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Radial Access: state of the art. Y. Louvard Massy, France. Transradial approach: the best way to reduce the vascular complication rate and the cost, and to improve patient comfort. Impact of Access Site Hematoma With Transfusion in Patients Undergoing PCI.

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slide1

Radial Access: state of the art

  • Y. Louvard
  • Massy, France
slide2

Transradial approach: the best way to reduce the vascular complication rate and the cost, and to improve patient comfort

impact of access site hematoma with transfusion in patients undergoing pci
Impact of Access Site Hematoma With Transfusion in Patients Undergoing PCI

6613 PCI (98-00)(NHLBI): hematoma w transfusion 1.8% (97% femoral)

Independent predictors: Older age, female, thrombotic lesion, 3-VD, renal disease, emergent PCI, prior aspirin

HWT no HWT p

Procedural death (%): 10.3 1.2 <0.001

death/MI (%): 18.1 3.55 <0.001

HWT is a predictor of death/MI (OR = 3.49; 95% CI: 1.98-6.14)

J. Slater Am J Cardiol 2003 (suppl) 92: 18L

clinical significance of bleeding complications
Clinical Significance of Bleeding Complications

From Blankenship Am Heart J 1999; 138: S287-S296

radial femoral approach meta analysis entry site complications
Radial / Femoral Approach meta-analysis: Entry site complications

Agostini P personal communication

slide8

ACCESS Study

Radial Brachial Femoral p

Approach failure (%) 7 4.3 0.3 <0.001

Procedural success (%) 91.7 90.7 90.7 NS

Equipment:

Guiding cath. (n) 1.3 1.3 1.3 NS

Balloons (n) 1.3 1.3 1.3 NS

Stenting (%) 4.7 7 4.7 NS

Procedural time (Min) 40+24 39+25 38+24 NS

Fluoro. Time (Min 13+11 12+10 11+10 0.06

Hospital stay (days) 1.5+2.5 1.8+3.8 1.8+4.2 NS

Kiemeneij JACC 1997;29:1269-75

radial artery diameter ultrasound n 120
Radial Artery Diameter (Ultrasound)n=120

5f 6f 7f 8f

2,9+0,6 mm

Y. Louvard unpublished

catheters devices technique compatibility
Catheters / Devices / Technique Compatibility
a randomized trial of 5 vs 6 french transradial percutaneous coronary interventions
A randomized trial of 5 vs. 6 French transradial percutaneous coronary interventions

5 Fr / 6 Fr guiding catheter, 171 pts with coronary lesions suitable for 5 Fr transradial approach

5 Fr 6 Fr p

Procedural success (%) 95.4 92.9

Cor. cannulation failure (%) 1.1 4.8 0.08

Minor hematomas (%) 1.1 4.8 0.07

Loss of radial pulse (%) 1.1 5.9 0.05

Dahm JB CCVI 2002; 57(2):172-6

carafe technical data
CARAFE (Technical Data)

Femoral Right Radial Left Radial

N= 70 70 70

Cross over 0 1 (1.4%)* 0

LCA catheter (n) 1.1+0.3 1.2+0.6 1.1+0.3

RCA catheter (n) 1.0+0.2 1.1+0.3 1.0+0.2

Total catheters (n) 2.1+0.4 1.4+0.7** 2.1+0.4

* p=ns : L Rad , ** p<.000 vs Femoral and L Rad

Y. Louvard CCVI 2001; 52: 181-187

looking for the best multipurpose catheter for right transradial coronary angiography
Looking for the best multipurpose catheter for Right transradial coronary angiography
  • Multipurpose (too much rotation)
  • Amplatz AL2 (AL1)
  • Champ (dead…)
  • JL 3.5 (for left and right!)
  • Tiger II +++
slide14
Transradial Approach Reduces Bleeding Complications and Length of Stay in Patients With GP IIb/IIIa Inhibitors

FA RA p value

N= 2432 164

GPIIbIIIa – (%) 61 90

Major bleeding (n) 164 0 <0.05

Major complication (n) 21 0 <0.05

Minor complication (n) 59 6 <0.05

Thrombocytopenia (n) 17 3 <0.05

Length of stay (hrs) 70.6 36.6 <0.05

*p <0.05, major bleeding (TIMI criteria), major (requiring surgical repair), and minor (pseudoaneurysm or charted hematoma) access site complications

G. Revtyak Am J Cardiol 2001; 88: 39G

slide15
Transradial vs. transfemoral approach in primary stent implantation for patients with acute myocardial infarction: TEMPURA trial

149 pts with AMI < 12 hr, randomized into 2 groups

TRI TFI

N= 77 72

Cross over (n) 1 0

Severe bleeding complication (n) 0 2

Success of reperfusion (%) 96.1 97.1

in-hospital MACE (%) 5.2 8.3

Saito CCVI 2003; 59(1):26-33

octoplus primary endpoint intention to treat analysis
OCTOPLUS: Primary endpoint, Intention to treat analysis

$ surgery, transfusion, Hb loss>3g/100ml-Ht loss>10%, ischemia, FA, vasc. Complic. leading to discharge delay *Large hematoma: discharge delay

safety of same day discharge radial percutaneous coronary intervention
Safety of same-day-discharge radial percutaneous coronary intervention

