Radial Artery Access: The Basics

Transcription

1 Radial Artery Access: The Basics Jeffrey J. Popma, MD Professor of Medicine Harvard Medical School Director, Interventional Cardiology Beth Israel Deaconess Medical Center Boston, MA 1

2 Radial Artery Access: The Basics History of Radial Artery Access Patient Selection Anatomic Considerations Procedural Tips and Tricks Equipment Selection Expanding Evidence Base 2

3 Stig Radner - Sweden

4 Ferdinand Kiemeneij - Amsterdam First radial PTCA First radial stent First outpatient radial PCI 4

5 Humble Beginnings of TRI Ferdinand Kiemeneij, Amsterdam Early 1990s 5

6 Palmaz-Schatz from the Wrist: 1993 Kiemeneij CCD 1993; 30: 173 6

7 ACCESS: Earliest RCT Radial V. Femoral There were no differences in MACE but reduced access site complications in this low risk population 2.5 Access Complications % 2.0% % Brachial Femoral Radial Kiemeneij et al JACC 1997;29:1269 7

8 Impact of TRI on Outcomes My favorite Jennifer Tremmel s Quote It s not that easy.. but it s not that hard Lack of training, education systems, additional CPT reimbursement, and time commitment required by operators is the major barrier to expanded use of transradial intervention but we need clinical trial data for: FDA Society Guidelines CMS endorsements 8

9 Radial Artery Access: The Basics History of Radial Artery Access Patient Selection Anatomic Considerations Procedural Tips and Tricks Equipment Selection Expanding Evidence Base 9

10 Use of Radial Access Varies by Country 10

11 Radial Artery Access is Expanding in US Feldman Circulation

12 No Randomized Data Needed Femoral Access Not Possible Obese Patients Anticoagulated Patients 12

13 No Randomized Data Needed Hildick-Smith CCI 2004; 61:

14 Therapy with vitamin K antagonists was maintained in all patients No bleeding complication except one patient had epistaxis at 8 days Provides evidence for safety of this approach in patients on warfarin therapy 14

15 Radial Artery Access: The Basics History of Radial Artery Access Patient Selection Anatomic Considerations Procedural Tips and Tricks Equipment Selection Expanding Evidence Base 15

16 Basic Forearm Anatomy Radial artery Smaller than ulnar More superficial Not a terminal artery Anatomic communication with ulnar artery Gray's Anatomy, 20th U.S. edition of Gray's Anatomy of the Human Body,

17 Recurrent Radial Artery Gray's Anatomy, 20th U.S. edition of Gray's Anatomy of the Human Body,

18 Radial Artery Loops Images courtesy of Mladen I. Vidovich, MD 18

19 Arteria Lusoria Aberrant right subclavian artery Runs posterior to esophagus Incidence ~ 1% Copyright Dr. Michell Royon, Wikipedia Commons under the GNU Free Documentation License 19

20 Radial Artery Access: The Basics History of Radial Artery Access Patient Selection Anatomic Considerations Procedural Tips and Tricks Equipment Selection Expanding Evidence Base 20

21 Radial Artery Access: Equipment 21

22 The Stick Radial Artery Access: Equipment cc SC lidocaine small bleb w/ 20G needle - too much local anesthetic can obliterate pulse). User-friendly transradial sheath kits (21-G single-entry Seldinger technique /sleeve or sheath). Recommended: Access 1-2 cm proximal flexor crease Exact location of stick much less important than for transfemoral approach. Enter at degree from horizontal (more shallow than femoral) 22

23 Radial Artery Spasm with Initial Puncture Sublingual nitroglycerin tablet 0.4 mg Subcutaneous nitroglycerin 100 mcg More Conscious sedation Courtesy of Kintur Sanghvi MD FACC FSCAI Deborah Heart and Vascular 23

