Presentation Beyond The Basics Performing Radial STEMI Procedures Dr Sugumaran 040616 TIS 255 04082016
2016-04-12
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4/10/2016 ™ Beyond The Basics: Performing Radial STEMI Procedures Rajkumar K. Sugumaran, MD Cardiac Solutions Phoenix, AZ TIS-255-04082016 Terumo Medical Corporation Disclaimer –The opinions expressed by Dr. Sugumaran during this presentation are his own and do not necessarily reflect those of Terumo Medical Corporation. Unattributed data, device selection and procedural guidance is a matter of physician preference and opinion derived from Dr. Sugumaran’s own observations and experiences and should be treated accordingly. –All visual representations and other imagery contained in this presentation are used with permission from Dr. Sugumaran. TIS-255-04082016 Objective Why Transradial PCI for STEMI? Perfusion Test and Patient Prep Radial Access Catheter Selection and Manipulation Hemostasis TIS-255-04082016 1 4/10/2016 Vascular Access Complications Hospital Resources Consumed in Treating Complications associated with Percutaneous Coronary Interventions For patients with only one complication, vascular complications were more common than all others combined (4.9% vs 3.3%) Estimates of the adjusted incremental hospital costs of treating any acute complication varied from $4k-$33k per patient TIS-255-04082016 Kugelmass A, Cohen D, Brown MD, Simon A, Becker E, and Culler S. American Journal of Cardiology 2006; 97: 322-327 Reduction in Bleeding Complications Retrospective analysis of 38,872 patients TRA showed 50% Reduction in Transfusion Rate TRA reduced 1yr Mortality from 3.9% to 2.8% MORTAL TRA n = 3507 TFA n =3514 STEMI radial showed 40% Reduction in primary outcome STEMI/ACS radial showed 63% Reduction in Major Vascular Complications RIVAL STEMI TRA (n = 500) vs. TFA (n = 501) 62% Reduction of Access site bleeding complications with TRA vs. TFA RIFLE-STEACS *The Association Of Arterial Access Site At Angioplasty With Transfusion And Mortality The M.O.R.T.A.L Study: (Mortality benefit of Reduced Transfusion After PCI via the Arm or Leg); Alex J Chase, Eric B Fretz, William P Warburton, W Peter Klinke, Ronald G Carere *Effects of Radial Versus Femoral Artery Access in Patients With Acute Coronary Syndromes With or Without ST-Segment Elevation. Shamir R. Mehta, MD, MSC,* Sanjit S. Jolly, MD, MSC *Radial Versus Femoral Randomized Investigation in ST-Segment Elevation Acute Coronary Syndrome The RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) Study. Enrico Romagnoli, MD, PHD,* Giuseppe Biondi-Zoccai, MD,† Alessandro Sciahbasi, MD TIS-255-04082016 Radial Continues to be Supported by Evidence Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (the MATRIX Trial)1 Study Methods Results • Randomised, Superiority trial • 8404 Patients, 74 Centers • Co-primary End Points • Radial garners superior outcomes • MACE • NACE Individual components of Composite out comes • All cause Mortality • Stroke • MI • Bleeding 1J Radial as compared with femoral access reduces NACE through a reduction of bleeding and all-cause mortality • Co-Primary End Points • Secondary End Points • • • 15% relative reduction in MACE • 17% relative reduction in NACE • Secondary End Points • 28% Reduction in all-cause mortality • 33% reduction in Bleeding TIS-255-04082016 Cardiovasc Transl Res. 2014 Feb;7(1):101-11. doi: 10.1007/s12265-013-9537-1. Epub 2014 Jan 7 2 4/10/2016 Transradial PCI for STEMI The Prevalence and Outcomes of Transradial PCI for STEMI Key Points: The authors concluded that the wider usage of TRI for STEMI may significantly improve patient outcomes. TRI patients were also significantly less likely to have vascular complications than the femoral PCI population. TRI was associated with a lower risk of bleeding and in-hospital mortality while there was no difference in procedural success. TIS-255-04082016 Baklanov DV, Kaltenbach LA, Marso SP et al. J Am Coll Cardiol. 2013 Jan 29;61(4):420-6 Transradial and Bivalrudin This figure demonstrates the rate of percutaneous coronary intervention-associated bleeding in 501,017 patients grouped by vascular access and anticoagulation. TIS-255-04082016 Baklanov D V et al. Circ Cardiovasc Interv. 