Bivalirudin or Heparinfor Prevention of Radial ArteryOcclusion in ad hoc Transradial PCI                               Exp...
Background•   Diagnostic cath lab since 1999•   First PCI at SRHC in November 2003•   Early adoption of bivalirudin as rou...
Background•   Challenges of new PCI lab    •   Temporary location – limited number of beds in recovery area    •   Repatri...
Radial Artery Thrombosis•   Radial artery more prone to vasospasm following canulation    than the femoral artery, which s...
Bivalirudin and Radial Access - SRHC•   Not an issue for elective PCI - Concerns about ad hoc PCI•   SRHC Protocol:    •  ...
Bivalirudin and Radial Access - SRHC•   This protocol has been associated with good clinical    outcomes with no apparent ...
SRHC Study•   Determine whether the SRHC protocol for radial artery    access results in acceptable radial artery thrombos...
Inclusion Criteria•   Angiography +/- PCI via the radial access.•   On ASA at the time of the procedure.•   On clopidogrel...
Exclusion Criteria•   Acute STEMI (primary PCI)•   Shock•   Allergy to ASA or clopidogrel•   Unable to come to follow-up v...
Methods•   Group 1 (n = 200); patients who underwent angiography and    PCI and who received IV bivalirudin.•   Group 2 (n...
Study DesignStudy Design                11
Baseline DataBaseline Data                12
Procedural Data                  13
RAO at Follow-up RAO at Follow-up                    14
RAOat Follow-upRAO    at Follow-up                   15
Patients with RAOPatients with RAO                     16
Independent Predictors for RAOIndependent Predictors of RAO                                 17
Discussion•   In our experience, delayed administration of heparin or    bivalirudin for transradial angiography followed ...
References             19
References             20
References   Ad hoc Transradial PCI - Bivalirudin                                          21
Ad Hoc Transradial PCI - Bivalirudin                                       22
Ad Hoc TransradialPCI - -Bivalirudin Ad hoc Transradial PCI Bivalirudin                                       23
Ad Hoc Transradial PCI - -BivalirudinAd hoc Transradial PCI Bivalirudin                                        24
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Bivalirudin or Heparin for Prevention of Radial Artery Occlusion in ad hoc Transradial PCI

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Plante S

  1. 1. Bivalirudin or Heparinfor Prevention of Radial ArteryOcclusion in ad hoc Transradial PCI Experience at SRHC .Sylvain Plante MDPCI ProgramSouthlake Regional Health Centre 1
  2. 2. Background• Diagnostic cath lab since 1999• First PCI at SRHC in November 2003• Early adoption of bivalirudin as routine drug for PCI• Publication of REPLACE-2 trial • Validated as a safe and cost-effective alternative to heparin and routine GP IIb/IIIa inhibition • Procedural simplicity• Experience with bivalirudin (site investigator in U.S.) 2
  3. 3. Background• Challenges of new PCI lab • Temporary location – limited number of beds in recovery area • Repatriation issues• Short half-life (early femoral sheath removal) • Radial access not routinely used 3
  4. 4. Radial Artery Thrombosis• Radial artery more prone to vasospasm following canulation than the femoral artery, which significantly increase the risk of permanent radial artery thrombosis.• RAO rarely associated with significant clinical symptoms, but may limit future access if other invasive procedures are needed.• To minimize the occurrence of painful spasm and the risk of thrombosis, anti-spastic agents (verapamil, nitroglycerin) and anticoagulant agents (heparin) are routinely administered immediately following canulation of the radial artery.• These simple measures have been very effective in reducing the rate of late radial artery thrombosis to < 5%. 4
  5. 5. Bivalirudin and Radial Access - SRHC• Not an issue for elective PCI - Concerns about ad hoc PCI• SRHC Protocol: • Intra-arterial verapamil administered after RA canulation • Coronary angiography • IV heparin or bivalirudin administration delayed until angiography is completed (10-15 min) and a decision made to proceed or not with PCI, based on the suitability of the coronary anatomy. • For patients not considered for ad hoc PCI, a bolus of IV heparin (70 U/ kg) is administered, the radial sheath is pulled out and hemostasis is achieved with the compressive bracelet. • For patients undergoing PCI, the IV bolus of bivalirudin is administered and followed by infusion. Depending on the procedure duration, bivalirudin infusion can be either discontinued or continued until the end, at the interventionalistʼs discretion. 5
  6. 6. Bivalirudin and Radial Access - SRHC• This protocol has been associated with good clinical outcomes with no apparent adverse events relating to radial artery thrombosis.• However, we felt it was important to document in a formal manner the actual radial artery thrombosis rate to ensure that it is not different from historical controls. 6
  7. 7. SRHC Study• Determine whether the SRHC protocol for radial artery access results in acceptable radial artery thrombosis rates.• Evaluate 400 consecutive patients who have undergone coronary angiography +/- PCI using a radial access.• Demonstrate that the rate of late radial artery thrombosis using our modified approach to anticoagulation was within normal range. 7
  8. 8. Inclusion Criteria• Angiography +/- PCI via the radial access.• On ASA at the time of the procedure.• On clopidogrel at the time of the procedure.• IV heparin was discontinued > 6h or last dose of LMWH >12h prior to the procedure.• Informed consent obtained. 8
  9. 9. Exclusion Criteria• Acute STEMI (primary PCI)• Shock• Allergy to ASA or clopidogrel• Unable to come to follow-up visit 9
  10. 10. Methods• Group 1 (n = 200); patients who underwent angiography and PCI and who received IV bivalirudin.• Group 2 (n = 200); patients who underwent angiography alone and who received IV heparin (controls).• Follow-up at 4-6 weeks• RA thrombosis defined by 2 different criteria: • absent waveform (Type D) on reverse Allen test using pulse oxymetry + • absent Doppler flow 10
  11. 11. Study DesignStudy Design 11
  12. 12. Baseline DataBaseline Data 12
  13. 13. Procedural Data 13
  14. 14. RAO at Follow-up RAO at Follow-up 14
  15. 15. RAOat Follow-upRAO at Follow-up 15
  16. 16. Patients with RAOPatients with RAO 16
  17. 17. Independent Predictors for RAOIndependent Predictors of RAO 17
  18. 18. Discussion• In our experience, delayed administration of heparin or bivalirudin for transradial angiography followed by PCI is safe and results in low radial artery occlusion rates.• Although not statistically significant as per our definition, delayed administration of IV heparin may result in RAO rates slightly above historical controls. • Administration route (IV vs IA) ? • Need for heparin immediately after canulation ? • Administration after sheath removal / placement of bracelet ? • Type of bracelet ? • Hydrophylic sheath ? • Selection bias ? 18
  19. 19. References 19
  20. 20. References 20
  21. 21. References Ad hoc Transradial PCI - Bivalirudin 21
  22. 22. Ad Hoc Transradial PCI - Bivalirudin 22
  23. 23. Ad Hoc TransradialPCI - -Bivalirudin Ad hoc Transradial PCI Bivalirudin 23
  24. 24. Ad Hoc Transradial PCI - -BivalirudinAd hoc Transradial PCI Bivalirudin 24
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