Distal transradial versus conventional transradial access ...
Sunil V. Rao MD The Duke Clinical Research Institute The Durham VA Medical Center Duke University...
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Transcript of Sunil V. Rao MD The Duke Clinical Research Institute The Durham VA Medical Center Duke University...
Sunil V. Rao MD
The Duke Clinical Research Institute
The Durham VA Medical Center
Duke University Medical Center
Transradial PCI in Octogenarians: Caveats,
Tips, and Tricks
Disclosures
Consultant, Honoraria Sanofi-Aventis/BMS, The Medicines
Company, Terumo Corporation, Astra Zeneca, Eli Lilly/Daiichi-Sankyo, Terumo
Research funding Cordis Corporation, Momenta
Pharmaceuticals, Portola Pharmaceuticals Off-label uses
May be discussed in this presentation
Transradial PCI in elderly patientsIssues
Comorbidities Higher risk – ischemia, bleeding Complex CAD Calcification Tortuous vasculature
These issues are not specific to transradial!!
PCI-related outcomes N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI
Klein LW, et. al. JACC 2002
PCI-related outcomes – Multivariable model N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI
Klein LW, et. al. JACC 2002
Independent predictors of major bleeding in marker- positive acute coronary syndromes
Independent predictors of major bleeding in marker- positive acute coronary syndromes
Moscucci, GRACE Registry, Eur Heart J. 2003 Oct;24(20):1815-23.
Predictors of Major Bleeding in ACS
► Older Age► Female Gender► Renal Failure► History of Bleeding► Right Heart Catheterization► GPIIb-IIIa Antagonists
► Older Age► Female Gender► Renal Failure► History of Bleeding► Right Heart Catheterization► GPIIb-IIIa Antagonists
Risk Factors for Bleeding- Adjusted Analysis
Variable OR 95% CI Square
Female 1.74 1.64-1.85
319.3
Age (per 10 yrs) 1.36 1.31-1.42
223.6
GFR (per 10 ml/min decrease)
1.11 1.10-1.13
210.2
Prior PCI 0.69 0.64-0.73
128.9
Cardiogenic Shock 1.87 1.66-2.10
104.7
Emergent/Salvage PCIUrgent PCI
2.221.46
1.98-2.491.34-1.57
81.7
COPD 1.31 1.23-1.39
70.6
All p values <0.001 Mehta SR. Circulation: CI 2009
Access sites bleeding in “real-world” PCI patients
TIMI Maj TIMI Min0
10
20
30
40
50
60
70
80
90
100
73.459
5.9
0.8
12.5
6.3
2.9
CVAGIRPHematoma
%
Kinnaird et al Am J Cardio 2003
5.4% 12.7%
Transradial PCI in Patients ≥ 75 years oldN=307 pts randomized to radial vs. femoral
RadialN=152
FemoralN=155
P-value
Duration of Dx angio
18.1 15.0 0.009
Fluoro time (min) 5.6 4.7 0.47
Crossover to other access
9% 0.6%
Major adverse events*
0 3.2% < 0.001
*Defined as death, MI, CVA, vascular complications requiring surgery, redcell transfusion, Hgb decrease > 3 g/dl
Achenbach S, et. al. CCI 2008
Transradial PCI – Outcomes by AgeN=593,094 pts in ACC-NCDR CathPCI Registry
< 75 yrs ≥ 75 yrs < 75 yrs ≥ 75 yrs0
0.5
1
1.5
2
2.5
3
3.5
0.47
2.05
0.13
0.44
1.42
2.99
0.62
1.00
r-PCIf-PCI%
Bleeding Complications
Vascular Complications
Rao SV, et. al. JACC:CI 2008
Transradial PCI – Outcomes by AgeN=593,094 pts in ACC-NCDR CathPCI Registry
Rao SV, et. al. JACC:CI 2008
While there is a trend toward less bleeding in the pts ≥ 75 years oldWith the radial approach, it does not reach statistical significance.This underscores the importance of non-access site bleeding
Bleeding and Outcomes
26,452 patients from PURSUIT, PARAGON A, PARAGON B, GUSTO IIb NST
Adjusted hazard ratios for 30d DeathStratified by Procedure and Non-procedure related bleeds
Bleeding severity
Procedure Related
Non-procedure Related
Mild 1.2 2.1*
Moderate 3.7* 2.5*
Severe 16.5* 10.9*
*p<0.0001
Rao SV, et. al. AJC 2005
Excessive Dosing of Antithrombotics by Age
LMW Heparin UF Heparin GP IIb/IIIa0
10
20
30
40
50
60
70
12.5
28.7
8.512.5
3733.1
16.5
38.5
64.5
< 65 yrs 65-75 yrs >75 yrs
% E
xc
es
siv
e D
os
e
Alexander KP, et. al. JAMA 2005
<55 55-64 65-740
2
4
6
8
10
12
14
6.57.1
9.0
11.0
7.0
8.6 8.6
12.2
Heparin(s) + GP IIb/IIIa Bivalirudin
ACUITY PCI: Ischemic outcomes by age
Patient age (years)
P=.75
≥75
P=.30 P=.77
P=.57
(n=1,346) (n=1,483) (n=1,454) (n=897)
Per
cen
tag
e (%
)
Lopes RD, et. al. JACC 2009
<55 55-64 65-740
2
4
6
8
10
12
14
4.3
5.7
6.7
12.3
1.7
3.0
4.2
6.1
Heparin(s) + GP IIb/IIIa Bivalirudin
≥75
ACUITY PCI: Non-CABG bleeding by age
Patient age (years)
(n=897)(n=1,454)(n=1,483)(n=1,346)
P=.007
P=.01P=.03
P=.001
Per
cen
tag
e (%
)
Lopes RD, et. al. JACC 2009
Issues specific to transradial in elderly patients
Tortuosity of arm and chest vessels Low threshold for angiography Deep breath to direct wire Get experience with other catheter curves
Complex PCI – few limitations with currently available 6Fr guiding catheters used via the transradial approach
Transradial PCI in the elderlyConclusions (1)
PCI-related ischemic outcomes have improved in older patients High rates of procedure success Low rates of peri-PCI ischemic events
Reducing bleeding risk is the priority Transradial is associated with reduced bleeding
risk, but… Crossover to femoral may be higher Non-access site related bleeding is important in
older patients
Strategies for reducing bleeding risk in older pateints include: Transradial Pharmacological therapies – appropriate dosing,
alternative antithrombin strategies Transradial tips/tricks
Low threshold for forearm/chest angiography Deep breath to direct equipment Use of other guide catheter curves New technology coming
Transradial PCI in the elderlyConclusions (2)