RADIAL OR BUSTRADIAL OR BUSTThe only choice for vascular The only choice for vascular

accessaccess

Jim NolanJim NolanUniversity Hospital of North StaffordshireUniversity Hospital of North Staffordshire

United KingdomUnited Kingdom

CONFLICTS OF INTERESTCONFLICTS OF INTEREST

ARTERIAL ACCESS – WHY AM I ARTERIAL ACCESS – WHY AM I INTERESTEDINTERESTED

(Heart 1995, Am Heart J 1997)(Heart 1995, Am Heart J 1997)

18

8

1.40

5

10

15

20

Leeds FemoralBailout

Leeds FemoralElective

Leeds Brachial

%

%

%

Majo

r V

asacu

lar

Com

plicati

on

s

BRACHIAL CUT DOWN BRACHIAL CUT DOWN COMPLICATIONSCOMPLICATIONS

NEURO-ANATOMY OF THE FEMORAL TRIANGLE

FEMORAL ACCESS PRACTICE FEMORAL ACCESS PRACTICE Two weeks at UHNSTwo weeks at UHNS

FEMORAL ACCESS FEMORAL ACCESS COMPLICATIONSCOMPLICATIONS

ACTIVE RETROPERITONEAL ACTIVE RETROPERITONEAL BLEEDBLEED

FEMORAL VASCULAR COMPLICATIONS FEMORAL VASCULAR COMPLICATIONS IN CONTEMPORARY UK PRACTICEIN CONTEMPORARY UK PRACTICE(Berry et-al, AJC 2004, n = 311)(Berry et-al, AJC 2004, n = 311)

2726

7

4

6

1.3

0

5

10

15

20

25

30

Pe

rce

nta

ge

Haematoma Groin pain Largehaematoma

(>5cm)

Vagal Prolongedadmission

Vascularintervention

MAJOR VASCULAR MAJOR VASCULAR COMPLICATIONSCOMPLICATIONS

1 RPH, 3 Pseudo-aneurysms

3 GA emergency surgery

13 units of blood

Total of 61 extra days in hospital

ANTITHROMBOTIC THERAPY AND ANTITHROMBOTIC THERAPY AND FEMORAL COMPLICATIONSFEMORAL COMPLICATIONS

0

5

10

15

20

%

DIAGNOSTICPOPULATIONBerry 2004

ANGINA PCIPOPULATIONMoutralescot 2005

MI/REO-PROPCI POPULATIONOtavio 2004

1.12.2

5.9

RESCUE PCIDauermau 2000

17.5

VACD – DEVICE FAILURE RATEVACD – DEVICE FAILURE RATE(Sesana et-al, JIC 2000, n = 827)(Sesana et-al, JIC 2000, n = 827)

9

11

0

2

4

6

8

10

12

COLLAGEN PLUG SUTURE

FA

ILU

RE R

ATE (

%)

VCD META ANALYSIS – RANDOMISED + OBSERVATIONAL

(Nikolsky et-al, JACC 2004, n = 37,066)

DOES IT ALL MATTER?DOES IT ALL MATTER?COMPLICATIONS OF PCI IN CONTEMPORARY COMPLICATIONS OF PCI IN CONTEMPORARY

PRACTICEPRACTICE(Heart 2005, n = 3071)(Heart 2005, n = 3071)

0

0.5

1

1.5

2

2.5

3

CVA MI DEATH MAVE

%

DOES IT ALL MATTER?DOES IT ALL MATTER?MEDICO-LEGAL CASES ARISING FROM MEDICO-LEGAL CASES ARISING FROM

CARDIAC CATHETERISATION CARDIAC CATHETERISATION PROCEDURESPROCEDURES (1992-2002 - MDU)(1992-2002 - MDU)

VASCULAR

CARDIAC

CNS

OTHER

NEURO-ANATOMY OF THE WRIST

VASCULAR COMPLICATIONSVASCULAR COMPLICATIONS(uhns transradial programme)(uhns transradial programme)

Heart 2003Heart 2003

RADIALRADIAL FEMORALFEMORAL

(n=1000)(n=1000) (n=727)(n=727)

TRANSFUSIONTRANSFUSION 0 (0%) 0 (0%) 4 (0.6%) 4 (0.6%)

VASCULAR INTERVENTIONVASCULAR INTERVENTION 1 (0.1%) 1 (0.1%) 6 (0.8%) 6 (0.8%)

INFECTIONINFECTION 2 (0.2%) 2 (0.2%) 2 (0.3%) 2 (0.3%)

3 (0.3%)3 (0.3%) 12 (1.7%) 12 (1.7%)

RADIAL VS FEMORAL ACCESS RADIAL VS FEMORAL ACCESS ––

RCT meta analysisRCT meta analysis(Agostoni et-al JACC 2004)(Agostoni et-al JACC 2004)

Grinfield Mann ACCESS BRAFE Mann Cooper CARAFE Gorge Moriyama

OCTOPLUS TEMPURA

MACE Procedural success

Procedural success 1999-2003

Access site complications

number

279

152

600

112

142

200

210

420

200

371

149

ARE RADIAL CASES TOO HARD TO DO ARE RADIAL CASES TOO HARD TO DO (Rao et al, JACCI 2008)(Rao et al, JACCI 2008)