2013;6:347-353 Common Hurdles with Transradial PCI for STEMI Learning Curve Length of Procedure (Initially) Length of Set Up Support Staff Resistance to New Technique Inability to use Larger Equipment TIS-255-04082016 3 4/10/2016 Transradial Advantages Benefits of radial access for all patients, especially STEMI to start performing radial STEMI? Why to perform radial STEMI? Discussing with your Cath Lab Staff in advance of radial STEMI case When TIS-255-04082016 Room Set-up and Prep TIS-255-04082016 ©2014 TERUMO MEDICAL CORPORATION ©2014 TERUMO MEDICAL CORPORATION Room Set up – Right Radial Some physicians will access radial artery with arm at 90 degrees. Once sheath is inserted and secured, bring right arm in near right groin site Other physicians works in same plane as wrist with equipment easily accessible TIS-255-04082016 4 4/10/2016 To work from the patient’s right, use pillows, straps or blankets to elevate arm ©2014 TERUMO MEDICAL CORPORATION Begin with the arm adducted 90 degrees ©2014 TERUMO MEDICAL CORPORATION Room Set up – Left Radial ©2014 TERUMO MEDICAL CORPORATION Assess position for patient comfort and compliance prior to prepping site TIS-255-04082016 Access the left radial with arm positioned at 90 degrees to patient ©2014 TERUMO MEDICAL CORPORATION Position the arm near patient’s left groin if working from the patient’s right ©2014 TERUMO MEDICAL CORPORATION ©2014 TERUMO MEDICAL CORPORATION Room Set up – Left Radial TIS-255-04082016 Room Set up – Considerations Shave and prep medial to lateral; from the mid forearm to the mid palm Shave the upper arm if RHC is to be performed Consider shave and or Prep femoral access site. Femoral access can prove useful for emergent access of the femoral artery or vein TIS-255-04082016 5 4/10/2016 Administering Heparin to Avoid RAO Comparison of the Effect of Intra-Arterial Versus Intravenous Heparin on Radial Artery Occlusion After Transradial Catheterization Key Points: No statistical difference between intra-arterial and systemic heparin administration in regards to RAO. 500 consecutive patients Early RAO 5.6% (ia) vs. 6% (systemic) Late RAO 4% (ia) vs 3.2% (systemic) TIS-255-04082016 Samir Pancholy: Volume 104, Issue 8, Pages 1083-1085 (15 October 2009) Radial Artery Spasm Reasons Vascular Trauma (Access) Friction as a result of catheter movement or sheath removal Patient Anxiety Difficulty of advancement or removal Gives great pain to the patient if the system is forced out What Happens The vessel grips onto the catheter/sheath Radial Artery Spasm occurs in 2%-6% of patients TIS-255-04082016 Patel’s Atlas of Transradial Intervention, The Basics and Beyond © 2012 by Tejas Patel Radial Artery Spasm Prevention Use of Hydrophilic sheath to reduce friction Use of Smaller sheaths and catheters Spasmolotic Cocktail (Nitroglycerin 200-400mcg, Verapamil 2.55mg). Consider alternate vasodilators/antispasmodic. Gentle Sedation Additional vasodilators if needed TIS-255-04082016 Patel’s Atlas of Transradial Intervention, The Basics and Beyond © 2012 by Tejas Patel 6 4/10/2016 Antispasmotic Cocktail ©2014 TERUMO MEDICAL CORPORATION Verapamil is a very acidic drug. To reduce burning effect, Physician should consider diluting cocktail with the patient’s blood in a 10-20mL syringe. Other substitutions would be Nicardipene or Cardene TIS-255-04082016 Coronary ©2014 TERUMO MEDICAL CORPORATION OPTITORQUE™ diagnostic catheter Available in 5 Fr and 6 Fr catheter sizes Radial shapes are designed to eliminate catheter swaps Shaft with 2-ply stainless steel braid designed for 1-to-1 torque and accurate placement Large lumen for high contrast flow Atraumatic soft tip Designed to provide greater visibility around the ostium and lower contrast pressure from the end hole TIS-255-04082016 ©2014 TERUMO MEDICAL CORPORATION HEARTRAIL™ Guide Catheters • Provides multiple points of contact against the contralateral wall • Ikari left offers versatility – for use in LCA and RCA • Optimal STEMI guide cath to reduce DTB TIS-255-04082016 7 4/10/2016 CASE 1 57 y/o morbidly obese WF with a h/o CAD s/p Anterior MI LAD stents 2014, HTN and HLD presented to hospital for worsening chest pain. Troponin 0.28 TIS-255-04082016 TIG 4.0 CATHETER TIS-255-04082016 IKARI 3.5 L GUIDE RUNTHROUGH® NS Coronary Guidewire TIS-255-04082016 8 4/10/2016 ASPIRATION THROMBECTOMY TIS-255-04082016 TIS-255-04082016 EXTRA SUPPORT WITH 6F GUIDELINER TIS-255-04082016 9 4/10/2016 TIS-255-04082016 POLLING QUESTION Which is the strongest independent predictor for radial artery spasm? A. Female gender B. Diabetes C. Hypertension D. Small radial artery diameter E. Unsuccessful access at first attempt TIS-255-04082016 Answer D. Small radial artery diameter TIS-255-04082016 10 4/10/2016 CASE 2 48 