37th HCS CONGRESS
When I do not go radial
TSIAFOUTIS N IOANNIS INTERVENTIONAL CARDIOLOGIST
RED CROSS HOSPITAL ATHENS
Why radial?
is it really radial? Better say forearm- two radial and two
ulnar art
THE DATA SAY SO
Ulnar Artery Interventions Non-inferior to Radial Approach
“TUA is non-inferior to TRA when performed by an experienced operator. The utilization of TUA as an access site option increases the chance of success with forearm access and reduces the need for crossover to femoral route.”
AJmer Ulnar ARtery (AJULAR) Intervention Working Group Study Results
Rajendra Gokhroo, DM; Kamal Kishor, MD, DM; Bhanwar Ranwa, DM; Devendra Bisht, DM; Sajal Gupta, DM; Deepak Padmanabhan, DM; A. Avinash, DM
J Invasive Cardiol. 2016;28(1):1-8
Why forearm
• Because data say so – guidelines also
• Same day discharge privilege
• Patients’ comfort and willingness
R I V A L
NSTE-ACS and STEMI (n=7021)
Radial Access (n=3507)
Femoral Access (n=3514)
Primary Outcome: Death, MI, stroke or non-CABG-related Major Bleeding at 30 days
Randomization
RIVAL Study Design
Key Inclusion: • Intact dual circulation of hand required • Interventionalist experienced with both (minimum 50 radial
procedures in last year)
Jolly SS et al. Am Heart J. 2011;161:254-60.
Blinded Adjudication of Outcomes
R I V A L
Primary and Secondary Outcomes
Radial(n=3507)
%
Femoral (n=3514)
%HR 95% CI P
Primary OutcomeDeath, MI, Stroke, Non-CABG Major Bleed
3.7 4.0 0.92 0.72-1.17 0.50
Secondary OutcomesDeath, MI, Stroke 3.2 3.2 0.98 0.77-1.28 0.90Non-CABG Major Bleeding 0.7 0.9 0.73 0.43-1.23 0.23
R I V A L
Other Outcomes
Radial(n=3507)
%
Femoral (n=3514)
%HR 95% CI P
Major Vascular Access Site Complications
1.4 3.7 0.37 0.27-0.52 <0.0001
Other Definitions of Major Bleeding
TIMI Non-CABG Major Bleeding
0.5 0.5 1.00 0.53-1.89 1.00
ACUITY Non-CABG Major Bleeding*
1.9 4.5 0.43 0.32-0.57 <0.0001
* Post Hoc analysis
1:1
1:1
NSTEACS or STEMI with invasive management Aspirin+P2Y12 blocker
Trans-Femoral Access
Heparin ±GPI
Bivalirudin Mono-Tx
Stop Infusion
Prolong≥ 6 hs infusion
1:1
Trans-Radial Access
MATRIX Access
Q: Is TRI superior to TFI ?
MATRIX Program registered at ClinicalTrials.gov, number NCT01433627
Am Heart J. 2014 Dec;168(6):838-45.e6.
8.8%
10.3%
15% significant reduction at nominal 5% alpha which is however NOT significant at the pre-specificed alpha of 2.5%
Primary EP: MACE
FemoralRadial
Rate Ratio 0.83; 95% CI, 0.73 to 0.96; p=0.0092
11.7%
9.8%
NNTB: 53FemoralRadial
Primary EP: NACE
Concerns about radial
• Anatomic variants • Low BMI patients • Complex pcis • Dialysis patients • Shock • Candidates for CABG • No access (Buerger,Reunaud) • Cath lab femoral discomfort
Is it suitable for anatomic variations?
• Anomalous origin of right radial artery Remnant radial High take off radial Try left radial or ulnar
• Tortuous artery Hydrophilic wire, coronary wire, balloon
assisted tracking
Balloon assisted tracking
Balloon assisted tracking
Remnant radial then ulnar 7 fr right ulnar
Is it suitable for low bmi pts?
• Not really a problem for 6 fr Try hydrophilic wires or choose left hand
Maybe more difficult 7 fr or more
Is it suitable for dialysis pts?
• Choose the other hand from fistulae Preferably ulnar artery • Allternatives for vascular surgeons
(brachial artery)
Is it suitable for graft use?
• There are data from OCT observation of radial after catheterization showing thickening and inflamation of arterial wall
Yonetsu et al. European Heart J 2010
Is it suitable for complex pcis?
• LMCA • BIFURCATION LESIONS • IVUS • ROTA CASES • CTO CASES • CABG PCI CASES
Left main-IVUS 7 fr radial
Left main-IVUS
Rotablation 7fr right radial burr 1.25- 1.75
Cto 7 fr right radial, 6 fr left radial
Bifurcation lesion tap technique6fr right radial
Use Guide extension support devicesguidezilla case
Use Guide extension support devicesguidezilla case
Use Guide extension support devicesguidezilla case
CABG left forearm for lima, or right with simons catheter
CABGleft ulnar access with left radial used!
Contraindications of “radial”
• Shock • Buerger’s disease • Raynaud syndrome
• 7-8fr guide in low bmi pts
Size matters!!
• The more you do the better you become the further you go
• High volume radial centers diminish femoral cross over
• There are forearm solutions for most cases but not all cases
Red cross cathlab 2015
2.500 coronary angio forearm access >98%
1100 pcis forearm access >95%
Same day discharge 90% coronary angio, 20% elective pcis
Thank you for your attention!