Transcript Lettura ed interpretazione dei lavori clinici
Radial access for coronary procedures
Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Latina, Italy [email protected]
Why should you like radial access?
BLEEDING THROMBOSIS
Why should you listen to me?
Why should you listen to me?
Biondi-Zoccai et al, Catheter Cardiovasc Interven 2011
Learning milestones • • • • Basics Indications and contraindications Advantages and disadvantages Potential complications
Google search for “radial access ppt”
Google search for “radial access ppt”
Radial, ulnar and interosseus arteries
Femoral and radial diameters
Oxymetry Allen test
Oxymetry Allen test
Choice of access kits
Right versus left radial artery PROCEDURAL FAILURE PROCEDURAL TIME
Biondi-Zoccai et al, Int J Cardiol 2013
Patent or mean BP-targeted hemostasis
Cubero et al, Catheter Cardiovasc Interven 2009
Radial implementation
Romagnoli et al, Int J Cardiol 2013
Learning milestones • • • • Basics Indications and contraindications Advantages and disadvantages Potential complications
Morbidly obese
Oral anticoagulants
Peripheral artery disease
Aortic dissection
Loops, spasm, abnormal origin, or tortuosity
Arteria lusoria
Upper limb atherosclerosis
Left internal mammary artery PCI
Large sheath procedures
RIMA vs radial artery vs RGEA vs SVG: functional occlusion
Benedetto et al, Eur J Cardiothorac Surg 2014
Indications • • • • • • • • • • • … … … … … … … Morbidly obese Peripheral artery disease Aortic dissection Oral anticoagulants (eg INR>2)
Contraindications • • • • • • • • • • • Extremely low height Anatomic anomalies (including arteria lusoria) Ulnar occlusion Upper limb atherosclerosis Vasculitis Know disease of brachial, axillary, subclavian or innominate arteries Prior radial grafting Need for radial grafts during CABG Chronic renal failure with potential need for AV fistula LIMA PCI Large sheath procedures
Learning milestones • • • • Basics Indications and contraindications Advantages and disadvantages Potential complications
Patient and personnel comfort
Flexibility of radial access
Biondi-Zoccai et al, J Cardiovasc Dis Diagn 2013
Reduced risk of entry site complications
Agostoni et al, J Am Coll Cardiol 2004
Reduced risk of major bleeding
Komocsi et al, Arch Med Sci 2014
Reducing risk of bleeding, even with bivalirudin
Marso et al, American College of Cardiology 2010
Reduced incidence of CIAKI
Cortese et al, Am J Cardiol 2014
Reduced risk of MACE
Komocsi et al, Arch Med Sci 2014
Reduced risk of NACE in cardiogenic shock requiring IABP
Romagnoli et al, Am Heart J 2013
Reduced risk of death
Komocsi et al, Arch Med Sci 2014
Meta-regression in STEMI
Biondi-Zoccai et al, Int J Cardiol 2013
More skills (or ultrasound) are required for puncture
Gu et al, Crit Care 2014
Door-to-balloon time
Weaver et al, Catheter Cardiovasc Interven 2010
Learning curve
Spaulding et al, Catheter Cardiovasc Diagnosis 1996
Radiation exposure
Lange et al, Catheter Cardiovasc Interven 2006
Lower catheter support
Tobita et al, J Invasive Cardiol 2013
Advantages • • • • • • • • • • • Increased patient comfort Reduced personnel burden Same day discharge possible and safe Reduced hospital stay Reduced costs Reduced risk of entry site complications Reduced risk of bleeding Reduced risk of DVT Reduced risk of CIAKI Reduced risk of MACE Reduced risk of death
Disadvantages • • • • • • • • • • • Ability to maintain arm position is required Less comfort for operator Anatomy highly variable Longer learning curve Increased radiation exposure, procedural duration, and contrast volume Limitation to sheath and catheter size (and no room for IABP) Less support for catheters and devices More difficult access to specific vessels (SVG, LIMA) Right heart cath possible but more difficult Dedicated materials required Repeat procedure may increase risk of complications
Learning milestones • • • • Basics Indications and contraindications Advantages and disadvantages Potential complications
Stroke
Hematoma
Radial perforation
Sanmartin et al, Rev Esp Cardiol 2004
Radial pseudoaneurysm
Cauchi et al, J Ultrasound Med 2014 Transradialworld.com
Arterio-venous fistula
Sanmartin et al, Rev Esp Cardiol 2004
Compartment syndrome
Sheath entrapment/radial avulsion
Arzamendi et al, Rev Esp Cardiol 2011
Radial occlusion
Radial occlusion * *1 radial perforation and 1 massive hematoma, both conservatively managed
Takeshita et al, Am J Cardiol 2014
Hand ischemia
Rhyne et al, Catheter Cardiovasc Interven 2010
Cardiovocal syndrome
Romagnoli et al, Int J Cardiol 2008
Cardiovocal syndrome
Romagnoli et al, Int J Cardiol 2008
Aseptic granuloma
• • • • • • • • • • • • • • • Potential complications Forearm pain Radial spasm Radial avulsion Radial dissection Radial occlusion Hand ischemia Radial perforation Hematoma Radial pseudoaneurysm Arterio-venous fistula Compartment syndrome Nerve injury Cardiovocal syndrome Stroke Inflammatory reaction to foreign body
Take home messages
Do you know how a train stops?
Atmospheric Pressure
Take home messages • • The benefits of radial access are so many that it is easier to remember its drawbacks (mainly increased learning curve, radiation exposure, procedural time, and access cross-over), rather than doing the opposite.
Accordingly, choice of access site for coronary procedures is best approached given the premise that radial access should be the default access site, with femoral or other accesses reserved only to highly selected cases.
One of the many reasons I like France
One of the many reasons I like France
Many thanks for your attention!
For any query: [email protected]
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