Transradial Primary PCI: Tips and Tricks for Success

1. Transradial Primary PCI:
Tips and Tricks for Success
TEJAS M. PATEL, MD, DM, FACC, FESC, FSCAI
PROFESSOR & HEAD
Department of Cardiovascular Sciences,
Smt. N.H.L. Municipal Medical College,
Sheth K.M. School of PG Studies & Research,
Sheth V.S. Hospital, Ahmedabad, India.
DIRECTOR
Department of Cardiovascular Sciences,
TCVS (Total Cardiovascular Solutions) Pvt. Ltd.
Ahmedabad, India.

2. Disclosure
I have no relevant disclosure
related to this presentation

3. Am J Cardiol. 1999; 83 (6): 966-8, A10
Efficacy of Transradial Primary Stenting
In Patients With Acute Myocardial Infarction
Ochiai M, Isshiki T, Toyoizumi H et al.
CONCLUSION:
Fifty-six patients with Killip Class I or II were subjected to
TRA for AMI interventions with 100% success in stent
deployment and 97% success in normalization of distal
coronary blood flow. No major vascular complications
occurred in this experience

4. SUCCESS
Transradial PCI in Setting of AMI 96.6%
Tift Mann et al. J Am Coll Cardiol 1999 (n=68) 96%
Delarche N et al. Am J Geritar Cardiol 1999 (n=46) 100%
Kim MH et al. J Invasive Cardiol 2000 (n=30) 90%
Mathias et al. J Invasive Cardiol 2000 (n=14) 100%
Mulkutla SR et al. Catheter Cardiovasc Interv 2002 (n=41) 100%
Hamon M et al. Catheter Cardiovasc Interv 2002 (n=119) 100%
Louvard Y et al. Catheter Cardiovasc Interv 2002 (n=267) 98%
Ziakas A et al. Am J Cardiol 1999 (n=100) 90%
Saito S et al. Catheter Cardiovasc Interv 2002 (n=77) 96%
Valsecchi O et al. Ital Heart J 2003 (n=163) 97%

5. Procedural Success Final TIMI 3 TRI TFI
Flow (n=665) (n=1726)
Tift Mann et al. J Am Coll Cardiol 1999 96 % 96 %
Ziakas A et al. Am J Cardiol 1999 99% 97%
Louvard Y et al. Cath Cardiovasc interv 2002 98% 97%
Saito S et al. Catheter Cardiovasc Interv 2002 96 % 97 %
Valsecchi O et. al Ital Heart J 2003 97% 96%
Pooled data 97% 97%
P = ns in all studies

6. TRI TFI
Major Vascular Complications (n=1604) (n=5211)
Kiemeneij F et al. 1996 J Am Coll Cardiol 0 2%
Ziakas A et al. Am J Cardiol 1999 0 1.5%
Tift Mann et al. J Am Coll Cardiol 1999 0 4%
Choussat R et al. Eur Heart J 2000 0 4.5%
Hildic S et al. 2000 0 6%
Louvard Y et al. Catheter Cardiovasc Interv 2002 0 1.3%
Saito S et al. Catheter Cardiovasc Interv 2002 0 3%
Valsecchi O et al. Ital Heart J 2003 0 1.2%
Lefevre T (TCT 2003) 0 2.3%
Pooled data 0.0% 3.8%

7. TRI: Impact of Gp IIb / IIIa Blockers
Absence of Major Vascular Complications
Major vascular complications TRI TFI
(n=244) (n=1953)
Choussat R et al. Eur Heart J 2000 0 4.5%
ESPRIT trial J Am Coll Cardiol 2003 0.7% 6.6%
Pooled data 0.4% 6.5%

8. TRI in AMI: No Delay In Reperfusion
TRI TFI
PROCEDURAL TIME (min)
(n=945) (n=2802)
Ziakas A et al. Am J Cardiol 1999 43 ± 19 50 ± 28
Louvard Y et al. (Centre A) Catheter Cardiovasc Interv 2002 45 ± 42 43 ± 32
Louvard Y et al. (Centre B) Catheter Cardiovasc Interv 2002 67 ± 25 68 ± 21
Saito S et al. Catheter Cardiovasc Interv 2002 44 ± 18 51 ± 21
Valsecchi O et al. Ital Heart J 2003 62 ± 23 61 ± 22
Lefevre T (TCT 2003) 45 ± 50 48 ± 55
P=ns

9. Catheter Cardiovasc Interv. 2010;75 (5): 695-9
Arterial access and door-to-balloon times for
primary percutaneous coronary intervention in patients
presenting with acute ST-elevation myocardial infarction
Weaver AN, Henderson RA, Gilchrist IC et al.
CONCLUSION:
Patients presenting with STEMI can undergo
successful PCI via radial artery approach without
compromise in D2B times as compared to femoral artery
approach

10. Catheter Cardiovasc Interv. 2010;75(7):991-5
Comparison of door-to-balloon times for primary PCI
using transradial versus transfemoral approach
Pancholy S, Patel T, Sanghvi K et al.
CONCLUSION:
Transradial approach to primary PCI provides similar
door-to-balloon times to transfemoral approach, and
significantly lowers access site related complications,
in patients presenting with STEMI

