Trans-Radial approach

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Transcript Trans-Radial approach

Trans-Radial approach in Overweight Patients

Hakim Ben Amer, MD On behalf the TROP study group

Predicting vascular complications in percutaneous coronary interventions

18,137 PCI pts in northern New England (1997-1999); vascular complication*

2.98%

Variables associated with increased risk in the

multivariate analysis

Age >or=70 OR 2.7 Female gender OR 2.4

Body surface area <1.6 m OR 1.9

History of congestive heart failure OR 1.4

Chronic obstructive pulmonary disease OR 1.5

Renal failure OR 1.9

Lower extremity vascular disease OR 1.4

Bleeding disorder OR 1.68

Emergent priority OR 2.3

Myocardial infarction OR 1.7

Shock OR 1.86

>or=1 type B2 lesions OR 1.32 type C lesions OR 1.7 3-vessel PCI OR 1.5

Thienopyridines OR 1.4

Glycoprotein IIb/IIIa inhibitors OR 1.9

*Vascular complications: access-site injury requiring treatment or bleeding requiring transfusion

Piper WD Am Heart J. 2003 Jun;145(6):1022-9

Complications following diagnostic coronary angiography: Predicting factors

All complications Major complications Vascular complications Factor Heart failure (Killip>1) Left / Right catheterization Senior physician (> 500) French: <6, =6, >6 Smoking Body weight (/10 kg) 0R 2.16; 95% CI 1.12-4.16; p= 0.03

0R 2.62; 95% CI 1.46-4.7; p= 0.003

0R 0.58; 95% CI 0.34-0.98; p= 0.04

0R 2.6; 95% CI 1.53-4.41; p= 0.0004

0R 2.35; 95% CI 1.0-5.51; p= 0.05

0R 2.54; 95% CI 0.93-7.02; p= 0.07

0R 2.76; 95% CI 1.14-6.73; p= 0.02

0R 3.93; 95% CI 1.28-12.06; p= 0.01

0R 1.23; 95% CI 0.95-1.44; p= 0.1

0R 1.4; 95% CI 1.01-1.95; p= 0.04

7,412 consecutive diagnostic cardiac catheterizations between 1990 and 2000 Ammann CCVI 2003;59:13-18

Impact of Access Site Hematoma With Transfusion in Patients Undergoing Percutaneous Coronary Intervention

6613 PCI (98-00)(NHLBI): hematoma w transfusion 1.8% (97% femoral) Predictors: Older age, Lower BMI, Female, renal disease, HTN, AMI, 3 VD, GPIIb/IIa -, Postprocedure heparin Independent predictors: Older age, female, thrombotic lesion, 3-VD, renal disease, emergent PCI, prior aspirin Procedural death: 10.3% w HWT 1.2% w/o HWT p <0.001

death/MI: 18.1% 3.55% <0.001 HWT is a predictor of death/MI (OR = 3.49; 95% CI: 1.98-6.14) J. Slater Am J Cardiol 2003 (suppl) 92: 18L

Clinical Significance of Bleeding Complications

Any Vascular Site Bleeding or Vascular Complication (Surgical) Median Length of Hospital Stay (Day) Extra Cost + 1 Others Incapacitation (days weeks) Return to normal activity delay Major or Minor Vascular Site Bleeding or Vascular Complication (Surgical) + 2 + 1327 $ Major Vascular Site Bleeding or Vascular Complication (Surgical) + 4 + 5896 $ From Blankenship Am Heart J 1999; 138: S287-S296

Radial / Femoral Approach meta-analysis: Entry site complications

Agostini P JACC

rans

adial Approach In

verWeight

atients

Multicentric European Registry , - Coronary angiography ( CA ) or angioplasty ( PCI ) - Centres where there is at least one operator with a wide experience in the transradial approach for CA and PCI. - We include in the registry all the overweight patients with BMI  35 , undergoing CA and/or PCI whatever the vascular approach chosen by the operator. -The primary end point is the occurrence of complications delaying the hospital discharge .

TROP Study Group

TROP Centers

Bergamo (Italy) - Brighton (England) - CHU Caen, (France) - HEP la Roseraie, (France) - Clinic Barcelona, (Spain) - Hôpital Bichat, Paris (France) - ICPS, Massy (France) - ICPS, Quincy (France) - Meixoeiro, (Spain) - Riga, (Latvia) - Szeged, (Hungary) - Val-de-Grâce (France) - Valle de Hebron, (Spain)

Brighton (E) Meixoeiro (S) Valle Hebron (S) Bichat (F) Massy (F) Bergamo (I) Quincy (F) Barcelona (S) Val de Grace (F) Roseraie (F) Szeged (H) Caen (F) Riga (L)

0 4 6 24 29 27 19 17 19 24 32 36 48

N = 346

61 20 40 60 80

TROP Study Group

Mean Age Sexe (Male)

