1. Dr Savvas S Constantinides, MBChB, MD, FRCP Consultant Interventional Cardiologist American Medical Center, Nicosia, Cyprus

2. Radial access in the elderly

3. Dehgani P et al. J Am Coll Cardiol Intv 2009; 2: 1057-64

4. ‘You are going nowhere near my groin!’

5. Why bother? Higher incidence of peri-procedural events
Higher incidence of access-site related bleeding complications
Higher incidence of comorbidities
Higher incidence of mobility problems e.g. chronic back pain, urinary frequency/incompetence/retention: early ambulation very important!

6. Why is it a bother?
More advanced atherosclerosis – often more complex cases (LMS, bifurcations, SVGs etc)
Tortuous aorta, subclavian and radial arteries
Advanced vessel calcification, more difficult radial and coronary access (rotablation)
Inadequate patient co-operation due to poor hearing/vision/mental comprehension being more common
Comorbidities more common: diabetes, renal failure, stroke

9. What is the evidence?
Feasible? Safe?

10. Transradial in young vs old
What is the evidence?
Transradial in young vs old

11. Delache N et al. ‘Direct Angioplasty for Acute Myocardial Infarction in Elderly Patients using Transradial Approach’. Am J Geriatr Cardiol. 1999
Prospective study
46 patients >70 years old with AMI included
-ve Allen test, thrombolysed patients excluded
Failed right transradial approach in 4 pts (9%)
PCI not necessary in 2 (4%)
Remaining 40 (87%) successful PCI
Conclusion: TRA feasible and highly successful in elderly patients.

12. Procedure success in 195 pts < 70 y.o. Vs 83 pts > 70y.o.
Caputo RP et al: ‘Transradial cardiac catheterization in elderly patients’ Catheter Cardiovasc Interv Nov;51 (3):287-90
Procedure success in 195 pts < 70 y.o. Vs 83 pts > 70y.o.
Elderly pts less likely to be selected for TRA (46% Vs 61%).
Elderly pts more often female (40% Vs 24%) and had smaller body surface area (1.9 Vs 2.0 m2)
Same procedural success
Similar procedure related variables (procedure time, amount of contast, number of catheters)

13. To assess safety, feasibility and efficacy of TRA in elderly
Valsecci O et al: ‘Safety and feasibility of transradial coronary angioplasty in elderly patients’ Ital Heart J 2004 Dec; 5(12):926-31
To assess safety, feasibility and efficacy of TRA in elderly
1125 (<70 n=802 Vs >70 n=323) consecutive patients TRA single operator
Radial and branchiocephalic anatomical toruosity more common in elderly (35.3 Vs 17.3%, p<0.05)
Equal procedural success rate (97.5 Vs 98.7%, p=NS)
No difference in cannulation and total procedural time
No difference in access site bleeding (0.4 Vs 0%), 30 day asymptomatic loss of radial pulse (1.5 Vs 1.4%, p=NS). No forearm ischaemia in either group.

14. No difference in vascular complications
Molinari G te al. ‘Safety and efficacy of the percutaneous radial artery approach for coronary angiography and angioplasty in the elderly’ J Invasive Cardiol Dec;17 (12): 651-4
850 patients – 600 < 70 (70.5%) Vs 250 > 70 (29.5%) who underwent transradial coronary angiography and/or PCI
No difference in procedure duration, X-ray time and number of catheters used
No difference in vascular complications
Stroke or TIA n=3 (1.2%) Vs n=1 (0.2%), p=0.08

15. Zheng et al. Chin Med J 2008; 121 (12): 1126-29

16. Transradial Vs transfemoral in the old
What is the evidence?
Transradial Vs transfemoral in the old

18. Rao SV et al. J Am Coll Cardiol Interv 2008; 1: 379-86

20. Secco G.G. et al. ‘Transradial Versus Transfemoral Approach for Primary Percutaneous Coronary Interventions in Elderly Patients’ J Invasive Cardiol 2013; 25(5): 254-6
283 consecutive elderly (>75) patients undergoing Primary PCI
177 (61%) TRA Vs 106 (39%) TFA
Door-to-balloon 103 Vs 110 min (p=NS)
Time of arterial puncture 10.6 Vs 12.1 min (p<0.01)
Time of balloon inflation 19.6 Vs 24.2 min (p<0.01)
Access site haematoma 1.7 Vs 8.5% (p<0.01)
Access site bleeding 1.1 Vs 4.7% (p=NS)

21. Jean-Pierre Dery et al. J Am Coll Cardiol 2010; 55: A209 E1975

22. S. Constantinides et al. ‘Transradial approach for Coronary Angiography and Intervention in Octogenarians’ Cath Cardiovasc Intervent 2015; 85: S1-S176
Retrospective analysis of 108 consecutive octogenarians having undergone coronary angiography (45%) or PCI (55%) over a 2 year period
83% (n=90) transradial – 17% (n=18) tranfemoral
Mean age 82.7 years (range 80-93)
39% (n=42) urgent, 11% (n=12) previous CABG, 4% (n=4) cardiogenic shock
Only 2.2% (2/90) of transradial procedures switched to femoral due to extreme subclavian tortuosity and radial spasm
No major vascular complications

23. Case Example
80 year old fragile Danish female tourist , 160cm and 55kgs
Risk factors: smoking, DM, HTN and dyslipidemia
Admitted to another centre with severe dyspnoea, reduced level of consciousness and restlessness
The patient was in pulmonary oedema with an admitting ECG showing ST depression inferolaterally. Elevated cardiac enzymes.
Mechanical ventilation instituted
Echo EF 35-40%. Inferolateral hypokinisia, apical akinisia. Mild to moderate AS gradient 35mmHg.
Following 48 hours of extubation and improvement she developed reccurrent chest pain and dyspnoea.
She was transferred to our facility for coronary angiography

24. Coronary angiogram via right radial 5F sheath

25. Coronary angiogram via right radial 5F sheath

26. PCI RCA, LMS/LCx, mid-LAD

27. PCI RCA, LMS/LCx, mid-LAD

28. PCI RCA, LMS/LCx, mid-LAD

29. Final LCA PCI result

30. Conclusions
Transradial approach for the elderly is not only feasible but safer than the transfemoral in experienced hands.
Difficulties may include calcification, tortuosity/spasm and other comorbodities: consider Lt Vs Rt radial approach.
If treated with patience and respect, vast majority of cases (>95%) can be successfully completed transradially irrespective of the age.

31. Transradial approach for the old?

32. Thank you! Enjoy Cyprus…