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ACCESO RADIAL EN LA ANGIOPLASTIA PRIMARIA:
UN DESAFÍO, UN OBJETIVO
Dr. Jorge Mayol
Centro Cardiológico Americano Montevideo - Uruguay
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Sangrado en ATC según clínica
30%
70% 55%
45% 30%
70%
Angina Estable 7,0%
24% 32%
Rao S et al, Transradial approach for PCI. JACC 2010 Vol. 55, No. 20:2187–95
Acceso Fuera del Acceso
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Heparina NF
Tienopiridina
AAS
Enoxaparina
Inh GP IIb/IIIa
Bivalirudina
Heparina NF
Tienopiridina
AAS
Enoxaparina
Inh GP IIb/IIIa
Bivalirudina
TBL
Antitrombóticos en los SCA
Escenario clínico
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Relación Sangrado -> Muerte
Sangrado Femoral
Discontinuar antiplaquetarios Anemia Transfusión
Reposo prolongado
Estado Protrombótic
o
Mortalidad
Isquemia Inflamació
n Trombosis
(stent)
Eritropoyetina
PAI-1
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Angioplastia Transluminal Coronaria Primaria: elección del acceso
Paciente
> riesgo de sangrado
Hemodinamia inestable (real o potencial)
BIACP
MP transitorio
ATCP
Acortar los tiempos
Catéteres 6 French (Tromboaspiración)
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Muerte: Radial/Femoral en IAMCST
2,5%
6,7% 6,7%
13,6%
0%
5%
10%
15%
Mortalidad 30 d Mortalidad 2 años
Radial Femoral
2006 a 2010 Registro Reino Unido n = 46.128
Femoral n = 28.091 (60,9%) Radial n = 18.037 (39,1%)
p < 0,0001 p < 0,0001
Mamas MA. Influence of Arterial Access Site Selection on Outcomes in Primary Percutaneous Coronary Intervention. Are the Results of Randomized Trials Achievable in Clinical Practice? J Am Coll Cardiol Intv 2013;6-7:698-706
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Muerte: Radial/Femoral en IAMCST 2006 a 2010 Registro Reino Unido n = 46.128
Femoral n = 28.091 (60,9%) Radial n = 18.037 (39,1%)
Mamas MA. Influence of Arterial Access Site Selection on Outcomes in Primary Percutaneous Coronary Intervention. Are the Results of Randomized Trials Achievable in Clinical Practice? J Am Coll Cardiol Intv 2013;6-7:698-706
HR 95% IC p
Edad (años) 1.05 1.04-1.06 <0.0001
Disfunción VI severa 6.23 4.67-8.30 <0.0001
Shock 5.10 3.62-7.18 <0.0001
IABP 3.07 2.15-4.40 <0.0001
* Ajustado por: edad, sexo, diabetes, hipertensión, hipercolesterolemia, tabaquismo, shock, AF, BCIA, IAM previo, cirugía previa, trombectomía, FEVI, año del procedimiento, GP IIbIIIa, acceso vascular.
Análisis Multivariado
Acceso Radial 0.71 0.52-0.97 <0.05
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Jolly S. et. al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 2011; 377: 1409–
20
RIVAL: Comparación Randomizada de Acceso Radial vs Femoral para intervención coronaria en SCA (n=7.021; 28% IAMcST)
Radial (%)
Femoral (%)
HR 95% IC p
Endpoint 1ario MACE*
3.7 4.0 0.92
0.72-1.17 NS
Endpoint 2ario Sangrado no Q.
