1. Primary PCI Radial Artery Access, Drug-Eluting Stents, and Thrombus Removal
Kirk N Garratt MSc MD FSCAI
Society for Cardiac Angiography and Interventions
Lenox Hill Heart and Vascular Institute of New York

2. Disclosures Speaker’s bureau: Research support: Consulting: Equity
DSI/Lilly
Consulting:
Boston Scientific
The Medicines Company
Research support:
Abbott Vascular
Boston Scientific
The Medicines Company
CardiacAssist
Equity
Infarct Reduction Technologies
Guided Delivery Systems
MedLogics

3. Thrombus
Removal
Radial Artery Access
Drug
Eluting
Stents

4. Thrombus
Removal
Radial Artery Access
Drug
Eluting
Stents

5. Jolly SS, et al. Lancet 2011;DOI:10.106/S0140-6736(11)60404-2
RIVAL Trial
Jolly SS, et al. Lancet 2011;DOI:10.106/S (11)

6. RIVAL Trial
NSTEMI
STEMI

7. RIFLE-STEACS
Romagnoli E, JACC 2012;60:2481-9

8. Nine Randomized Trials Radial versus Femoral Access and Mortality
Joyal D, Am J Cardiol 2012;109:813-18

9. NCDR CathPCI Registry Trans-radial in STEMI
Baklanov D, JACC 2013;61:420-6

10. How Would This Work? Increased bleeding = increased mortality
RIVAL found no difference in bleeding but a significant difference in mortality rates
Radial artery use may have other benefits
Earlier ambulation
Ease of management
Earlier hospital discharge

12. ESC Recommendations
If performed by an experienced radial operator, radial acess should be preferred over femoral access (IIa,B)
Steg G, Eur Heart J 2012;33:

13. Conclusions of The Thought Leaders
“…the underlying mechanisms related to the bleeding reduction… are straightforward: the radial artery is superficial, small in caliber, and easily compressed… patients appear to prefer the radial to the femoral approach (and the) reduction in vascular and bleeding complications is associated with cost savings from the hospital perspective.”
“A procedural approach that has been consistently associated with reduced bleeding and vascular complications is trans-radial cardiac catheterization and PCI… Both the randomized and observational data show a consistency in directionality of the effect of the radial approach on bleeding.”
Harold L. Dauerman, Sunil V. Rao, Frederic S. Resnic, and Robert J. Applegate. JACC 2001;58:1-10

14. Thrombus
Removal
Radial Artery Access
Drug
Eluting
Stents

15. De Carlo M, JACC CV Intv 2012;5:1223-30
MUSTELA Trial
De Carlo M, JACC CV Intv 2012;5:

16. De Carlo M, JACC CV Intv 2012;5:1223-30
MUSTELA Trial
De Carlo M, JACC CV Intv 2012;5:

21. ESC Guidelines
Manual catheter thrombus aspiration should be considered during PCI of the culprit lesion in STEMI (IIb)
Steg G, Eur Heart J 2012;33:

22. AHA/ACC/SCAI Guidelines
IIa
IIb
III
Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI. B

23. Thrombus
Removal
Radial Artery Access
Drug
Eluting
Stents

24. First Generation DES vs BMS In STEMI
Kalesan B, Eur Heart J 2012

25. HORIZONS AMI Three Year Mortality
Stone GW, Lancet 2011;377:

26. DES Evidence Network Meta-Analysis
Palmerini T, JACC CV Intv 2013;62:

27. DES Evidence Network Meta-Analysis
DES were associated with better overall outcomes than BMS
Second-generation DES (especially CoCr-EES) performed best
Palmerini T, JACC CV Intv 2013;62:

28. ACC/AHA/SCAI Guidelines
IIa
IIb
III A
Placement of a stent (BMS or DES) is useful in primary PCI for patients with STEMI. I
IIa
IIb
III
BMS* should be used in patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next year. I
IIa
IIb
III B
DES should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents.
Harm
*Balloon angioplasty without stent placement may be used in selected patients.

29. Conclusions
Use of radial artery access for cardiac catheterization and intervention in the setting of STEMI is associated with meaningful reductions in short-term cardiac mortality
Mechanisms not understood
Increased use of radial artery access in setting of primary PCI is warranted

30. Conclusions Thrombus aspiration is probably worth the effort
Utility in improving outcomes uncertain
Simple to do
Use aspiration catheters unless very large thrombus burden

31. Conclusions Drug-eluting stents work in STEMI patients
Reduce restenosis rates
No mortality penalty
Should not be used if concerns about compliance with DAPT or bleeding risks

32. Thank You