Session III: Advance concepts in Transradial PCIMinimising Radial Artery Injury Dr Sudhir Rathore MD, MRCP(UK), FACC Consultant Cardiologist Fortis Escorts Hospital and Research Centre, New Delhi, India Visiting Cardiologist St Georges Hospital, London
I, Dr Sudhir Rathore, DO NOT have a financial interest/arrangement or affiliation with one ormore organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
Background Recently Transradial access has become alternative and preferred vascular access site. Radial artery is medium sized muscular artery. Repeated coronary procedures needs patent and healthy radial artery. Radial artery is being used increasingly as a conduit for coronary revascularisation. Transradial access potentially results in injury to radial artery and can range from endothelial dysfunction to RA occlusion. All efforts must be made to minimise radial artery injury following TRA.
Extent of Injury- Contemporary practice Radial artery Occlusion: 4-10% (Early), 2-6% (Late) during contemporary practice. Non-occlusive radial artery injury: Reported in around 50% of the RA in the form of neo-intimal hyperplasia, radial artery stenosis etc. Vascular function reduced in RA in majority of the cases. RA size, sheath to artery ratio, DM, number of catheters used, use of heparin, female gender are shown to be predictors of injury.
Acute Injury Intimal tears: 32% Medial dissect.:16% Thombi: 20%Chronic InjuryHigher neo-intimalthickness in patients with repeatedprocedures Taishi Yonetsu et al. EHJ, April 22, 2010
Histopathological study- Distal andProximal RA Staniloe CS, et al. Vasc. Health and management, June 2009
Prophet Study- Patent Haemostasis Pancholy S. CCI, 72:335-340, 2008
Radial artery Occlusion: Role of heparinand ulnar artery compression Bernat, I, Bertrand, O et al. AM Journal Cardiology, 2011
Predictors of Radial artery OcclusionVariables Odds 95% C.I P value RatioMale sex 0.61 0.29-1.28 0.194Younger age 1.02 1.00-1.04 0.036Smaller wrist size 1.39 1.06-1.80 0.014No operator RAS 0.53 0.31-0.90 0.021No Heparin usage 7.12 3.75-13.52 <0.001
Results-1- Coated sheath-FMD(PRE-POST)Figure 1. Changes in FMD (%) in the catheterized and non-catheterized arms pre and post-procedure. Data is presented as mean ± SD. *, significantly different from pre P<0.05
Uncoated sheath-FMD(PRE-POST)Figure 2. Changes in FMD (%) in the catheterized and non-catheterized arms pre and post-procedure. Data is presented as mean ± SD. *, significantly different from pre P<0.05
Coated- FMD (POST-RECOV)Figure 5. Changes in FMD (%) in the catheterized and non-catheterized arms post and recov. Data is presented as mean ± SD. *, significantly different from pre P<0.05
Uncoated-FMD(POST-RECOV)Figure 6. Changes in FMD (%) in the catheterized and non-catheterized arms post and recov. Data is presented as mean ± SD. *, significantly different from pre P<0.05
Comparison between coated anduncoated sheaths FMD in the catheterized arm decreased significantly from 10.3±3.8 to 5.3±3.3% and from 8.1±2.4 to 5.2±3.7% in the coated and uncoated groups, respectively. These values returned towards baseline levels ~3 months later (6.4±1.4 and 9.4±4.1, coated and uncoated, respectively). GTN decreased significantly from 14.8±7.2 to 9.5±4.1% in the coated group and from 12.2±4.6 to 7.5±4.2% in the uncoated group. Values returned to baseline at ~3mths (16.6±5.6% and 12.1±3.9%, coated and uncoated respectively).
Vascular function- Impact of Artery tosheath ratio
FMD: Impact of no. of catheters and smoking Heiss. C et al. JACC Interv. 2:1067-1073, 2009
Impact of Sheath size: 4Fr vs 6FrLei H, Dong WY, at al. Chinese Medical Journal, 123: 1373-1376, 2010
Take Home Message 1 Radial artery injury is common after TRA. RA occlusion rates could be significantly reduced by adopting routine patent haemostasis and use of Heparin (5000 Units or more). Compression devices should be removed early and in timely fashion. Radial artery spasm should be avoided and treated promptly using vasodilators and other measures to reduce radial artery injury and occlusion. Predictors of RA injury should be identified and adequate measures taken.
Take Home Message 2 RA endothelial function (FMD) and GTN mediated function are significantly impaired after TRA. Vascular functions recover to baseline in three months time. RA to sheath ratio (<1), smoking and higher number of catheter exchanges seems to result in higher extent of injury. Less injury with smaller diameter catheters (4- 5Fr vs. 6Fr). Secondary prevention of risk factors could potentially reduce vascular injury. Role of Prehab. Or Isometric exercise of forearm ? Reduce vascular injury (Work in progress)