11. Impact of
bleeding & transfusion on
the procedural outcome

12. Heart 2008;94:1530-1532
EDITORIAL
Should radial artery access be the "gold standard" for PCI?
Martial Hamon1, James Nolan2
1 University Hospital of Caen, Caen, France
2 University Hospital of North Staffordshire, Stoke-on-Trent, UK

13. Catheter Cardiovasc Interv. 2007; 69 (7): 961-6
Access site hematoma requiring blood transfusion predicts
mortality in patients undergoing percutaneous coronary
intervention: data from the National Heart, Lung, and
Blood Institute Dynamic Registry
Yatskar L, Selzer F, Feit F et al.
CONCLUSION:
Access site complications, especially hematoma requiring
transfusion, remain a very important predictor of adverse
procedural success and patient outcome

14. Heart 2008;94:1019-1025
Association of the arterial access site at angioplasty with
transfusion and mortality: the M.O.R.T.A.L study
(Mortality benefit of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg)
A J Chase, E B Fretz, W P Warburton et al.
Design, setting and patients:
By data linkage of three prospectively collated provincial
registries, 38 872 procedures in 32 822 patients in British
Columbia were analysed. The association between access site,
transfusion & outcomes was assessed. Main outcome measures:
30-Day and 1-year mortality

15. CONCLUSION:
• The MORTAL study ,which looked at a
registry of 33,000 Canadian patients,
showed 50% less blood transfusions
and accompanying reductions in
mortality for patient done radially
• By probit regression the absolute
increase in risk of death at 1 year
associated with receiving a transfusion
was 6.78%

16. JACC 2009

17. JACC 2009

18. JACC 2009

19. J Am Coll Cardiol Intv, 2008; 1:379-386
Trends in the Prevalence and Outcomes of Radial and
Femoral Approaches to Percutaneous Coronary
Intervention: A Report From the National Cardiovascular
Data Registry
Sunil V. Rao, Fang-Shu Ou, Tracy Y et al.
CONCLUSION:
Study looked at 593,094 U.S. patients and found that radial
patients experienced 58% less bleeding complications

20. Experience
• From Jan - 1992 to Nov - 2001
• 25,450 Transfemoral procedures
• 6,360 coronary interventions through TFA
• From Dec - 2001 to June - 2011
• 35,202 Transradial procedures
• 9,152 coronary interventions through TRA
• 291 Peripheral intervention through TRA
• 98% procedures through TRA

21. Our Experience
Percutaneous interventions in AMI
(n=880)
Retrospective
analysis
Exclusion (n=26) Transradial
Percutaneous Interventions
in AMI (n=854)

22. Radial Access Major Vascular Complications
Vascular Surgery 0
Hand Ischemia 0
Transfusion (bleeding from puncture site) 0

23. Have there been challenges to performing
transradial interventions in acute MI?
Yes, of course….

24. UNPROTECTED LMCA STENTING
Extensive anterior wall MI-1 hour

32. LMCA total occlusion

39. Complex RCA lesion
Anomalous origin Absence of „nipple‟

43. Deep Intubation in AMI

52. Arteria Lusoria

53. Evolving inferior wall MI:
Challenges encountered

54. Anomalous origin of right subclavian
artery from descending aorta

55. Real Challenge

56. Cobra Loop

57. Cobra Loop

58. Cobra Loop

59. Arteria lusoria with
Subclavian tortuosity

67. Transfemoral Route
We all have seen this happen often…
Big hematoma with extravasation

68. Transfemoral Route
We all have seen this happening at times….
Retroperitoneal hematoma

69. Advantage
• TRA in acute MI situation gives an
operator liberty of performing
intervention even if patient has already
received thrombolysis or GPIIbIIIa
inhibitor
• There is no retroperitoneal space …!

70. J Am Coll Cardiol Intv 2010;3:845-50
Retroperitoneal Hematoma After Percutaneous Coronary
Intervention: Prevalence, Risk factors, Management,
Outcomes & Predictors of Mortality
Santi Trimarchi, Dean E. Smith, David Share et al.
CONCLUSION:
Retroperitoneal hematoma is an uncommon complication of
contemporary percutaneous coronary intervention associated
with high morbidity & mortality. Independent predictors of
mortality in patients with RPH include female sex, history of
MI, cardiogenic shock, renal impairment & LVEF < 50%

71. Clear Choice
We don’t need to wrestle with this question any longer
Transradial route is the clear option for Virtually all patients of AMI

72. A word of caution
Treat AMI patients
via Trans-Radial route only
after your “new learning curve” is over

73. TRI in setting of AMI
• Safe
• Feasible
• Procedural Success and Time
are similar to TFI when performed
by experienced radialists……..

74. TR STEMI Intervention program is an
important off-shoot of an elective TRI
program

75. No formalized guidelines

76. Our Recommendation
• 250 elective coronary angiograms
• 75 elective PCI
through TRA in stable cases…
Why ???

77. Our Recommendation
• 25 hemodynamically stable AMI cases
Over-coming a “new learning curve”
without delay in reperfusion…

78. • Simultaneous wrist and
groin preparation
Why ???

79. • Inject contrast through puncture
cannula before introducing the
sheath
Why ???

80. I am scared of
Bleeding & Major vascular
complications…!!!

82. The Story would have
been different if….

84. Major advantage
Major vascular
complication rate is nearly 0% ...

85. Achilles heel
„A new learning curve‟
&
“Mental block”

86. Thank You
www.transradialWORLD.org