Clinical Datas

61.2 +/- 10.9 years (30/83) 52.9 % Mean Weight Mean Height Mean BMI 108 +/- 15 Kg 1.67 +/- 0.1 M 38.7 +/- 3.4 Kg/m2 (79/155) (1.45/1.90) (35/56) Renal Insuf 7.8% TROP Study Group

70 60 50 40 30 20 10 0

Clinical Datas

64,4 11,3 24,3 8,4 ANGIO PCI ANGIO + PCI EMERGENCY

TROP Study Group

Clinical Datas

P = .0006

Angio (%) Radial N = 249 171 (49.4) Femoral N = 97 52 (14.7) PCI (%) Angio/PCI (%) 19 (5.5) 59 (17.1) 21 (6.1) 25 (7.2) TROP Study Group

Clinical Datas

80 60 40 20 0 73,9 68,5 23,5 41,6 38,4

Hype rtens Hype ion rcho l.

Fam ily H ist Diab etes Smo king TROP Study Group

5 0 10 15

Clinical Datas

20 18,5 17,3 5,5 4,6 3,2 1,7

Prior MI Prior CAB Prior G PCI Vasc ul Dis Prior stro Caro ke tid D is TROP Study Group

Vascular Access

Transradial approach IT: 249/346 ( 71.9% ) Transradial approach AC: 243/346 ( 70.2% ) Reasons for using Femoral access: 97/346 ( 28.1% ) - Physician choice (76): 78.4% - Dialysis (1): 1% - Need for 7F catheters (5): 5.2% - Abnormal Allen test (1): 1% - CABG (double Mam) (4): 4.1% - No or to small radial (4): 4.1% - Other (ring, prior rad failure…) (6): 6.2% IT: Intention To Treat AC: After Cross over TROP Study Group

Vascular Access

Cross over: 17 (4.9%) - Radial to femoral: - Radial to radial: - Femoral to radial: - Radial to Ulnar 9 (3.6%) 4 (1.6%) 3 (3.1%) 1 (0.4%)

TROP Study Group

Vascular Access: Size

250 211 200 150 100 50 34 89 12 4 F 5 F 6 F 7 F 0 Patients

TROP Study Group

100 80 60 40 20 0

INDICATIONS

4,9 6,1 89

Valvulopathy Cardiac Insuffi.

Ischemic TROP Study Group

Clinic Presentation

39,3 30 20 10 19,9 11,6 4,64,4 7,2 13

Atypical chest pain ACS ST elevated ACS ST not elevated Silent ischemia Stable angina Post MI No ischemia

TROP Study Group

Documented Ischemia

40 39,9 34,1 30 20 10 17,9 6,4

No test EKG Scintigraphy Stress test Other

1,7 0 Patients

TROP Study Group

Vascular Access

Radial difficulties: 249 patients - Failure: - No difficulty - Catheterism diff.

- Spasm - Loops - Others - TOTAL 10 (4%) 210 (84.3%) 10 (4%) 6 (2.8%) 10 (4%) 2 (0.8%) 29 (11.6%) TROP Study Group

40 30 20 10 0

CAD extension

39,9 29,7 17,9 12,5 4 No vessel One vessel Two vessels Three vessels Left Main

TROP Study Group

PCI

(N = 124 pts) - Transradial access: 78/124 ( 62.9% ) - Femoral access: 46/124 ( 38.1% ) - PCI success/Vessel: 163/169 ( 96.5% ) - Clinical Total Success: 118 ( 95.2% ) - QMI: 4 ( 3.2% ) - MACE: 1 ( 3.2% ) - Emergent CABG: 0 ( 0% ) - Death: 0 ( 0% )

TROP Study Group

Fem vs Rad access

Mean age (y) Male (%) BMI (Kg/m2) Radial (n=243) 61.2 +/- 11.3

138 (56.7) 39 +/- 14 Femoral (n=103) 60.5 +/- 10.1

56 (54.4) 38 +/- 5 P NS NS 0.04

TROP Study Group

Fem vs Rad access

Hypertension (%) Hypercholesterolemia (%) Family History (%) Smokers (%) No Current Past Diabetes (%) No ID NID Radial (n=243) 180 (70) 165 (68) 41 (17) 137 (56) 30 (12) 60 (25) 137 (56) 24 (10) 82 (34) Femoral (n=103) 76 (70) 72 (70) P NS NS 40 (39) 0,001 60 (58) 17 (16) 26 (25) 65 (63) 9 (9) 29 (28) NS NS TROP Study Group

Fem vs Rad access

Prior MI (%) Prior CABG (%) Prior PCI (%) Radial (n=243) 37 (15) 11 (45) 42 (18) Femoral (n=103) 27 (26) 8 (8) 17 (16) P NS NS NS TROP Study Group

Fem vs Rad access

Nb Cath used Angio (n) Contrast Total (ml) Contrast Angio (ml) Total Duration (min) Angio Duration (min) Hosp stay (d) Hosp stay after C (d) Vascular complication (%)* Hematoma (%) * With transfusion Radial (n=243) 1.9 +/- 0.8

