Single Center Experience With Transradial Approach for Primary Percutaneous Coronary Intervention

1. Single Center Experience With
Trans-Radial Approach for
Primary PCI
Aharon Frimerman, Simcha Meisel,
Michael Shochat, Rinat Malka, Avi
Shotan
Hillel Yaffe Medical Center, Hadera,
Israel

2. What is the rationale for
trans- radial approach in
primary PCI?

3. Typical scenario at the ICCU
after trans-femoral approach

4. Not very rare outcome after
trans-femoral approach
• Hematoma
• Retro-
peritoneal
bleeding
• Pseudo-
aneurysm
• Fistula

5. Trans-Radial approach
setup at the Cath Lab

6. The radial sheath is pulled-out at the Cath
Lab immediately at the end of the procedure
both diagnostic or therapeutic
Radial Sheath

7. The patient is mobile and can
leave the Cath Lab walking

8. Radial entry site several hours
after the end of the procedure

9. Radial VS Femoral approach
MACE
Agostoni P Et Al:Radial versus femoral approach for percutaneous coronary
diagnostic and interventional procedures; Systematic overview and meta-analysis
of randomized trials.J Am Coll Cardiol. 2004 Jul 21;44(2):349-56.

10. Radial VS Femoral approach
Entry site complications
Agostoni P Et Al:Radial versus femoral approach for percutaneous coronary
diagnostic and interventional procedures; Systematic overview and meta-
analysis of randomized trials.J Am Coll Cardiol. 2004 Jul 21;44(2):349-56.

11. PRIMARY PCI, is a Bleeding
Prone Scenario
Anti aggregation therapy during PPCI:
Aspirin, Plavix, Prasogrel, Anti 2b3a
(ReoPro, Integrilin, Aggrastat).
• Anti coagulation therapy during PPCI:
Heparin, Clexane, Bivalirudin,
• Sometimes thrombolytic therapy on board!
• Sometimes the patient is on Coumadin

12. Mortality closely tied to major
bleeds at primary PCI
HORIZONS-AMI (9/08): >3600 patients getting PCI for acute ST-segment-
elevation MI (STEMI) randomized to get bivalirudin or unfractionated
heparin (UFH) plus a glycoprotein IIb/IIIa inhibitor
Hazard ratiosa (HR) for primary-end point components as
predictors of 30-day mortality in HORIZONS-AMI
multivariate analysis
Major non-CABG-related bleeding
End point
HR (95% CI)
p
as well as reinfarction were both
significant predictors of 30-day all-
Reinfarction
9.13 (2.62-31.85)
<0.001
cause mortality in the trial,
Stroke
2.65 (0.74-9.43)
0.13
independent of baseline features
and all other clinical events. A
Ischemia- 1.15 (0.31-4.20)
0.83
major bleeding event, on its own,
driven TVR
raised the mortality risk by a factor
of up to five (p<0.001), depending
Major 5.08 (3.10-8.35)
<0.001
on the analysis.
bleedingb

13. Mortality closely tied to major
bleeds at primary PCI
Pooled analysis from three major bivalirudin trials—
REPLACE-2, ACUITY, and HORIZONS: PCI during
ACS-STEMI (from the last four years)
Independent hazard ratio of non-CABG-related major
bleeding and MI within 30 days on mortality within one
year
Event
Hazard ratio
Deaths within 1 y, n p
(95% CI)
Non-CABG 3.1 (2.4-3.9)
104
<0.001
major bleed
MI
2.8 (2.2-3.6)
77
<0.001
Data presented at the European Society of Cardiology 9/09 Congress-Barcelona

