• From Jan - 1992 to Nov - 2001 • 25,450 Transfemoral procedures • 6,360 coronary interventions through TFA• From Dec - 2001 to June - 2011 • 35,202 Transradial procedures • 9,152 coronary interventions through TRA • 291 Peripheral intervention through TRA • 98% procedures through TRA
  31. 31. Radial Artery Spasm
  32. 32. Working throughCalcified Radial Artery
  33. 33. Radial Artery Perforation
  34. 34. Higher puncture of Radial artery
  35. 35. Very low radial loop & High puncture
  36. 36. High Puncture
  37. 37. Lateral Puncture
  38. 38. Addressing the loops
  39. 39. Simple loop
  40. 40. Morechallenging loop
  41. 41. Mostchallenging loop
  42. 42. “Downsize the Catheter” Diagnostic 5F  4F
  43. 43. Intervention throughLoop & Perforation
  44. 44. Intervention through Loop & Spasm
  45. 45. Practice makes you perfect…
  46. 46. Acute angle crossed using a PTCA catheter
  47. 47. Catheter Knot Reduction
  48. 48. Another exampleCatheter Knot Reduction
  49. 49. Axillo-Subclavian Dissection
  50. 50. Working through Extreme Subclavian Tortuosity “use of pigtail catheter”
  51. 51. Working throughSubclavian Tortuosity“use of PTCA catheter”
  52. 52. Another example Balloon-assistedguide catheter tracking through a small RA
  53. 53. Working throughArteria Lusoria
  54. 54. Effect of dilatation and distortion of aorta
  55. 55. Schematic diagram of different loops produced due to distortion of aorta• Normal• Z–loop• Roller-coaster loop• Cobra loop
  56. 56. Arteria Lusoria
  57. 57. Arteria LusoriaAnterior Posterior Oblique
  58. 58. Arteria Lusoria
  59. 59. Arteria Lusoria‘Roller-coaster loop’
  60. 60. Arteria Lusoria - Cath Maneuver
  61. 61. Arteria Lusoria ‘Cobra loop’
  62. 62. Cobra loopRCA stenting
  63. 63. Cobra loop coronarycannulation
  64. 64. Arteria lusoria withSubclavian tortuosity
  65. 65. Practice makes you perfect…
  66. 66. Again…Practice makes you perfect…
  67. 67. Working throughRight Aortic Arch – Right TRA
  68. 68. LIMA Cannulation using RRA
  69. 69. RCAAir Embolization
  70. 70. LMCA Bifurcation Rota-Stent
  71. 71. LMCA intervention… A real nightmare
  72. 72. RCA CTO
  73. 73. Unprotected LMCA StentingExtensive anterior wall MI-1 hour
  74. 74. Acute IWMI &Cardiogenic Shock
  75. 75. PeripheralInterventions
  76. 76. Our experience Through TRARenal 107Iliac 36SFA 11SMA 02Subclavian 28Vertebral & Basilar 66ICA 41Total 291
  77. 77. Published data by our group Patel T, Kuladhipati I, Shah S. et al. Successful percutaneous endovascular management of acute post traumatic superior mesenteric artery dissection using transradial approach. J. Invasc. Cardiol. 2010; 22: 4: 61-64 Patel T, Shah S, Pancholy S, Coppola J. et al. Contralateral transradial approach for carotid artery stenting: A feasibility study. Cathet Cardiovasc Interv 2010; 75: 2: 268-275 Patel T, Shah S, Radadia R. et al. Transradial approach for stenting of vertebro-basilar stenosis: A feasibility study. Cathet Cardiovasc Interv 2009; 74: 925-931
  78. 78. Renal Artery Stenting
  79. 79. Bilateral iliac &SFA Stenting
  80. 80. SuperiorMesenteric Artery Stenting
  81. 81. Subclavian Artery Stenting
  82. 82. Vertebral Artery Stenting Ostial Lesion
  83. 83. Vertebral Artery Stenting Intra-cranial
  84. 84. Chronic Basilar Artery Occlusion
  85. 85. Left Carotid Stenting through Right Radial Route
  86. 86. What is the limitation ?
  87. 87. Anterior Tibial PTA
  88. 88. It is the limitation of hardware…
  89. 89. Thank Youwww.transradialWORLD.org

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