943 Pts same-day discharge radial PCI: entry site complications or repeat angiogram and/or PCI within 24 hours and 1 month ,

811 patients responded , 38 patients died, 94 alive but refused to participate/impossible to contact

24 h 1 month

Access complication (%) 2.8 0

Chest pain (%) 2 11.5

repeat angio (%) 0.1 1.3

Vessel occlusion (%) 0 0.5

(+ lost for FU pts) 0.2

Ziakas Am Heart J. 2003; 146: 699-704

slide20

Transradial carotid bifurcation stenting

J. Théron, Caen, France, personal communication

transradial approach failure in relation to volume
Transradial Approach Failure in Relation to Volume

%

*Failure to enter ascending aorta

p= 0.002

Y. Louvard, unpublished

slide25

Predictive Factors of Radial Approach Failure

Success Failure* p

n= 2347 53

Age (years) 61.6+11.3 65+11.2 0.03

Male (%) 84 73.7 0.068

Hypertension (%) 42.2 43.4 ns

Dyslipidemia (%) 72.9 69.8 ns

Diabetes (%) 8.4 13.2 ns

Smoking (%) 26.9 22.6 ns

Left radial (%) 3.2 18.9 0.000

Re-radial (%) 21.9 17 ns

N° of Same Radial (n) 1.3+0.7 1.3+0.6 ns

N° Dis. Coro. Vessels (n) 1.8+0.8 1.7+0.7 ns

Weight (kg) 76.9+13.5 72.8+13.8 0.029

Height (cm) 169.3+8.3 166.4+10.3 0.03

*Failure to enter ascending aorta

predictors of failure of transradial approach for coronary angiography and interventions
Predictors of Failure of Transradial Approach for Coronary Angiography and Interventions

A multivariate analysis of a large series: 6,962 TRA (94-98)

Causes of the 475 TRA failures (7%): unsuccessful puncture (69%), difficult anatomy (16%), brachial artery spasm (8%), unsuccessful canulation (5%) or miscellaneous (2%)

G.Barbeau AHA 1999

evaluation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures
Evaluation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures

Automatic pullback device, efficacy of an intra-arterial vasodilating cocktail (verapamil 5 mg, nitroglycerine 200 µg) in reducing radial artery spasm

Cocktail No cocktail p value

N= 50 50

Pain (%) 14 34 0.019

Pain score 1.7 + 0.94 2.08 + 1.07 = 0.03

Maximal pullback force (kg) 0.53 + 0.52 0.76 + 0.45 = 0.013

MPF > 1.0 kg (%) 8 22 = 0.029

Kiemeneij CCVI 2003; 58: 281-4

tortuous right subclavian artery prevalence and predictive factors
Tortuous Right Subclavian Artery: Prevalence and Predictive Factors

2,341 consecutive right radial approaches

Prevalence (%) 10.8

Cross-over to Left Radial or Femoral (%) 4

Complications (%) 0

Independent predictive factors:

OR 95% CI p

Hypertension 1.6 1.3-2.1 <0.0003

Age 1.4 1.2-1.7 0.0001

BMI 1.2 1.0-1.4 0.015

Cha CCVI 2002; 56: abst 69

slide32
A New and Objective Method for Transradial Approach Screening: Comparaison With the Allen's Test in 1010 Patients

1010 pts, 32% female, 19% diabetics, age 62y, weight 76 kg, height 1.66 m

Right Left Right or Left

MAT < 9 seconds (%) 87 86

Positive PL* + Ox (%) 96 95

MAT exclusion (%) 6.3

PL + Ox (%) 1.5

MAT: modified Allen’s test, plethysmography (PL) and oxymetry (Ox)

Barbeau 2001, 37, 2, Suppl A, 1A-648A

slide33

Early ultrasonic results

270 patients

4 radial occluded (1.3%) :

- 2 with a negative flow

- 2 without flow

J. Monsegu

radial artery sheath diameter ratio a predictor of severe radial artery flow reduction
Radial Artery/Sheath Diameter Ratio: A Predictor of Severe Radial Artery Flow Reduction

Saïto CCVI 46: 173-178, 1999

use of the radial artery graft after transradial catheterization is it suitable as a bypass conduit
Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit?

67 pts underwent isolated CABG using the radial artery (RA)

preop. transradial no transradial p value

catheterization catheterization

N= 22 45

Stenosis-free graft patency

Left mammary artery (%) 88 90 = 0.87

Radial artery (%) 77 98 = 0.017

Saphenous vein (%) 87 84 = 0.42

Intimal hyperplasia of RA (%) 68 39 = 0.046

Kamiya Ann Thorac Surg. 2003; 76(5): 1505-9

conclusions 1
Conclusions (1)
  • Transradial approach is the best way to reduce the vascular complication rate of diagnostic and therapeutic coronary (vascular) catheterism: less expensive, preferred by patients and nurses…
  • At the price of a slight increase in procedural duration and X-Ray exposure for diagnosis only
  • It is specially effective in high risk populations like old patients, AMI, patients treated with powerful anticoagulant or antiplatelet drugs
conclusions 2
Conclusions (2)
  • Transradial approach allows the use of all devices and techniques of modern coronary intervention
  • Peripheral vascular diagnosis and intervention is feasible with the same advantages: Subclavian, Renal, Mesenteric, Carotid?
  • Learn it in Kamakura Live Course…