ΚΕΡΚΙΔΙΚΗ ΠΡΟΠΕΛΑΗ ΑΝΑΚΟΠΗΗ ΣΕΛΕΤΣΑΙΩΝ ΔΕΔΟΜΕΝΩΝ

Transcription

1 ΚΕΡΚΙΔΙΚΗ ΠΡΟΠΕΛΑΗ ΑΝΑΚΟΠΗΗ ΣΕΛΕΤΣΑΙΩΝ ΔΕΔΟΜΕΝΩΝ Dr ΝΙΚΟΛΑΟΣ ΚΑΥΚΑΣ MD, FESC Διεσθσνηής, Υπεύθσνος Αιμοδ/κού Εργαζηηρίοσ Καρδιολογική Κλινική Γεν. Νοζοκομείο Κ.Α.Τ.

2 OUTLINE Introduction Radial in the world Economics ppci and Radial Radiation and Radial Technical Issues Conclusions

3 OUTLINE Introduction Radial in the world Economics ppci and Radial Radiation and Radial Technical Issues Conclusions

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5 Therapeutic Hypothesis in the Radial World Association Between Bleeding and Outcome in ACS and PCI Reducing bleeding improves outcome

6 Chatriwalla AK et al. JAMA 2013;

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8 Site of Non-CABG Major Bleeds (RIVAL definition) *Sites of Non Access site Bleed: Gastrointestinal (most common site), ICH, Pericardial Tamponade and Other Jolly SS et al. Am Heart J. 2011;161:254-60

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10 OUTLINE Introduction Radial in the world Economics ppci and Radial Radiation and Radial Technical Issues Conclusions

11 HISTORY of RADIAL APPROACH Rander 1948, radial cutdown 8-10F Campeau 1989, radial angiography Kiemeneij and Laarman, TR for stenting 1993 Technique has gained widespread acceptance

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13 Caputo RP et al. Catheter Cardiovasc Interv. 2011;78:823-39

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26 Cooper et al. Am Heart J 138;430,1999 Jolly et al. Lancet 2011

27 NY Times July 27, 2009

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29 OUTLINE Introduction Radial in the world Economics ppci and Radial Radiation and Radial Technical Issues Conclusions

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42 OUTLINE Introduction Radial in the world Economics ppci and Radial Radiation and Radial Technical Issues Conclusions

43 RIVAL Study Design NSTE-ACS and STEMI (n=7021) Key Inclusion: Intact dual circulation of hand required Interventionalist experienced with both (minimum 50 radial procedures in last year) Randomization Radial Access (n=3507) Femoral Access (n=3514) Blinded Adjudication of Outcomes Primary Outcome: Death, MI, stroke or non-cabg-related Major Bleeding at 30 days Jolly SS et al. Am Heart J. 2011;161:

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47 Radial vs Femoral Randomized Investigation in ST Elevation Acute Coronary Syndrome the RIFLE STEACS study F Principal investigators: E Romagnoli,G Biondi-Zoccai, G Sangiorgi, J Am Coll Cardiol 2012 Dec 18;60(24): R

48 RIFLE STEACS - flow chart Design 1001 patients enrolled between January 2009 and July 2011 in 4 clinical sites in Italy DESIGN: Prospective, randomized (1:1), parallel group, multi-center trial. INCLUSION CRITERIA: all ST Elevation Myocardial infarction (STEMI) eligible for primary percutaneous coronary intervention. ESCLUSION CRITERIA: contraindication to any of both percutaneous arterial access. international normalized ratio (INR) > 2.0. Femoral arm (N=501) Femoral arm (N=534) Clinical follow-up at 1 month in 100% Radial arm (N=500) Radial arm (N=467) Clinical follow-up at 1 month in 100% Intention-to-treat analysis

49 RIFLE STEACS results 30-day bleeding rate femoral arm radial arm p = p = p = % 47% 7.8% 6.8% 2.6% 5.4% 5.2% Bleedings Access site related Non access site related

50 RIFLE STEACS results 30-day MACCE rate p = femoral arm radial arm 9.2% 5.2% p = p = p = % 1.2% 1.8% 1.2% 0.6% 0.8% Cardiac death Myocardial Infarction Target Lesion Revascularization Cerebrovascular Accident

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53 REDUCTION OF MORTALITY IN AMI USE OF CCU FIBRINOLYSIS PRIMARY PCI? PRIMARY PCI WITH RADIAL APPROACH

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55 SAFARI-STEMI Trial

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58 Radial and Women

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61 OUTLINE Introduction Radial in the world Economics ppci and Radial Radiation and Radial Technical Issues Conclusions

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63 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

64 EuroIntervention 2013;9: Radiation - the double-edged sword of interventional procedures 2013 EuroIntervention. All rights reserved.

