radial access just another artery? › wp-content › uploads › 2016 › 12 › oldroyd… ·...
TRANSCRIPT
Radial Access
Just another artery?
Keith G Oldroyd
Department of Cardiology
Western Infirmary
Glasgow
Brachial access
Not just another artery!
Femoral access
Not just another artery!
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
1.20%
Pre Dr X Post Dr X
Incidence of femoral artery false aneurysms
C Ilsley; personal communication
Femoral access
Not just another artery!
• 45 year old women– Moderate obesity
– Elective catheterisation – RFV/RFA
• Major retroperitoneal haemorrhage– CT scan; 6 unit transfusion
– Discharged on day 6
• Readmitted on day 9– RCFA false aneurysm
– Doppler, CT, thrombin injections
• Discharged day 13
Radial access: just another artery?History of transradial catheterisation
• 1964
– Campeau, Montreal Heart Institute
– Cut-down on proximal RRA
• 1970/80’s
– Percutaneous approach
– Axillary > Femoral > Brachial
• 1989
– Percutaneous transradial coronary angiography/PTCA
Radial access: just another artery?Why bother?
• Pre-Colombian
– Aspirin
– Persantin
– Warfarin
– Dextran
– 8-9F sheaths
– 1 week in hospital
– No closure devices
– 10% bleeding
– 5-10% SAT
• Post-Colombian
– Aspirin
– Clopidogrel
– 6F(5F) sheaths
– day case/23 hours
– Closure devices
– <1% bleeding
– <1% SAT
Radial access: just another artery?ACCESS Study
• Randomised comparison of different access sites
• Experienced operators
• No difference in procedural or fluoroscopy times
Radial Brachial Femoral
PCI’s (n) 300 300 300
Coronary cannulation 93% 95.7% 99.7%
Procedural success 91.7% 90.7% 90.7%
Length of stay (days) 1.5(2.5) 1.8(3.8) 1.8(4.2)
Major access site complications 0 2.3 2.0
JACC 1997; 29: 1269-75. Amsterdam, NL
Radial access: just another artery?Carafe Study
• Randomised
• Two experienced
operators
• ~50% follow-on PCI with
closure devices for
femoral cases
• Radial groups
– Reduced pain
– Earlier ambulation and
discharge
– Lower costs
RRA
(n=70)
LRA
(n=70)
Fem
(n=70)
X-overs 1-LRA 0 0
Caths 1.4* 2.1 2.1
Time 12.4 14.2* 11.2
X-rays 3.8 4.2 3.1*
Quality ?LCA OK OK
Vasc.
Complns
0 0 2
CCVI 2001; 52:181-7. Massy, France
Radial access: just another artery?Multiple procedures
• 812 patients
• 1438 procedures
• 6F – 45%
• 5F – 55%
Failed procedures
(%)
5th3rd2nd
30103.5Men
50207.9Women
CCVI 2001;54: 204-8. Fukuoka, Japan
Radial access: just another artery?
Radial access: just another artery?Difficult radial anatomy – small vessels (1)
• Randomised trial of 5Fr vs 6Fr transradial PCI in
171 patients with a +ve Allen test
5Fr 6Fr
Procedural success 95.4% 92.9%
Failed coronary cannulation 1.1% 4.8%
Minor haematoma 1.1% 4.8%
Radial occlusion 1.1% 5.9%
CCVI 2002; 57: 172-6. Greifswa, FRG
Radial access: just another artery?Difficult radial anatomy – small vessels (2)
• 90 patients
• Randomised to
hydrophilic sheath vs
conventional sheath
• Automatic pullback
with an electronic
traction guage
CCVI 2001; 54: 289-94.
Quebec Can0
500
1000
PTF
0
2
4
6
PS
Radial access: just another artery?
Radial access: just another artery?
Radial access: just another artery?
Radial access: just another artery?
Radial access: just another artery?Difficult radial anatomy
• Preprocedural ultrasound in 115 patients
• Anatomic variations in 11 (9.6%)
– Tortuosity 6 - proceed
– Stenoses 2 - proceed
– Hypoplasia 2 - femoral
– Radioulnar loop 1 - femoral
• Success 111 (97.4%)
CCVI 2000; 49: 357-62 Tokyo, Japan
Radial access: just another artery?
Radial access: just another artery?Difficult subclavian anatomy
• Retro-oesophageal right subclavian artery
• 11 patients in 3730 attempted transradial
procedures
• Increased failure rate (7%)
CCVI 2001; 54: 202-3. Massy, France
Radial access: just another artery?Difficult coronary anatomy
• LIMA
– LRA is access site of choice
– Specific catheters to approach from RRA
• RIMA
– RRA is access site of choice
• Anomalous origin of RCA from L sinus of valsalva
– Series of case reports
– RRA appears to be access site of choice
• Saphenous vein grafts
– Avoid during initial experience
Radial access: just another artery?Comparison with closure devices (1)
• Two groups of 109 consecutive PCI’s
• Not randomised but matched for usual
demographic parameters
• Experienced operators
Radial Perclose
Device not used N/A 20 (18%)
Failed haemostasis 0 9 (10%)
Procedural time 44 (22) mins 57 (22) mins*
Ambulated same day 95% 56%
CCVI 2000; 49: 157-9. Raleigh, NC, USA
Radial access: just another artery?Comparison with closure devices (2)
• 6 high volume operators in a high volume centre
• Prospective non-randomised registry
Radial Prostar
PCI’s (n) 376 580
Device not used N/A 3%
Failed haemostasis 0 9.6%
Infection requiring a/b’s 0 2 patients
Transfusion 0 1 patient
CCVI 2000; 51: 417-21. Massy, Fr
Radial access: just another artery?GP IIb/IIIa inhibitors
• 150 consecutive patients treated with GPIIb/IIIa
inhibitors
Radial Femoral
PCI’s (n) 83 67
Event free @ 1/12 94% 94%
Length of stay (days) 5.0 4.9
Major access site
bleeding
0 5 (7.4%)
Eur Heart J 2000; 21: 662-7. Toulouse, Fr.
Radial access: just another artery?Acute myocardial infarction
• Two centre registry of 1224 patients with AMI
treated by primary PCI
Radial Femoral
Closure
Femoral
No closure
PCI’s (n) 277 947
Success 95% 95%
Time No difference
Major access site
bleeding
0 2% 7%
CCVI 2002; 55: 206-11. Massy, Fr
Radial access: just another artery?Non-coronary intervention
• Carotid - Case report– Castriota F et al. J Endovasc Surg 1999; 6: 385-6
• Vertebral - Case report– Fessler RD et al (Buffalo, NY) Neurosurg 2000; 46:
1527-8
• Renal - 25 patients; 27 arteries; 100%
success– Galli Met al (Como, It) J Inv Cardiol 2002; 14:386-90
Radial access: just another artery?Potential effect on interventional activity
• Elective day case PCI
– Reduced costs compared to groin closure
– No failed haemostasis
– Convert beds to reclining chairs
• In-patient PCI programme
– Reduced bed utilisation
– Fewer complications
– Reduced LOS
Radial access: just another artery?
The only artery!
Normal arterial anatomy in forearm
Brachial tortuosity