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Transradial PCI in Octogenarians: Caveats, Tips, and Tricks

Transradial PCI in Octogenarians: Caveats, Tips, and Tricks. Sunil V. Rao MD The Duke Clinical Research Institute The Durham VA Medical Center Duke University Medical Center. Disclosures. Consultant, Honoraria

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Transradial PCI in Octogenarians: Caveats, Tips, and Tricks

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  1. Transradial PCI in Octogenarians: Caveats, Tips, and Tricks Sunil V. Rao MD The Duke Clinical Research Institute The Durham VA Medical Center Duke University Medical Center

  2. Disclosures • Consultant, Honoraria • Sanofi-Aventis/BMS, The Medicines Company, Terumo Corporation, Astra Zeneca, Eli Lilly/Daiichi-Sankyo, Terumo • Research funding • Cordis Corporation, Momenta Pharmaceuticals, Portola Pharmaceuticals • Off-label uses • May be discussed in this presentation

  3. Transradial PCI in elderly patientsIssues • Comorbidities • Higher risk – ischemia, bleeding • Complex CAD • Calcification • Tortuous vasculature These issues are not specific to transradial!!

  4. PCI-related outcomes N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI Klein LW, et. al. JACC 2002

  5. PCI-related outcomes – Multivariable model N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI Klein LW, et. al. JACC 2002

  6. Predictors of Major Bleeding in ACS • Older Age • Female Gender • Renal Failure • History of Bleeding • Right Heart Catheterization • GPIIb-IIIa Antagonists Independent predictors of major bleeding in marker- positive acute coronary syndromes Moscucci, GRACE Registry, Eur Heart J. 2003 Oct;24(20):1815-23.

  7. Risk Factors for Bleeding- Adjusted Analysis All p values <0.001 Mehta SR.Circulation: CI 2009

  8. Access sites bleeding in “real-world” PCI patients 5.4% 12.7% Kinnaird et al Am J Cardio 2003

  9. Transradial PCI in Patients ≥ 75 years oldN=307 pts randomized to radial vs. femoral *Defined as death, MI, CVA, vascular complications requiring surgery, red cell transfusion, Hgb decrease > 3 g/dl Achenbach S, et. al. CCI 2008

  10. Transradial PCI – Outcomes by AgeN=593,094 pts in ACC-NCDR CathPCI Registry Rao SV, et. al. JACC:CI 2008

  11. Transradial PCI – Outcomes by AgeN=593,094 pts in ACC-NCDR CathPCI Registry While there is a trend toward less bleeding in the pts ≥ 75 years old With the radial approach, it does not reach statistical significance. This underscores the importance of non-access site bleeding Rao SV, et. al. JACC:CI 2008

  12. Bleeding and Outcomes 26,452 patients from PURSUIT, PARAGON A, PARAGON B, GUSTO IIb NST Adjusted hazard ratios for 30d Death Stratified by Procedure and Non-procedure related bleeds *p<0.0001 Rao SV, et. al. AJC 2005

  13. Excessive Dosing of Antithrombotics by Age Alexander KP, et. al. JAMA 2005

  14. ACUITY PCI: Ischemic outcomes by age P=.57 P=.30 P=.77 P=.75 Percentage (%) ≥75 (n=1,346) (n=1,483) (n=1,454) (n=897) Patient age (years) Lopes RD, et. al. JACC 2009

  15. ACUITY PCI: Non-CABG bleeding by age ≥75 P=.001 P=.03 P=.01 P=.007 Percentage (%) (n=1,483) (n=897) (n=1,346) (n=1,454) Patient age (years) Lopes RD, et. al. JACC 2009

  16. Issues specific to transradial in elderly patients • Tortuosity of arm and chest vessels • Low threshold for angiography • Deep breath to direct wire • Get experience with other catheter curves • Complex PCI – few limitations with currently available 6Fr guiding catheters used via the transradial approach

  17. Transradial PCI in the elderlyConclusions (1) • PCI-related ischemic outcomes have improved in older patients • High rates of procedure success • Low rates of peri-PCI ischemic events • Reducing bleeding risk is the priority • Transradial is associated with reduced bleeding risk, but… • Crossover to femoral may be higher • Non-access site related bleeding is important in older patients

  18. Transradial PCI in the elderlyConclusions (2) • Strategies for reducing bleeding risk in older pateints include: • Transradial • Pharmacological therapies – appropriate dosing, alternative antithrombin strategies • Transradial tips/tricks • Low threshold for forearm/chest angiography • Deep breath to direct equipment • Use of other guide catheter curves • New technology coming

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