Neurologic complications after transradial or transfemoral approach for diagnostic and interventional cardiac catheterization.

Transcription

1 Neurologic complications after transradial or transfemoral approach for diagnostic and interventional cardiac catheterization Dr Paolo Buja

2 Trend Patients undergoing PCI in UK FEMORAL RADIAL Ratib JACC CV Int 2015

3 Rationale Catheters designed for TFA: curve, mechanic, size and backup Catheter manipulation: finger- vs wrist-based, clock- vs counterclockwise Friction and resistance points FEMORAL LEFT RADIAL RIGHT RADIAL 1 POINTS 1 POINTS 2 POINTS Modified by Segeve IHS 2011 Technical issues

4 Rationale Tortuosity

5 Rationale Radial embolization risk compared to femoral?

6 Subclinical events Cerebral embolism during left catheterization TC doppler study GAS 92.1% Proportional to contrast volume Especially during catheter flush Radial = femoral Not new cerebral lesions RCT FEMORAL Jurga Stroke % of patients R. RADIAL SOLID 7.9% Radial > femoral Median 56 vs 36 p New cerebral lesions Lund Eur Heart J 2005

7 Subclinical events RADIAL P TC doppler study 100% of patients RIGHT (n 20) LEFT (n 20) Pacchioni Int J Card 2012

8 Subclinical events Neurocognitive impairment MRI Lund Eur Heart J 2005 P 0.03 % DW-MRI cerebral infarct P NS Hamon Am Heart J 2012

9 Characterization of CVA Hemorragic 10% Ischemic transient 21.8% Ischemic permanent 68.2% ISCHEMIC 90% PERMANENT >2/3 Didier Am Heart J 2016, Hoffmann JACC Int 2011

10 Outcome 50 With CVA/TIA 45 Without CVA/TIA 40 P<0.004 for all DEATH HR 10.2 P< y death In-h death CV death MI AKI Bleeding Transfusion Vascular Modified by Didier Am Heart J 2015, Jolly Eur Heart J 2013

11 ????

12 Trend - CVA Pts undergoing PCI from 2002 to 2014 Neurological events 110 = 0.43% Didier Am Heart J 2016

13 Radial vs Femoral femoral- -Registry Registry Pts undergoing PCI Events 386 (0.11%) P NS Pts undergoing PCI Ratib JACC CV Int 2015 and Am Heart J 2013

14 Radial RadialvsvsfemoralFemoralRegistry - RCT MATRIX 8000 ACS undergoing PCI: randomized multicentre trial Stroke incidence and risk COMBINED P NS Valgimigli Lancet 2015

15 Radial vs femoralradial Right vsregistry Left Pts undergoing PCI ,12 p ,1 Ratib Am Heart J ,08 0,06 0,04 0,02 0 RIGHT TRA right LEFT TRA left Biondi-Zoccai Int J Card 2013

16 vs femoralregistrycomplications Independent Radial predictors of neurological Ratib Am Heart J 2013

17 80 Learning curve P P< P Time to PCI end (min) RADIAL 20 FEMORAL 10 LOW MID HIGH PCI/y >146 0 LOW MID HIGH 1 P NS 0,9 0,8 0,7 0,6 Stroke rate (%) 0,5 0,4 0,3 0,2 0,1 0 Jolly JACC 2014 LOW MID HIGH

18 Radial vs femoralregistry Catheter number and size 70 Hoffman JACC Int 2012 No stroke with 5 Fr Guiding catheter caliber No. of catheters 4 5+ Pacchioni Int J Card 2012 % %

19 Radial vs femoralregistry Local complication NERVE DAMAGE Extremely rare Our preference or patient preference/needing? Kanei Cath Card Int 2011

20 Radial vs femoralregistry And our risk? Brain malignancy in 35 interventionalist Half glioblastoma, 86% left temporal Practice: mean 23 years RADIATION Class I carcinogen Known causal agent Roguin Eur Heart J and SOLACI 2014, Eurointerevention 2012 Small studies suggest OR 6 for brain tumors among radiologist

21 Radial vs femoralregistry And our risk? Randomized single center study (n 297) Radiation exposure 50% microsv Radial 100% Femoral Diagnostic PCI Lange Cath Card Int 2006

22 Radial vs femoralregistry And our risk? Radial volume and air kerma (mgy) Radial 1600 Femoral Interaction P P P P LOW MID HIGH PCI/y > LOW MID HIGH Jolly JACC Int 2013

23 Conclusion Overall risk very very low for clinical events: harmful, impressive, permanent, outcome solid embolism (plaque, thrombus) radial= femoral (expert operators) Almost all patients subclinical events: DTC: air embolism during flush or high volume injection MRI: silent ischemia neurocognitive impairment radial > femoral Association to catheter size and number Learning curve Local complications Riks is present also for operators

24 How can we prevent it? Heparinization Catheters: aspirate and flush religiously reduce size minimize manipulation and exchanges Continuous training Choice right vs left radial access on patient s preference Protect yourself

25 Thank you Paolo Buja

26 Rationale Cathter shape and manipulation Catheters are designed for TFA: curve, mechanic, size and backup Catheter movements and holding: - finger- vs wrist-based - clock- vs counterclock-wise JL 3.5 TRA JL 4 TFA Modified by Segeve IHS 2011

27 Rationale RADIAL worse than FEMORAL? Plaque embolization Air embolism Thrombus formation ISCHEMIC TRA = TFA Pharmacological treatment Predisposing anatomy Trauma HEMORRAGIC

28 Characterization Pts undergoing PCI NON TRANISENT 78% CVA incidence 0.37% (n 89) Hoffmann JACC Int 2011

29 Mortality >10000 Pts 1/3 Pts die after PCI related stroke HR (95%CI, ) P< Jolly Eur Heart J 2015

30 Radial vs femoral - Registry Pts undergoing PCI from 2006 to 2012 Neurological events 0.16% Raposo Cath Card Int 2015

31 Radial vs femoral- Registry Pts undergoing PCI TRA = TRF Ratib JACC CV Int 2015

32 Catheters Microemboli occurrence Pacchioni Int J Card 2012

33 Subclinical events TC doppler study 100% of patients FEMORAL Jurga Stroke 2011 R. RADIAL

34 Subclinical events NEUROCOGNITIVE IMPAIRMENT 100% of patients (n 47) TC doppler GAS 92.1% Proportional to contrast volume Especially during catheter flush Radial = femoral SOLID 7.9% Radial > femoral median 56 vs 36 p MRI Lund Eur Heart J 2005

35 Subclinical embolization Silent cerebral infarcts after cardiac catheterization for aortic stenosis: randomized comparison of radial (n 83) vs femoral (n 77) % DW-MRI cerebral infarct (p ns) Hamon Am Heart J 2012

36 Radial vs femoralregistry And our risk? Paolo Buja - December 2015

37 Radial vs femoralregistry And our risk? More patients, more experience Plourde JACC 2015

38 Radial vs femoralregistry And our risk? BRAIN study Radiation exoposure outside and inside the cap Reeves JACC Int 2015