Post-Procedure Care and Same-Day PCI. Arnold Seto, MD, MPA
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1 Post-Procedure Care and Same-Day PCI Arnold Seto, MD, MPA
2 Post-Procedure Care Success of radial program depends upon effective access site management Training of staff critical to increase comfort with new procedures
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4 Post Procedure Care o Sheath removed immediately independent of anticoagulation status o Application of compression device o Patient can sit up right away o Circulation checks
5 Various Products available Hemoband TR Band Bengal Band Finale Helix RadiStop
6 Bertrand, JACC: Interv (10):
7
8 Typical TR band protocol Withdraw sheath 2-3 cm from vessel Apply band with green marker over puncture site Inflate cc air using Inflator Remove sheath Deflate band until bleeding is observed, inflate 2 cc additional to ensure hemostasis Check distal radial pulsation or oximetry Tape TR band syringe to patient Deflate band in 2 hours (diagnostic cath) or 4 hours (PCI) and remove. Progressive deflation unnecessary. Reinflate if bleeding occurs.
9 Pancholy, SB, J Int Card 21; 2009
10 Impact of Two Different Hemostatic Devices (Hemoband vs TR band) on Radial Artery Outcomes after Transradial Catheterization. Pancholy, SB, J Int Card 21; 2009
11 Pancholy, CCI 2008, 72: Patent Hemostasis
12 Patent Hemostasis Impact on radial artery occlusion rates MAP guided Standard 15 cc (n=176) (n=175) P MAP (mm Hg) 98 ± 15 95± 18 NS Pressure exerted (mm Hg) 102 ± ± cc of Air 9 ± 2 15 ± Compression time (min) NS Radial occlusion (%) 2 (1) 21(12) Cubero et al, CCI 73:467, 2009
13 Post-Procedure Assessment Assess for bleeding Assess for pain Assess for radial artery occlusion
14 Kanei, CCI 2011 May, epub Complications
15
16 Radial Artery Occlusion? Bertrand, JACC: Interv (10):
17 Reverse Allen s Test
18 Radial Artery Occlusion: Rx Asymptomatic no Rx? Symptomatic Warm compresses Vasodilators LMWH x 4 wks 1 may lead to 67-83% recanalization Radial artery angioplasty Retrograde Antegrade 1. Zankl. Clin Res Cardiol :841-7
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20 Discharge Instructions Avoidance of heavy lifting (>5 lbs) or pushing off with affected wrist for 24-48hrs Tegaderm 24 hours Do not submerge wrist in water for 3 days Patients can ambulate after moderate sedation wears off
21 Same day discharge after PCI Transradial access offers rapid hemostasis and immediate ambulation Discharge or transfer is facilitated Current practice survey: 13% of radial operators discharge >50% of PCIs on same day Third party payers/providers may increasingly pursue same day discharge. Bertrand, JACC: Interv (10):
22 Randomized Trial of Same Day Discharge after Femoral PCI Heyde. Circulation :
23 Randomized Trial of Same Day Discharge after Femoral PCI Heyde. Circulation :
24 Safety of same day discharge after PCI Outcomes of 2400 patients with elective PCI and same day discharge 30 day MACCE and bleeding only 0.96% Radial only in 11 patients, femoral closure in 90% Patel, Sharma. JACC:Interv : 851
25
26 Rao, JAMA Oct 2011
27 Safety of same-day-discharge radial percutaneous coronary intervention 943 Pts same-day discharge radial PCI: entry site complications or repeat angiogram and/or PCI within 24 hours and 1 month, 811 patients responded, 38 patients died, 94 alive but refused to participate/impossible to contact 24 h 1 month Access complication (%) Chest pain (%) repeat angio (%) Vessel occlusion (%) (+ lost for FU pts) 0.2 Ziakas Am Heart J. 2003; 146:
28 Circulation :
29 Economics of Same Day-Discharge after PCI Same day discharge cost $1117 vs $2258 for overnight stay patients. Rinfret JACC:Interv 3(1):1011
30 SCAI Consensus Document on Same-Day PCI 2009 CCI :
31 Going beyond the guidelines 100 consecutive patients with same day PCI, Only 15% met SCAI/ACC guideilnes Gilcrist, CCI, 2011 May
32 Same day discharge after PCI Bertrand, JACC: Interv (10):
33 Summary Same day discharge is potentially feasible in a significant proportion of PCI patients. Appropriate guidelines are critical Radial access facilitates early ambulation and same day discharge Increasing financial limitations may make same-day PCI the norm in the future
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