Transradial access for primary percutaneous coronary intervention and shock

1. Transradial Access for Primary
PCI and Shock
Mauricio G. Cohen, MD, FACC, FSCAI
Director, Cardiac Catheterization Lab
Associate Professor of Medicine

2. Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company
Grant/Research Support Astra Zeneca
Consulting Fees/Honoraria Abiomed / Terumo Medical / Accumed /
Medtronic / Edwards Lifesciences / The
Medicines Company / Merit Medical /
Daichii Sankyo
Major Stock Shareholder/Equity Accumed
Royalty Income None
Ownership/Founder None
Intellectual Property Rights None
Other Financial Benefit None

3. RIVAL Trial
Mehta S. et al. J Am Coll Cardiol 2012;60:2490–9

4. STEMI: NCDR CathPCI 2007-2011
n=294,769
1,204 hospitals
Baklanov DV et al. J Am Coll Cardiol 2013;61:420-6

5. Bleeding in Stable angina, NSTEMI, & STEMI
NCDR CathPCI Rates
Rao SV, et. al., JACC 2010
Stable Angina
Overall rate = 2.1%
NSTEMI
Overall rate = 4.8% STEMI
Overall rate = 12.7%

6. Cardiac death Myocardial
Infarction
Target Lesion
Revascularization
Cerebrovascular
Accident
femoral arm radial arm
p = 0.020
30-day MACCE rate
RIFLE STEACS – results
p = 1.000 p = 0.604 p = 0.725
9.2%
5.2%
1.4% 1.2% 1.8% 1.2% 0.6% 0.8%
Romagnoli E et al. J Am Coll Cardiol 2012;60:2481-9

7. 30-day bleeding rate
RIFLE STEACS – results
p = 1.000
12.2%
6.8%
2.6%
5.4% 5.2%
p = 0.026
Bleedings Access site related Non access site related
femoral arm radial arm
7.8%
47%
p = 0.002
Romagnoli E et al. J Am Coll Cardiol 2012;60:2481-9

8. 12 studies
(N = 5,055)
Karrowni,W et al. J Am Coll Cardiol Intv 2013;6:814–23

9. STEMI: The New Frontier
NCDR CathPCI 2007-2011
n=294,769
1,204 hospitals
Baklanov DV et al. J Am Coll Cardiol 2013;61:420-6

10. Issues unique to Primary PCI
• Most important – the team MUST have experience
with radial diagnostic and interventional cases
• Success of transradial primary PCI is dependent
almost entirely on the cath lab staff
 The set-up is the rate-limiting factor
• Starting a transradial primary PCI program is
reasonable when:
 1 year of experience with “radial first” elective PCI
OR
 100 elective PCI cases AND
 Femoral crossover rate ≤ 4%
Rao SV, et. al. Transradial Best Practices. CCI 2014

11. Transfer
to
Cath
Lab
STEMI in
Emergency
Room
Dual antiplatelet Rx
Parenteral
anti-thrombin Rx
Radial
Access
Angio
non-IRA
IRA
PCI of IRA
Left Radial Approach:
→prior CABG
→age ≥ 70 years
→height ≤ 5’5”
> 3 min
> 10 min
> 20 min
FEMORAL BAILOUT
Timeline for TR Primary PCI Access
Rao SV, et. al. Transradial Best Practices. CCI 2014

12. Difference = 3 min
Cantor WJ et al. Circ Cardiovasc Interv. 2015
June 2010 and September 2011
2947 patients
Cath Lab arrival
to first balloon inflation

13. Systematic use of LRA in Primary
PCI
Lahey Clinic as a case study
Larsen P, et. al. CCI 2010

14. Systematic use of LRA in Primary
PCI
Lahey Clinic as a case study
• No left side procedure
failures
• 2 failures from the right
side (n=85)
• Procedure and flouro
times similar
Larsen P, et. al. CCI 2010

15. Inject Culprit or Non-Culprit First?
PCI First
(n=562)
Angio First
(1,338)
P-value
Contrast (ml) 187±64 183±67 0.25
DTB (min) 32 (24-52) 40 (30-69) <0.0001
DTB ≤ 60 min 80% 71% <0.0001
DTB ≤ 90 min 93% 84% <0.0001
Procedure time (min) 42±22 41±21 0.47
Fluoro time (min) 11±9 12±8 0.23
Plourde G et al. Am J Cardiol 2013;111:836-840

16. How About Using a Single Catheter?
Needle to Balloon Time
Moon KW et al. J Interven Cardiol 2012;25:330–336
13.8 14.1
7.6

17. PCI to LAD

18. Engagement of RCA

20. Challenges in Shock Patients
• Simultaneous resuscitation efforts
 Airway – Ventilation
 Hypotension – Hypoperfusion
 Non-palpable pulses
• Need for percutaneous LV assist device

21. Am Heart J 2014;167:900-908
Utilization Radial and Femoral Access in Patients with Cardiogenic Shock
(January 2006-December 2012)

22. Am Heart J 2014;167:900-908
30-day mortality HR 0.56 95% CI 0.46-0.69 P < 0.001
In-hospital MACCE HR 0.64 95% CI 0.53-0.76 P < .0001
Major bleeding HR 0.37 95% CI 0.18-0.73 P < .004
p< 0.001

23. Pancholy S et al. Am Heart J 2015;170:353-361
8 studies - 8,131 patients with CS undergoing PCI
TRA: 2,321 – TFA: 5,810 patients)

24. Femoral
(n=209)
Radial
(n=112)
P value
NACE 57.4% 36.6% 0.001
MACCE 38.3% 25.9% 0.027
Death 34.9% 19.6% 0.004
Bleeding 33.5% 16.1% 0.001
Access related 18.7% 6.3% 0.002
Non-access related 14.8% 9.8% 0.204
Transfusions 14.8% 9.8% 0.023
Romagnoli E, et al Am Heart J 2015;170:353-361

25. Ultrasound Guided Access

26. Ultrasound Guided Access

27. 3.05
1.65
0
1
2
3
4
Attempts
Palpation
Number of Attempts
p<0.0001
Ultrasound
N = 237 N = 236
43.9%
64.8%
0%
20%
40%
60%
80%
100%
Percentage
First Pass Success Rate
p<0.0001
UltrasoundPalpation
N = 237 N = 236
Seto A et al. JACC Intv 2015;8:283–91

28. Use Ultrasound and Fluoro to Guide Femoral Access for PLVAD

30. Conclusions
• Transradial access in primary PCI is
associated with a consistent mortality benefit
• Need established transradial program
 Skilled operators / Trained staff
• Technical aspects
 Consider left TR access in selected patients
 Use ultrasound guidance
 Consider single catheter techniques
• Shock is not a contraindication
 Observational studies suggest benefit
 Overcome challenges