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66 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

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68 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

69 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

70 JACC Vol. 55,No

71 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

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76 Plourde G et al. AIM RADIAL 2013

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78 EuroIntervention 2013;9: A novel lead attenuator to reduce operator exposure to scattered radiation in transradial coronary procedures 2013 EuroIntervention. All rights reserved.

79 EuroIntervention 2013;9: A novel lead attenuator to reduce operator exposure to scattered radiation in transradial coronary procedures 2013 EuroIntervention. All rights reserved.

80 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

81 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

82 OUTLINE Introduction Radial in the world Economics ppci and Radial Radiation and Radial Technical Issues Conclusions

83 Allen s Test

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86 OCT Radial after sheath removal

87 OCT Radial after sheath removal of 2nd cath.

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93 Introducers and Radial artery 6F in 82-92% of pts 7F in 57-77% of pts 8F in 25-65% of pts

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96 Theory of Catheter Backup

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100 Beyond the coronaries.

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103 EuroIntervention 2010 Jun;6(2):240-6.

104 Κερκιδική Προζπέλαζη ζε Σύμπλοκες βλάβες Σηεθανιαίων αγγείων, ζε αζθενή με πρόζθαηο τειροσργηθέν ανεύρσζμα κοιλιακής αορηής Κασκάς Ν,.Μπάμπαλης Δ. ΕΚΕ 2011,52:124-8

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107 ΤΧΝΟΣΗΣΑ ΑΙΣΙΑ ΚΑΙ ΠΡΟΒΛΕΠΣΙΚΟΙ ΠΑΡΑΓΟΝΣΕ ΑΠΟΣΤΧΙΑ ΚΕΡΚΙΔΙΚΗ ΠΡΟΠΕΛΑΗ ΕΝΔΕΙΞΗ ΚΑΘΕΣΗΡΙΑΜΟΤ Ο 55% ΛΟΙΠΑ 45% ΑΠΟΣΤΧΙΑ ΚΕΡΚΙΔΙΚΗ ΠΡΟΠΕΛΑΗ 5,9% Το υψηλότερο ποςοςτό αποτυχίασ κατεγράφη ςε γυναίκεσ>70 ετών και το μικρότερο ςε άνδρεσ< 70 ετών (10,9% ζναντι 5,8%) πασμός: 2,3% Ελικώσεις κερκιδικής: 1,3% Ελικώσεις Βραχ/λικού τελέχους: 1,2% Αποτυχία παρακέντησης: 0,7% Κακή στήριξη καθετήρα : 0,4%

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109 CONCLUSIONS RADIAL APPROACH (-) (+)

110 FUTURE Studies involving transradial prosedures should focus on: Minimize radial artery injury Discover methods to reduce fluoroscopy times and radiation exposure Best practices for the application of transradial primary PCI

111 Σας Eυχαριστώ

112 EuroIntervention 2013;9: A novel lead attenuator to reduce operator exposure to scattered radiation in transradial coronary procedures 2013 EuroIntervention. All rights reserved.

113 EuroIntervention 2013;9: A review of radiation exposures associated with radial cardiac catheterisation 2013 EuroIntervention. All rights reserved.

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115 Challenges during RA puncture

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119 Risk of death (hazard Ratio) Procedure- and Non-Procedure-Related Bleeds are Associated with an higher 30-Day Mortality in NSTEMI N=26,452 ACS patients from GUSTO IIb, PURSUIT and PARAGON A & B Procedure-related GUSTO bleeds Non-procedure-related GUSTO bleeds None Mild Moderate Severe None Mild Moderate Severe Rao et al. Am J Cardiol 2005;96:

120 Other Outcomes Radial (n=3507) % Femoral (n=3514) % HR 95% CI P Major Vascular Access Site Complications Other Definitions of Major Bleeding TIMI Non-CABG Major Bleeding < ACUITY Non-CABG Major Bleeding* < * Post Hoc analysis

121 R I V A L Subgroups: Primary Outcome Death, MI, Stroke or non-cabg major Bleed Overall Age <75 75 Gender Female Male BMI < >35 Radial PCI Volume by Operator >142.5 Radial PCI Volume by Centre Lowest Tertile Middle Tertile Highest Tertile Diagnosis at presentation NSTE-ACS STEMI Radial better Femoral better Hazard Ratio (95% CI) p-value Interaction

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