0.7 0.9 0.73 0.43-1.23 NS
Complicación mayor del acceso 1.4 3.7 0.37 0.27-0.52
<0.0001
Sangrado mayor ACUITY 1.9 4.5 0.43 0.32-0.57 <0.000
1 *MACE: muerte, IAM, stroke, sangrado mayor no Q
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Muerte: SCAcEST vs. SCAsEST
Mehta S. et al. RIVAL: Effects of Radial Versus Femoral Artery Access in Patients With Acute Coronary Syndromes With or Without ST-Segment Elevation. JACC Vol. 60, No. 24, 18, 2012:2490–99
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Karrowni et al. Radial Versus Femoral Access in Primary PCI. JACC Intervention. Aug. 2013. Vol 6,8:814-23
Sangrado Acceso: Radial vs. Femoral en IAMCST
Todos (95%) 2390 2466 100% 0.35 (0.25-0.50)
Favorece Radial
Favorece Femoral
Metanálisis 12 Estudios Randomizados
2003 – 2012 n = 4.685
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Karrowni et al. Radial Versus Femoral Access in Primary PCI. JACC Intervention. Aug. 2013. Vol 6,8:814-23
Muerte global: Radial vs. Femoral en IAMCST Metanálisis
12 Estudios Randomizados 2003 - 2012 n = 4.685
Todos (95%) 2308 2377 100% 0.54 (0.40-0.76)
Favorece Radial
Favorece Femoral
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Acceso radial en USA
Feldman T. et al. Adoption of Radial Access in PCI in USA. Circulation. 2013;127:2295-2306
SCAsST Angor Estable IAMST
% R
ad
ial
2007 2008 2009 2010 2011 2012
20
16
12
8
4
0
8%
Paradoja del uso del acceso radial_1
18%
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Wimmer N et al. Risk‐Treatment Paradox in the Selection of Transradial Access for Percutaneous Coronary Intervention.
ahaoa 2013;2:- AHAVolume 2(3):- June 21, 2013
Acceso vascular según riesgo de complicación del acceso femoral en IAMcST
69,7
85,4 89
30,3
14,6 11
0
20
40
60
80
100
<1% 1 - 2% >2%
Femoral
Radial
Lineal (Femoral)
Lineal (Radial)
%
Riesgo predicto de complicación del acceso femoral
Paradoja del uso del acceso radial_2
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Paradoja: “>Riesgo <Radial” Causas:
1. Equipos no consideran el acceso radial
2. Temor a demorar:
1. Necesidad de cruzar a femoral
2. Lograr el acceso vascular
3. Maniobras durante la ATC
Mas temor cuanto menos experiencia
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¿Qué dicen las guías de ATCP?
El acceso radial debiera ser el método preferido,… pero el éxito depende de la experiencia del operador
O’Gara et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. JACC E79 January 29, 2013:e78 140. Vol. 61, No. 4, 2013
2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal (2014) 35, 2541–2619
2013
2014
Es preferible el acceso radial, si es realizado por un operador radial experiente
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Escalera de uso de radial
CACG en hombres <70años
ICP en lesiones Tipo A/B Nivel 1
CACG en SCANST
ICP todos los ptes. estable
CACG en todos los ptes.
Nivel 2
IAMST Nivel 3
Hamon M. et al. Consensus document on the radial approach in percutaneous cardiovascular interventions:
position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care
and Thrombosis of the European Society of Cardiology . EuroIntervention 2013;8:1242-1281
No pacientes
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Duración ATC por radial 1er. año
Looi JL et al. Learning Curve in Transradial Coronary Angiography.
Am J Cardiol. 2011;Volume 108, Issue 8: 1092–1095.
* *
*
*
x x x x Radialistas
Femoralistas
1er 2º 3er 4º Trimestres
p<0.001 p<0.001
NS NS
Du
raci
ón
to
tal (
min
)
0
5
10
15
20
25
30
35
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Ball et al. Characterization of operator learning curve for transradial coronary interventions. Circ Cardiovasc Interv 2011;4:336-41
OR
0 50 100 150 200 250 300
1.00
0.75
0.50
0.25
0.00
Volumen ICP/operador
Cambio de acceso
La mayor caída del OR es luego de los 50. Muy poca caída luego de 100.
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¿Cuánta mas demora?