159 +/- 95 117 +/- 64 35.3 +/- 25.4

26.1 +/- 19.0

3.7 +/- 4.1

1.7 +/- 2.2

3 (1.2) 4 (1.6) §: with 8 Closing Device Femoral (n=103) 2.3 +/- 0.7

189 +/- 102 122 +/- 70 55.6 +/- 23.3

31.3 +/- 17.7

4.4 +/- 4.6

2.7 +/- 4.3

P 0,0005 0.01

NS 0.0001

0.03

NS 0.02

3 (2.9) 9 (8.7) § NS 0.001

TROP Study Group

BMI (kg/m2) N=95435 Death (%)

Impact of Weight for in Hospital Outcome after PCI

< 18,5 N=924 3,8 18,5/24,9 N=25010 1,1 25/29,9 N=41175 0,8 30/34,9 N=19329 0,7 35/39,9 N6252 0,6 >40 N=2745 1,4 P 0,001 Transmural MI (%) Emergent CABG (%) MACE (%) 0,5 0,9 5 Vascular Injury (%) 1,4 0,3 1,3 2,6 0,6 0,3 1,1 2,1 0,5 0,4 1,1 2,0 0,5 0,3 1,2 1,8 0,5 0,3 0,8 2,4 0,9 0,227 <0,001 <0,001 <0,001 RM, Minuella Am J cardiol 2004;93:1229-32

Conclusion 1

• Obesity is a risk factor for CAD (Hypertension, Dyslipidemia, Diabetes) • Obesity is more frequent in female gender • Obesity is a factor of complication in diagnostic angiography and coronary intervention

Conclusion 2

• Preliminary analysis of this study • Radial approach in obese patients reduces the rate of vascular complications • Subgroup analysis (pending) is necessary to better define patients at higher risk, interest of closure devices for femoral procedures… • Potential other advantage of radial approach: prevention of infectious complication

Bleeding Complications

F.V Aguirre et al, Circulation 1995;91:2882-90

Bleeding complications

Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients Distribution of patients who underwent cardiac catheterization procedures by BMI N Cox, Am J Cardiol 2004;94:1174–1177

Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients N Cox, Am J Cardiol 2004;94:1174–1177

Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients Vascular complications by BMI. The patients with the smallest BMIs experienced the highest rate of vascular complications N Cox, Am J Cardiol 2004;94:1174–1177

Comparison of the Risk of Vascular Complications Associated With Femoral and Radial Access Coronary Catheterization Procedures in Obese Versus Nonobese Patients Overall vascular complication rate in nonobese and obese (BMI >30.0) patient subgroups stratified by vascular access approach N Cox, Am J Cardiol 2004;94:1174–1177

Low-Normal or Excessive Body Mass Index: Newly Identified and Powerful Risk Factors for Death and Other ComplicationsWith Percutaneous Coronary Intervention

Major Cardiac Outcomes and Complications Stephen G. Ellis, Am J Cardiol 1996;78:642-64

Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other Complications With Percutaneous Coronary Intervention

Peripheral Vascular Complications Stephen G. Ellis, Am J Cardiol 1996;78:642-64

Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other Complications With Percutaneous Coronary Intervention

Independent Correlates of Death With and Without BMI Stephen G. Ellis, Am J Cardiol 1996;78:642-64

Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other Complications With Percutaneous Coronary Intervention

Causes of Death Stephen G. Ellis, Am J Cardiol 1996;78:642-64

Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other ComplicationsWith Percutaneous Coronary Intervention

Stephen G. Ellis, Am J Cardiol 1996;78:642-64

Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox)

H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox)

H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox)

H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

Impact of Body Mass Index on Outcome After Percutaneous Coronary Intervention (The Obesity Paradox)

H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45

Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI Procedural Characteristics of Study Patients According to BMI H. Gurm J Am Coll Cardiol 2002;39:834–40

Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI Incidence and Odds Ratios of In-Hospital Events According to BMI: PTCA Group H. Gurm J Am Coll Cardiol 2002;39:834–40

Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI Incidence and Odds Ratios of In-Hospital Events According to BMI: CABG Group H. Gurm J Am Coll Cardiol 2002;39:834–40

Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI Incidence and OR of Long-Term Mortality According to BMI: PTCA Group (n=2,090) H. Gurm J Am Coll Cardiol 2002;39:834–40

Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From BARI Incidence and OR of In-Hospital Events According to BMI: CABG Group H. Gurm J Am Coll Cardiol 2002;39:834–40

Obesity a risk for CABG surgery

N.J.O. Birkmeyer Circulation 1998;97:1689-94

Obesity a risk for CABG surgery

CVA Cerebrovascular Accident SWI Sternal Wound infection N.J.O. Birkmeyer Circulation 1998;97:1689-94

Trans-Radial approach

Transcript Trans-Radial approach