y/o Hispanic female with a h/o Diabetes mellitus, HTN, and HLD developed shortness of breath and crushing chest pain after dinner. Troponin 0.20 TIS-255-04082016 IKARI 3.5 L GUIDE, RUNTHROUGH® NS Coronary Guidewire TIS-255-04082016 TIS-255-04082016 11 4/10/2016 TIS-255-04082016 DES 3.0X16 TIS-255-04082016 IKARI 3.5 L GUIDE TIS-255-04082016 12 4/10/2016 IKARI 3.5 L GUIDE RUNTHROUGH® NS Coronary Guidewire PRIMARY STENTING DES 2.5 X12 TIS-255-04082016 3.0 X10 NC POST DILATION TIS-255-04082016 TIS-255-04082016 13 4/10/2016 POLLING QUESTION Which of the following is a predictor of RAO ( Radial arterial occlusion)? A. Female gender B. Length of procedure C. Lack of blood flow during compression D. Insufficient anticoagulation E. Ratio of artery diameter/ diameter of sheath < 1 F. All of the above TIS-255-04082016 Answer F. All of the above TIS-255-04082016 Radial Artery Occlusion (RAO) Remaining Challenges and Opportunities for Improvement in Percutaneous Transradial Coronary Procedures Key Points: • The authors grouped strategies aimed at minimizing the risk of arterial occlusion into three categories: Proven to Reduce Risk, May Reduce Risk, or Not Shown to Reduce Risk. • The Four “Proven to Reduce Risk” strategies were: Adequate Anticoagulation Patent Hemostasis Smaller Diameter Arterial Sheaths Minimizing the times that the artery is accessed TIS-255-04082016 Rao SV, Bernat I, Bertrand OF. Eur Heart J. 2012 Oct; 33(20)2521-6 14 4/10/2016 Complications While rare, complications from Transradial Access can occur. TIS-255-04082016 RAO Dosing Considerations • The current Society for Cardiac Angiography and Interventions best practice guidelines suggest a heparin dose of 50 units/kg (up to a 5,000unit maximum dose) for a radial diagnostic procedure. • Prophet Study used anticoagulation protocol of 50 units/kg to a maximum dose of 5000 Units Rao SV, Tremmel JA, Gilchrist IC, et al. Best practices for transradial angiography and intervention: a consensus statement from the society for cardiovascular angiography and intervention’s transradial working group. Catheter Cardiovasc Interv. 2014;83:228-236 Pancholy S, Coppola J, Patel T, Roke-Thomas M. Comment in Catheter Cardiovasc Interv. 2008 Sep 1;72(3):341-2 TIS-255-04082016 GLIDESHEATH® SLENDER™ Introducer Sheaths The smallest 6 Fr sheath on the market Take advantage of compatibility with 6 Fr devices Perform diagnostic and interventional procedures without upsizing to a larger sheath Incorporates Terumo Glide Technology™ for ease of insertion and removal 6 Fr Glidesheath Slender is compatible with 6 Fr guiding catheter while maintaining outer diameter of current 5 Fr sheath 6 Fr Sheath Equivalent Lumen 6 Fr Equivalent Diameter ©2014 TERUMO MEDICAL CORPORATION 5 Fr Sheath TIS-255-04082016 15 4/10/2016 Catheter Selection & Manipulation TIS-255-04082016 Radial Hemostasis TIS-255-04082016 Radial Hemostasis Prevention of Radial Artery Occlusion – Patent Hemostasis Evaluation Trial (PROPHET Study) A Randomized Comparison of Traditional Versus Patency Documented Hemostasis after Transradial Catheterization Conclusion Patent hemostasis is successful in significantly lowering the incidence of radial artery occlusion after TRA, without compromising hemostatic efficacy TIS-255-04082016 Pancholy S, et al Catheterization and Cardiovascular Interventions 72:335-340 2008 16 4/10/2016 Radial Hemostasis Impact of Two Different Hemostatic Devices on Radial Artery Outcomes after Transradial Catheterization Conclusion • TR BAND® Radial Compression Device provides equivalent hemostatic efficacy and a lower incidence of radial artery occlusion after transradial catheterization compared to the HemoBand. A device with a lower incidence of this complication is desirable over other available choices. TIS-255-04082016 Pancholy S. J Invasive Cardiol 2009 Mar;21(3):101-4 Radial Hemostasis At the conclusion of the procedure, a hemostasis device is recommended for access site management TIS-255-04082016 Radial Hemostasis • Important to understand the “Patent” hemostasis technique. • Close attention to placement of the TR BAND® Radial Compression Device • Monitor duration of compression ©2014 TERUMO MEDICAL CORPORATION • TIS-255-04082016 17 4/10/2016 Radial Hemostasis Once hemostasis is achieved transport the patient with the inflation syringe attached either to the patients chart or taped to the patient. TIS-255-04082016 Thank you! Questions? TIS-255-04082016 18
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