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!