Transcript radial vs femoral access

RADIAL OR BUST
The only choice for vascular
access
Jim Nolan
University Hospital of North Staffordshire
United Kingdom
CONFLICTS OF INTEREST
ARTERIAL ACCESS – WHY AM I INTERESTED
(Heart 1995, Am Heart J 1997)
Major Vasacular Complications
20
18 %
15
10
8%
5
1.4 %
0
Leeds Femoral
Bailout
Leeds Femoral
Elective
Leeds Brachial
BRACHIAL CUT DOWN COMPLICATIONS
NEURO-ANATOMY OF THE FEMORAL TRIANGLE
FEMORAL ACCESS PRACTICE
Two weeks at UHNS
FEMORAL ACCESS
COMPLICATIONS
ACTIVE RETROPERITONEAL
BLEED
FEMORAL VASCULAR COMPLICATIONS
IN CONTEMPORARY UK PRACTICE
(Berry et-al, AJC 2004, n = 311)
27
30
26
25
Percentage
20
15
7
6
10
4
1.3
5
0
Haematoma
Groin pain
Large
haematoma
(>5cm)
Vagal
Prolonged
admission
Vascular
intervention
MAJOR VASCULAR
COMPLICATIONS
 1 RPH, 3 Pseudo-aneurysms
 3 GA emergency surgery
 13 units of blood
 Total of 61 extra days in hospital
ANTITHROMBOTIC THERAPY AND
FEMORAL COMPLICATIONS
20
17.5
15
%
10
5.9
5
1.1
0
DIAGNOSTIC
POPULATION
Berry 2004
2.2
ANGINA PCI
POPULATION
Moutralescot
2005
MI/REO-PRO
PCI POPULATION
Otavio 2004
RESCUE PCI
Dauermau 2000
VACD – DEVICE FAILURE RATE
(Sesana et-al, JIC 2000, n = 827)
11
FAILURE RATE (%)
12
10
9
8
6
4
2
0
COLLAGEN PLUG
SUTURE
VCD META ANALYSIS – RANDOMISED +
OBSERVATIONAL
(Nikolsky et-al, JACC 2004, n = 37,066)
DOES IT ALL MATTER?
COMPLICATIONS OF PCI IN CONTEMPORARY
PRACTICE
(Heart 2005, n = 3071)
3
2.5
2
%
1.5
1
0.5
0
CVA
MI
DEATH
MAVE
DOES IT ALL MATTER?
MEDICO-LEGAL CASES ARISING FROM
CARDIAC CATHETERISATION
PROCEDURES (1992-2002 - MDU)
VASCULAR
CARDIAC
CNS
OTHER
NEURO-ANATOMY OF THE WRIST
VASCULAR COMPLICATIONS
(uhns transradial programme)
Heart 2003
RADIAL
FEMORAL
(n=1000)
(n=727)
TRANSFUSION
0 (0%)
4 (0.6%)
VASCULAR INTERVENTION
1 (0.1%)
6 (0.8%)
INFECTION
2 (0.2%)
2 (0.3%)
3 (0.3%)
12 (1.7%)
RADIAL VS FEMORAL ACCESS –
RCT meta analysis
(Agostoni et-al JACC 2004)
number
279
Grinfield
152
Mann
600
ACCESS
112
BRAFE
142
Mann
200
Cooper
210
CARAFE
420
Gorge
Moriyama 200
OCTOPLUS 371
TEMPURA 149
MACE
Procedural
success
Procedural
success
1999-2003
Access site
complications
ARE RADIAL CASES TOO HARD TO DO
(Rao et al, JACCI 2008)
DOES EVERYBODY BENEFIT FROM RADIAL ACCESS
(Rao et-al JACCI 2008)
DOES EVERYBODY BENEFIT FROM RADIAL ACCESS
(Rao et-al JACCI 2008)
DOES EVERYBODY BENEFIT FROM RADIAL ACCESS
(Rao et-al JACCI 2008)
IS PCI RELATED BLEEDING A BAD THING
(MORTAL study, Heart 2008, n=38,872)
DOES PREVENTION OF ACCESS SITE
BLEEDING IMPROVE OUTCOME
(MORTAL study, Heart 2008, n=38,872)
VASCULAR COMPLICATIONS – ECONOMIC IMPACT
(Nowamagbe et-al, JACC 1995, n = 1,012 CAVEAT-1)
LENGTH OF STAY
HOSPITAL COSTS
30,000
14
12.1
12
8
6
25,000
COST ($)
LOS (DAYS)
10
28,003
20,000
15,000
15,499
5.2
10,000
4
5,000
2
0
0
NO COMPLICATION
FEMORAL
COMPLICATION
NO COMPLICATION
FEMORAL
COMPLICATION
TRANSRADIAL APPROACH
PATIENT PREFERENCE
100
Radial
Femoral
percent
80
60
40
20
0
CARAFE 2001
Cooper 1998
Kiemeneij 1996
TRANSRADIAL APPROACH
NURSING PREFERENCE
(Amoroso, EJCVN, 2005, n = 260)
Cath lab
Ward
Femoral
Radial
Femoral
Radial
RADIATION EXPOSURE IS IMPORTANT
Skin injury due to cardiac intervention
RADIATION EXPOSURE IS IMPORTANT
Accessory pathway ablation
3 weeks
5 months
6.5 months
OPERATORS ALSO GET RADIATION
INDUCED SKIN INJURY
UHNS RADIATION EXPOSURE STUDY
Mean fluoroscopy time and patient
and operator radiation doses
(Heart 2007)
P=NS
25
21.9 22.4
20
15
P=NS
10
6.5 5.9
P<0.05
5
2.4 1.5
0
FT (min)
DAP
(Gycm2)
Radial
Femoral
Operator
dose (uSv)
UHNS RADIATION EXPOSURE STUDY
Mean procedure duration (min) and time to ambulation (min)
(Heart 2007)
P<0.0001
300
257.2
250
200
150
100
P<0.005
50
12.6
7.2
6.2
0
Procedural time
Radial
Time to ambulation
Femoral
PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004
TLD BADGE READINGS - UHNS
15
10
5
0
A
B
C
D
E
Mont Blanc Summit Ridge
September 2007
TRANSRADIAL APPROACH
THE LEARNING CURVE
25
23
22
Procedural time / min
21
20
18
Technical failure
18
17
16
14
15
10
13
7%
5%
5%
5
4%
2%
3%
2%
2%
1%
0
1-100 101200
201300
301400
401500
501600
601700

701- 900900 1500
Lefevre TCT 2003
Procedure number
 Puncture failure, spasm, different guide manipulation
 “…the radial approach has become increasingly popular
with the potential advantage of a greater opportunity for
same day discharge”
 “…shorter bed rest and hospital stay when the radial
approach is used”
 “…the use of the radial approach is likely to increase”
RADIAL Vs FEMORAL PCI
(BCIS DATABASE)
40
36.1
35
30
27
25
20
15
10
% of total PCI
15.7
10.3
5
0
2004
2005
2006
2007
THE RADIAL ARTERY






Reduces access site bleeding
Impact on mortality
Efficient
Preferred by patients
Endorsed by BCIS
Taken up by increasing numbers of UK
interventionists
THE ONLY CHOICE FOR VASCULAR ACCESS
THANKS TO MARK GUNNING