Transradial Intervention in Chronic kidney Disease (CKD) Patients

1. TRI in Chronic Kidney
Disease (CKD) Patients
Bernard Chevalier
ICPS Massy
FRance
Chamonix – Mont-Blanc 1-2 Avril 2011

2. SPECIFIC FEATURES OF CAD IN CKD PTS
PCI IN CKD PTS
RENAL PROTECTION FOR CKD PTS

3. CKD (GFR<60): A risk factor
Insuffisance Rénale Dialysée
• HTN, LVH, CHF
• >35% of CKD pts have evidence of
ischemic disease at the time of
presentation to nephrologist
• Prognosis is mainly related to the severity
of atheroma before End-Stage Renal
Disease (ESRD)
• Importance of ischemia detection

4. Athérosclérose Accélérée
Not specific risk factors
• Age
• Male gender
• HTN
• Diabetes
• Dyslipidemia
• Smoking
Specific risk factors:
• Hyperparathyroidism
• Hyperphosphatemia
• Anemia
• Hyperhomocystéinémy
• Oxidative stress
• Inflammation
• Renin-angiotensin activation

5. Inflammation-Thrombose
5888 pts > 65 ans, 647 pts(11%) Insuffisants rénaux
M.G. Shlipak et al, Circulation 2003;107:87-92

6. CKD: a predictive factor for CAD
outcome
• 3 times higher 1y mortality in AMI (Shlipak
et al)
• 6 times higher 6 m mortality in GUSTO/
PURSUIT/PARAGON (Suwaidi et al.)
• Higher impact in young CKD patients
• Part of GRACE score with
– HR 2.09 for GFR between 30 & 60 (stage 3)
– HR 3.71 for GFR < 30 (stage 4&5)

7. CKD: impact on treatment
• In case of ACS, CKD pts
– Are underdiagnosed
– Receive less « guidelines » medications
– Have more limited access to angiography
– Get less PCI
– Have less secondary prevention medication
• However PCI pts have similar longterm
decrease of renal function than medically
treated pts

8. Coronary disease in ESRD
• Cardiovascular disease is the leading
cause of mortality
• 10 times risk than 5 Framingham RF pts!

9. Survie chez les patients dialysés
Sarnak MJ. Circulation 2003;108:2154-69

10. Vascular calcification
• Consequence of bone mineral disorder
• Accelerated on dialysis patients
• Possible ways to limit:
– Dialysis protocol, low dose Vit D regimen,
sevelamer
• Has direct impact on
– Quality of PCI (plaque modification/stent
deployment)
– Quality of hemostasis at vascular access

11. ATHEROME de l’INSUFFISANT RENAL
PCI in CKD Patients
RISQUE et PREVENTION du
d’INSUFFISANCE RENALE en
CARDIOLOGIE INTERVENTIONNELLE

12. Higher number of PCI
• Severity of disease &
crucial role of PCI
• Higher rate of recurrence
after DES

13. Bleeding risk of PCI in CKD

15. Bleeding
profile

16. Yatskar L, Catheterization and Cardiovascular Interventions 69:961–966 (2007)

17. Bleeding in all comers

18. Impact of In-Hospital Major Bleeding on
Early and Late Mortality in REPLACE-2
Stone GW J Invas Cardiol 2004, 16(suppl G): 12G-17G

19. Adverse effect of transfusion?

20. Pros TRI in CKD
Less bleeding / Less renal event

21. P. Agostoni JACC 2004; 44:349-56

22. Cantor W, Catheterization and Cardiovascular Interventions 69:73–83 (2007)

23. Primary Angioplasty
Moins de Complications Locales
20
p < 0.01
Acces Site Complications (%)
15
p < 0.05
10 p < 0.05
5
0
TRA FA Perclose FA Manual
Y. Louvard et al. CCVI 2002; 55: 206-211

24. Vuurmans T, Heart 2010;96:1538-1542.

25. Vuurmans T, Heart 2010;96:1538-1542.

26. Vuurmans T, Heart 2010;96:1538-1542.

27. Cons for TRI in CKD
Radial occlusion

28. Radial in ESRD?
• Vascular access is the lifeline !
• Native AV Fistula > Prothetic graft > central
venous catheter
– Impact on prognosis
• Non maturation 20 to 50% (artery diameter
> 2 mm, more predictable in forearm)
• Venous neointimal hyperplasia (vein
quality) alters patency: 12 to 18 months
• Forearm AV fistula are the best ones (?)

29. Sheath/artery ratio

30. COMPRESSION RADIALE
- 300 patients
- Compression with elastic dressings as
shorter as possible
- Doppler evaluation
- Early results: 4 radial occluded (1.3%) :
- Late results: about 270 patients
• any new occlusion after hospital discharge
• about 4 initial occlusions : 3 spontaneous
recanalization and 1 persistent
less than 1% radial occlusion rate
Monségu Ann Cardiol Angeiol 2003; 52: 135-8

31. Relationship between compression and
radial occlusion
Radial patent Radial occlusion p
10.5%
No flow before 49% 54% 0.41
sheath removal
No flow after 63% 66% 0.49
placing
compression
No flow before 54% 90% 0.002
compression
removal
Sanmartin Catheter Cardiovasc Interv 2007; 70: 185-9

32. Radial artery occlusion
Pancholy J Invasive Cardiol 2009; 21: 101-4

33. Tips & tricks for TRI in severe CKD
(stage 4 & 5 = GFR < 30)
• Vascular calcification + HTN = loops +++
– Prefer left radial?
• Never use a sheath larger than radial
artery
– 5F PCI or sheathless 6F
– 4F?
• Keep always one radial artery free of
puncture
– If possible the one with best venous system
• Apply good hemostasis technique

34. ATHEROME de l’INSUFFISANT RENAL
RISQUE SAIGNEMENT et
VOIE d’ABORD RADIALE
RENAL PROTECTION for CKD patients

35. 1. HYDRATION
- 100 ml/h Nacl 0.9%/bicarbonate 14/1000 4 h avant
examen
- 1000 ml sérum 0.9%/bicarbonate 14/1000 24h
après examen
2. Low osmolarity contrast media
3. Contrast load < 4 x GFR

36. CKD patients
• Are highly exposed to CAD
• Have a specific vascular atheroma
• With a higher risk of suboptimal result of
PCI with more restenosis risk
• And higher bleeding complications related
to access site
• Leading to a high number of coronary
interventions

37. The choice of TRI
• Limits bleeding & renal events with
significant impact on outcome
• Is possible in pts not yet on dialysis using
very strict rules particularly for ESRD
• Could be considered with a lot of caution
to avoid impairment of existing and future
AV fistula
• Femoral route is a back-up choice using
closure device