DOES EVERYBODY BENEFIT FROM RADIAL ACCESSDOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)(Rao et-al JACCI 2008)

DOES EVERYBODY BENEFIT FROM RADIAL ACCESSDOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)(Rao et-al JACCI 2008)

DOES EVERYBODY BENEFIT FROM RADIAL ACCESSDOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)(Rao et-al JACCI 2008)

IS PCI RELATED BLEEDING A BAD THINGIS PCI RELATED BLEEDING A BAD THING(MORTAL study, Heart 2008, n=38,872)(MORTAL study, Heart 2008, n=38,872)

DOES PREVENTION OF ACCESS SITE DOES PREVENTION OF ACCESS SITE BLEEDING IMPROVE OUTCOMEBLEEDING IMPROVE OUTCOME

(MORTAL study, Heart 2008, n=38,872)(MORTAL study, Heart 2008, n=38,872)

VASCULAR COMPLICATIONS – ECONOMIC IMPACTVASCULAR COMPLICATIONS – ECONOMIC IMPACT(Nowamagbe et-al, JACC 1995, n = 1,012 CAVEAT-1)(Nowamagbe et-al, JACC 1995, n = 1,012 CAVEAT-1)

5.2

12.1

0

2

4

6

8

10

12

14

NO COMPLICATION FEMORALCOMPLICATION

15,499

28,003

0

5,000

10,000

15,000

20,000

25,000

30,000

NO COMPLICATION FEMORALCOMPLICATION

LO

S (

DA

YS

)

LENGTH OF STAY HOSPITAL COSTS

CO

ST (

$)

TRANSRADIAL APPROACHTRANSRADIAL APPROACHPATIENT PREFERENCEPATIENT PREFERENCE

TRANSRADIAL APPROACHTRANSRADIAL APPROACHNURSING PREFERENCENURSING PREFERENCE

(Amoroso, EJCVN, 2005, n = 260)(Amoroso, EJCVN, 2005, n = 260)

Femoral Radial Femoral Radial

Cath lab Ward

RADIATION EXPOSURE IS IMPORTANTRADIATION EXPOSURE IS IMPORTANTSkin injury due to cardiac interventionSkin injury due to cardiac intervention

RADIATION EXPOSURE IS IMPORTANTRADIATION EXPOSURE IS IMPORTANTAccessory pathway ablationAccessory pathway ablation

3 weeks

5 months6.5 months

OPERATORS ALSO GET RADIATION OPERATORS ALSO GET RADIATION INDUCED SKIN INJURYINDUCED SKIN INJURY

2.4 1.5

21.9 22.4

6.5 5.9

0

5

10

15

20

25

FT (min) DAP(Gycm2)

Operatordose (uSv)

Radial Femoral

UHNS RADIATION EXPOSURE STUDYUHNS RADIATION EXPOSURE STUDYMean fluoroscopy time and patient Mean fluoroscopy time and patient

and operator radiation dosesand operator radiation doses(Heart 2007)(Heart 2007)

P<0.05

P=NS

P=NS

UHNS RADIATION EXPOSURE STUDYUHNS RADIATION EXPOSURE STUDYMean procedure duration (min) and time to ambulation (min)Mean procedure duration (min) and time to ambulation (min)

(Heart 2007)(Heart 2007)

12.6 6.2 7.2

257.2

0

50

100

150

200

250

300

Procedural time Time to ambulation

Radial Femoral

P<0.005

P<0.0001

PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004TLD BADGE READINGS - UHNSTLD BADGE READINGS - UHNS

0

5

10

15

A B C D E

Mont Blanc Summit Ridge Mont Blanc Summit Ridge September 2007September 2007

TRANSRADIAL APPROACHTRANSRADIAL APPROACHTHE LEARNING CURVETHE LEARNING CURVE

Lefevre TCT 2003Lefevre TCT 2003

Puncture failure, spasm, different guide manipulationPuncture failure, spasm, different guide manipulation

“…“…the radial approach has become increasingly popular the radial approach has become increasingly popular with the potential advantage of a greater opportunity for with the potential advantage of a greater opportunity for same day discharge”same day discharge”

“…“…shorter bed rest and hospital stay when the radial shorter bed rest and hospital stay when the radial approach is used”approach is used”

“…“…the use of the radial approach is likely to increase”the use of the radial approach is likely to increase”

RADIAL Vs FEMORAL PCIRADIAL Vs FEMORAL PCI(BCIS DATABASE)(BCIS DATABASE)

10.3

15.7

27

36.1

0

5

10

15

20

25

30

35

40

2004 2005 2006 2007

% of total PCI

THE RADIAL ARTERYTHE RADIAL ARTERY

Reduces access site bleedingReduces access site bleeding Impact on mortalityImpact on mortality EfficientEfficient Preferred by patientsPreferred by patients Endorsed by BCISEndorsed by BCIS Taken up by increasing numbers of UK Taken up by increasing numbers of UK

interventionistsinterventionists

THE ONLY CHOICE FOR VASCULAR ACCESSTHE ONLY CHOICE FOR VASCULAR ACCESS

THANKS TO MARK GUNNINGTHANKS TO MARK GUNNING