14. Studies of the Impact of Blood Transfusion on Mortality After PCI
Impact of
Transfusion on
Frequency of Mortality [95%
Patient STEMI Blood Confidence
Author (Ref. #) Patients (n) Population Included? Transfusion (%) Interval] p Value
Jani et al. (12) 4,623 Anemic patients Yes 22.3 In-hospital, <0.0001
with MI adjusted OR:
2.02 [1.47–
2.79]
Doyle et al. (6) 17,901 Unselected Yes 6.8 30 days, 1–2 U <0.0001
adjusted HR:
8.9 [6.3–12.6]
3+ U adjusted <0.0001
HR: 18.1 [13.7–
24]
Kinnaird et al. 10,974 Unselected Yes 5.4 1 year, OR per <0.0001
(1) unit transfused:
1.47 [1.36–
1.55]
Kim et al. (5)* 567* Severe bleeding Yes 25.7 1 year, RR: 2.03 0.0028
Chase et al. (13) 38,872 Unselected Yes 3.5 30-day adjusted <0.0001
OR: 4.01 [3.08–
5.22]
Doyle, B. J. et al. J Am Coll Cardiol 2009;53:2019-2027 1-year adjusted <0.0001
OR: 3.58 [2.94–
4.36]

15. Possible Mechanisms Linking Post-Percutaneous Coronary Intervention Bleeding With
Increased Mortality
In 85% of cases!!!
Doyle, B. J. et al. J Am Coll Cardiol 2009;53:2019-2027
Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.

16. The Hillel Yaffe Medical
Center Experience with
Trans-Radial Approach for
Primary PCI

17. Trans-Radial Approach for
Primary PCI
Methods: More than 90% of the procedures in our
Cath Lab are done as trans-radial approach. Since
January 2007 we adopted the radial approach for all
new patients with STEMI referred to primary PCI.
Patients with weak radial pulse, severe
dysrhythmias, CHF or hypotension were excluded.
We used published world data on primary PCI for
time table, fluoroscopy time and contrast volume
reference.

18. Trans-Radial Approach for
Primary PCI
Results: 98 STEMI patients, 88 males, 10
females, mean age 58±12 years, underwent
primary PCI/TRA as a routine procedure (right
radial all).
IRA were: LAD: 42, LCX: 15, RCA: 41.
Full patency restoration of the IRA was achieved
in 100% of the patients.

19. Trans-Radial Approach for
Primary PCI
In 32 cases we used thrombus aspiration
devices.
In 5 patients a bifurcation PCI with kissing
balloon was performed successfully.
Ten patients had slow reflow phenomenon
resolved after IC Adenosine injection.
In 4 cases IABP was inserted trough the
femoral artery due to low blood pressure
and slow reflow.

20. Trans-Radial Approach for
Primary PCI
There were no major bleeding, pseudo-aneurysm
or fistula. There was no need for blood transfusion
In one case (treated by Integrilin Heparin and
Plavix) there was a large hematoma in groin (IABP
insertion site) and small one in the forearm. There
were 5 more cases with minor hematoma in the
forearm.
There was no cerebral ischemic event.

21. Time Table, Fluoroscopy time,
Contrast volume
World data Our experience in PCI/
TRA
Symptom onset Median 218 min 90-840 (median 267)
to Balloon min
Hospital door to 83-120 (median 116) 45-180 (median 72) min
Balloon min
Cath Lab door to 20-53 min 20-35 (median 27) min
Balloon
Fluoroscopy time 18.3 ± 12.2 min 8±5 min
Contrast volume 265±130 ml 161±63 ml
PCI/TRA: Primary PCI using trans-radial approach

22. Trans-Radial Approach for
Primary PCI
Conclusions: Following a meticulous
learning curve, the trans-radial approach
can be applied for primary PCI with high
success rate, short door to balloon
interval, and low complication rate. This
approach improves patient’s convenience
and well being.

23. Trans-Radial Approach for
Primary PCI
The very low bleeding and vascular
complication rate increases the safety margin
for this procedure that involves intense use of
anti-coagulation/aggregation medications and
can improves long term survival.
We are now in a process of assessing the
long term outcome of these patients.

24. Thank You