1. Remaining Challenges and Opportunities for Improvement In Percutaneous Transradial Procedures
Sunil V. Rao MD
The Duke Clinical Research Center
Duke University Medical Center
The Durham VA Medical Center

2. Disclosures Consultant ZOLL, Terumo Medical, The Medicines Company
Research funding
Ikaria, sanofi-aventis
Off-label uses may be discussed

3. Remaining challenges and opportunities for improvement
Radial procedure technique
Radial access site bleeding
Radial artery injury and occlusion
Increased radiation exposure
Radial procedure implementation
Transradial primary PCI

4. Radial artery access site bleeding
Patent hemostasis
2000u UFH
5000u UFH

5. Predictors of radial access site bleeding
Odds Ratio
95% CI
Female sex
4.40
2.49 – 7.81
CrCL < 60 ml/min
3.26
1.10 – 8.67
Procedure duration > 1 hr
2.95
1.12 – 8.31
Sheath size ≥ 6F
5.34
1.44 – 34.65
Non-occlusive hemostasis ??
Bertrand OF, et. al. AHJ 2009
Tizón Marcos H, et. al. AHJ 2009

6. Bertrand OF, et. al., Circulation 2006

7. Radial artery injury
Yonetsu T, et. al. EHJ 2010

8. Titrate to least necessary pressure
Slide courtesy of Samir Pancholy MD

9. Anticoagulation Patent hemostasis UFH 70-100 u/kg No UFH 70 u/kg No
Or Bivalirudin No
UFH 50u/kg
Yes
UFH u/kg
Yes
UFH 5000 u
Yes +
Ulnar compression
Rao SV. JACC Intv 2012

10. Collateralization in UE is more than we think
Extensive interosseous collaterals
Dynamic recruitable non-visible circuits.

11. Recruitable circulation
JACC Vol. 46, No. 11, 2005 December 6, 2005:2013–7

12. Abnormal Allen’s = ischemia?
JACC Vol. 46, No. 11, 2005 December 6, 2005:2013–7

13. Hand ischemia following TRI
Normal pre-procedure Allen’s test
Rhyne D, Mann T. CCI 2010

14. Radiation exposure
Rao SV, Bernat I, Bertrand OF. EHJ 2012

15. Minimizing Radiation
Don’t fluoro the J-wire going up the arm unless there is resistance
Don’t fluoro catheter exchanges
Use Fluoro-Save as much as possible
Operator experience matters1
Left radial may also help
Distance
Shorter procedures (less subclavian tortuosity)2
1Kuipers G, et. al. JACC Intv 2012
2Sciahbasi A, et. al. Circ Intv 2011

16. Radial vs. Femoral in STEMI N=3347 pts from randomized, case-control, and cohort studies incl. RIVAL
Mortality
Procedure time (min)
Joyal D, et. al. AJC 2012

17. RIFLE STEACS – results 30-day NACE rate p = 0.003 p = 0.029 p = 0.026
21.0
17.3
p = 0.029
p = 0.026
13.6
12.2
11.4
10.0
9.3
7.8
7.2
Net Adverse Clinical Event (NACE) = MACCE + bleeding
Major Adverse Cardiac and Cerebrovascular event (MACCE) = composite of cardiac death, myocardial infarction, target lesion revascularization, stroke
Bleeding Academic Research Consortium (BARC) = bleeding definition adopted 17

18. RIFLE STEACS – results 30-day MACCE rate p = 0.020 p = 1.000 p = 0.604
9.2
7.2
5.2
p = 1.000
p = 0.604
p = 0.725
1.8
1.3
1.4
1.5
1.2
1.2
0.7
0.6
0.8 18

19. Issues unique to Primary PCI
Most important – the team MUST have experience with radial diagnostic and interventional cases
Success of transradial primary PCI is dependent almost entirely on the cath lab staff
Barbeau test can be checked within seconds of arriving in lab
The set-up is the rate-limiting factor
Do NOT do transradial primary PCI until you have at least 1 year of experience with “radial first” elective PCI, 100 cases, and a femoral crossover rate ≤ 4%
Access – can obtain access without fluoroscopy
Always prep groins for quick bailout, adjunctive devices (IABP, Pacemaker)
Catheters – same approach as femoral (diagnostic catheter for non-involved coronary, guide for IRA)

20. Algorithm for transradial primary PCI
ASA + Clopidogrel pre-treatment
Exclude pts with absent pulses/abnormal Barbeau test*
Prep Radial and both groins (LRA for pts > 75 y.o. or height ≤ 165 cm)
≤ 3 min for radial access
6F sheath/5F diagnostic catheter(s)
Bivalirudin bolus and drip started when catheter is in ascending Ao; Bailout 2b3a as needed
6F guide catheter
Total time from sheath to engaging IRA ≤ 15 min; total time from access to crossing lesion ≤ 25 min
Sheath removed at end of case
Bailout to
femoral
for failure

21. Summary There is growing interest in and adoption of radial approach
It should not be viewed as a gimmick – we need good science to support its use
Remaining challenges
Radial artery access site bleeding – early recognition and treatment are key
RAO – anticoagulation, sheath size, and non-occlusive hemostasis are key (drug-eluting sheaths?)
Recognize the importance of reducing radiation exposure
Don’t let the “irrational exuberance” for transradial primary PCI affect patient outcomes