Dominique Joyal et al. Meta-Analysis of 10 Trials on the Effectiveness of the Radial Versus the Femoral Approach in
Primary Percutaneous Coronary Intervention. Am J Cardiology 2012;109:813-818
tiempos Radial Femoral Δt Valor p
RIVAL Randomización a fin de ATCP
58´ 53´ 5´ 0.0009
Demora media: 1.76 min (0.59-2.92) (95% IC)
*Experiencia de los operadores en radial (>50 PCI/año); ≥ 50% radial
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De Luca G y cols. Time-delay to treatment and mortality in primary angioplasty for acute myocardial infarction: Every minute counts. Circulation 2004. 109:1223
• Relación exponencial entre tiempo “dolor-balón” y mortalidad a 1 año. • Por c/30´ de demora, 8% RR de muerte al año • Por c/1´ de demora, 0,26% RR de muerte al año
Cada minuto cuenta:
Tiempo dolor-balón
Mo
rta
lid
ad
1 a
ño
(%
) p<0.0001
n=1.791 ATC 1aria
0 60 120 180 240 300 360
0
2
4
6
8
10
12
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Boersma E, Maas AC, Deckers JW, et al: Early thrombolytic treatment in acute myocardial infarction: Reappraisal of the golden hour. Lancet 348:771, 1996
Tiempo desde el inicio de los síntomas (hs)
Nº
Vid
as s
alv
adas
por
10
00
pte
s t
rata
dos c
on F
BL
Valoración de la hora dorada
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Acceso radial en el shock
Suele evitarse
Pulso radial mas débil (hipotensión)
Menor evidencia: exclusión de pacientes
con shock en ER
Uso de BIACP promueve “femoral-
femoral” en lugar del “femoral-radial”
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Riesgo de sangrado en ATC
15 5 0
0 10 15
0 15 15
Modelo de riesgo de sangrado NCDR – Cath PCI Registry 2013
5 0 10
0 15
10 0
0 35 35
Rao SV, et al. An updated bleeding model to predict the risk of post-procedure bleeding among patients undergoing PCI: from the National Cardiovascular Data Registry CathPCI Registry. J Am Coll Cardiol Intv 2013;6:897–904.
0 10 25 30
0 20 40 40
0 20
IAMST No Si
Edad (años) <60 60-70 71-79
IMC 20 20-30 31-39
PCI previa No Si
Enf.Renal No Leve Mod. Dialisis
Shock No Si
PCR <24hs. No Si
Mujer No Si
Hb. <13 13-15 >15
PCI Electiva Urg. Emerg
Shock No Si
IAMST No Si
PCI Electiva Urg. Emerg
100 17.00
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Complicaciones en el shock
Femoral (%) Radial (%) p
Muerte 64,3 32,5 0.001
MACE 73,8 43,8 0.001
Comp. del acceso
11,9 2,5 0.03
Transfusión 7,1 0 0.04
Oriol Rodríguez-Leor et al. Transradial percutaneous coronary intervention in cardiogenic shock: A single-center experience. Am Heart J 2013;165:280-5.
Registro 1.400 ptes.; 8,7% shock cardiogénico; 65,5% acceso radial
Análisis Multivariado para riesgo de mortalidad:
Acceso radial: OR: 0.39 [0.15-0.97] [IC:95%]
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Acceso ATCP en IAMcST
Radial (%)
Femoral (%) total
No Shock 4.313 (95,7) 196 (4,4) 4.509
P.Vázquez ; J.Mayol; G.Vignolo; y col. Coronary Interventional Cardiology and Transradial Approach in Uruguay. JIC JANUARY 2015 VOLUME 27/ SUPPLEMENT A AimRADIAL 2014 3rd Advanced International Masterclass. Chicago, Illinois. October 23–25, 2014
* p=<0.001
Registro: 2010 – 2013 n=4.786
Shock 227 (82,2) 50 (17,8) 277 (5,7%)
Paradoja del uso del acceso radial_3
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ATC: Acceso vascular n: 10.510 24% IAMcST
0
200
400
600
800
1000
12002
00
3
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
20
13
20
14
20
15
Radial
Femoral
Cubital
Braquial
Centro Cardiológico Americano - Depto. de Hemodinamia. Montevideo - Uruguay
75,3 86,5
94,0
95,8
94,1
96,3
95,8
95,2 94,4
95,7 96,4 93,9
93,5
ATC
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Acceso radial en ATC en IAMcST: Conclusiones
• El IAMcST es la situación clínica con mayor
riesgo de sangrado
• Disminuye las complicaciones vasculares, el
sangrado y la muerte
• Es la indicación de mayor beneficio
• Mayor beneficio en pacientes de mayor riesgo
(shock cardiogénico)
• Las guías “condicionan” su uso a la experiencia
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Acceso radial en ATC en IAMcST: Mensaje para llevar a casa
Individualizar la decisión: ¿horas de evolución del IAM?
¿riesgo de sangrado?
¿mi experiencia y de mi equipo?
“Mentalidad de primero radial” Femoralistas:
Preparar ambas regiones
Intentar por radial
Rápido cruce si fuera necesario
Acelerar la curva de aprendizaje en el día a día