24 Radial Artery Access: Trouble Shooting Difficulty Advancing Sheath Don t Push Radial artery angiogram is extremely useful to understand radial loop/dissection/ perforation Downsizing the sheath to 4 French sheath due to a small radial artery diameterl Shoulder Tortuosity Lubricious 0.35 guide wire Magic Torque of Wholey wire Hydrophilic Tactile feedback + fluoroscopy Avoid engaging carotids/vertebrals 300 cm exchange-length wire after access Tall pts > 6 4 or sleeve > 36 longer catheter 24

25 Radial Artery Access: The Basics History of Radial Artery Access Patient Selection Anatomic Considerations Procedural Tips and Tricks Equipment Selection Expanding Evidence Base 25

26 Guide Catheter choice XB VODA JL 3.5 AR1 MAC 3.0 EBU JR4 26

27 International Survey of Radialist J Am Coll Cardiol Intv. 2010;3(10): doi: /j.jcin

28 Guide Liner Extra Support 28

29 Radial Artery Access: The Basics History of Radial Artery Access Patient Selection Anatomic Considerations Procedural Tips and Tricks Equipment Selection Expanding Evidence Base 29

30 Meta-Analysis: Major Bleeding is Reduced Jolly SS, et al. Am Heart J. 2009;157:

31 R I V A L RIVAL - Trial 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:

32 R I V A L Outcomes stratified by STEMI vs. NSTEACS 2N Primary Outcome NSTE/ACS 5063 STEMI 1958 Death, MI or stroke NSTE/ACS 5063 STEMI 1958 Death NSTE/ACS STEMI Non CABG Major Bleed NSTE/ACS 5063 STEMI Major Vascular Complications NSTE/ACS STEMI % % Radial Femoral Interaction p-value Radial better Femoral better

33 LBCT TCT 2013 Tuesday Oct 29, 2013 A Registry-Based Randomized Trial Comparing Radial and Femoral Approaches In Women Undergoing Percutaneous Coronary Intervention: The Study of Access site For Enhancement of PCI for Women (SAFE-PCI for Women) Trial Sunil V. Rao MD, Connie N. Hess MD, Britt Barham, Laura H. Aberle BSPH, Kevin Anstrom PhD, Tejan B. Patel MD, Jesse P. Jorgensen MD, Ernest L. Mazzaferri MD, Sanjit S. Jolly MD, Alice Jacobs MD, L. Kristin Newby MD, C. Michael Gibson MD, David F. Kong MD, Roxana Mehran MD, Ron Waksman MD, Ian C. Gilchrist MD, Brian J. McCourt, Eric D. Peterson MD MPH, Robert A. Harrington MD, Mitchell W. Krucoff MD on behalf of the SAFE-PCI for Women Investigators

34 Trial conduct After 1120 women had been randomized, routine review of trial endpoints by DSMB Primary efficacy event rate markedly lower than expected Trial unlikely to show a difference at the planned sample size Recommended termination of the trial No harm noted in either the radial or femoral groups Steering committee voted to continue study until enrollment in a quality-of-life substudy was complete (N=300)

35 Results Primary efficacy and feasibility endpoints Total randomized cohort Radial (N=893) Femoral (N=894) OR (95% CI) P BARC 2, 3, 5 bleeding or Vasc Complications Access site crossover 0.6% 1.7% 0.3 ( ) % 1.9% 3.7 ( ) <0.001 Interaction term for primary efficacy endpoint not significant for PCI vs. no PCI Most common reason for needing to convert from radial to femoral access to complete the procedure was radial artery spasm (43.6% of crossovers) Only one patient did not have the procedure successfully completed was randomized to femoral

36 Results Secondary endpoints PCI cohort Radial (N=290) Femoral (N=291) P Procedure duration (min) 51.6 ± ± Total radiation dose (mgy) 1604 ± ± Total contrast volume (ml) ± ± day death, vascular complications, or unplanned revasc Patient prefers assigned access site for next procedure 5.2% 3.4% % 23.5%

37 The Future: Transradial Lounge St. Joseph s Heart and Vascular Institute Images courtesy of Jack P. Chen, MD 37