Access site choice and risk adverse neurological events, CS Kwok

1. AIM-Radial September 2016
Access site choice for cardiac catheterization and risk
of adverse neurological events: A systematic review
and meta-analysis
Presented by:
Dr Chun Shing Kwok
Academic Clinical Fellow in Cardiology , Honorary Clinical Lecturer
& Specialist Registrar in Cardiology

2. DISCLOSURES
I have no conflict of interest to declare

3. Stroke
• Stroke
– Ischaemic or haemorrhagic
• Rare but devastating
– 0.1% in general population1
– 0.2-0.4% in PCI2
• Associated with MACE and
mortality3
• Mechanism is arterial embolism
– Catheter exchanges4
– Caliber of PCI guide catheter4
– Right radial approach theoretical risk
due to crossing brachiocephalic artery
1Lee S et al. BMJ Open. 2011;1:e000269. 2Hamon M, et al. Circulation. 2008;118:678-683.
3Kwok CS, et al. Eur Heart J .2015;36:1618-28. 4Hoffman SJ, et al. JACC Cardiovasc Interv 2012;5:200-6.

4. • Radial PCI has grown to be
default in UK5
– Reduced mortality, MACE and
bleeding6
• Previous review suggested
no difference in
complications between
radial and femoral access7
• There are new studies so we
performed an updated
review
Radial access
5Mamas MA, et al. Circulation. 2016;133:1655-67. 6Mamas MA, et al. J Am Coll Cardiol.
2014;64:1554-64. 7Patel VG, et al. Int J Cardiol. 2013;168:5234-5238.

5. • Inclusion criteria
– Radial vs femoral cardiac catheterization
– Stroke or subclinical neurological event
– Results for quantitative analysis
• Search MEDLINE and EMBASE Sept 2015
– Population: (angiography or angiogram or catheterization or
catheterization or PCI or percutaneous coronary intervention)
– Exposure: (transradial or transfemoral or radial artery or femoral
artery or radial access or femoral access)
– Outcome: (stroke or microemboli or cerebral infarction or dementia or
cognitive impairment)
• Independent double screening and extraction
• Random effects meta-analysis on Review Manager using
Mantel-Haenszel method
Systematic review and meta-analysis
8Sirker A, et al. Am Heart J. 2016; 181:107-119.

6. Flow diagram

7. Study design
Full table not shown because of constraints of slide.

8. Quality assessment
Full table not shown because of constraints of slide.

9. Results
Full table not shown because of constraints of slide.

10. Results
Stroke rate:
• Radial 0.14%
(358/249,073)
• Femoral 0.19%
(472/251,095)

11. Ischaemic stroke
Haemorrhagic stroke

12. Limitations and Conclusions
Limitations
• Publication bias
• Stroke is rare event need large
studies
• Subclinical lesions
• Unmeasured confounders
• Not individual patient study
Conclusions
• Radial access for cardiac
catheterization is not associated
with an increased risk of stroke
events
• Previous expressed concerns
about risk of neurological
problems is not evidence based
• Our study provides reassurance
regarding risk of neurological
events associated with radial and
femoral approaches

13. Thank you
References
1. Lee S, Shafe AC, Cowie MR. UK stroke incidence, mortality and cardiovascular risk management 1999-2008:
time-trend analysis from the General Practice Research Database. BMJ Open. 2011;1:e000269.
2. Hamon M, Baron JC, Viader F, Hamon M. Periprocedural stroke and cardiac catheterization. Circulation.
2008;118:678-83.
3. Kwok CS, Kontopantelis E, Myint PK, Zaman A, Berry C, Keavney B, Nolan J, Ludman PF, de Belder MA,
Buchan I, Mamas MA. Stroke following percutaneous coronary intervention: type-specific incidence outcomes
and determinants seen by the British Cardiovascular Intervention Society. Eur Heart J. 2015;36:1618-28.
4. Hoffman SJ, Routledge HC, Lennon RJ, Mustafa MZ, Rihal CS, Gersh BJ, Holmes DR Jr, Gulati R. Procedural
factors associated with percutaneous coronary intervention-related ischemic stroke. JACC Cardiovasc Interv.
2012;5:200-6.
5. Mamas MA, Nolan J, de Belder MA, Zaman A, Kinnaird T, Curzen N, Kwok CS, Buchan I, Ludman P,
Kontopantelis E. Changes in arterial access site and association with mortality in the United Kingdom:
Observations from a national percutaneous coronary intervention database. Circulation. 2016;133:1655-67.
6. Mamas MA, Anderson SG, Carr M, Ratib K, Buchan I, Sirker A, Fraser DG, Hildick-Smith D, de Belder M,
Ludman PF, Nolan J. Baseline bleeding risk and arterial access site practice in relation to procedural outcomes
after percutaneous coronary intervention. J Am Coll Cardiol. 2014;64:1554-64.
7. Patel VG, Brayton KM, Kumbhani DJ, Banerjee S, Brilakis ES. Meta-analysis of stroke after transradial versus
transfemoral artery catheterization. Int J Cardiol. 2013;168:5234-5238.
8. Sirker A, Kwok CS, Kotronias R, Bagur R, Bertrand O, Butler R, Berry C, Nolan J, Oldroyd K, Mamas MA.
Influence of access site choice for cardiac catheterization on risk of adverse neurological events: a systematic
review and meta-analysis. Am Heart J. 2016;181:107-119.