Presentation Beyond The Basics Performing Radial STEMI Procedures Dr Sugumaran 040616 TIS 255 04082016

: Pdf Beyond The Basics Performing Radial Stemi Procedures- Dr Sugumaran 040616 Tis-255-04082016 Beyond_The_Basics_Performing_Radial_STEMI_Procedures-_Dr__Sugumaran_040616_TIS-255-04082016_ 4 2016 pdf

Open the PDF directly: View PDF .
Page Count: 18

4/10/2016

1

™

Beyond The Basics: Performing Radial

STEMI Procedures

Rajkumar K. Sugumaran, MD

Cardiac Solutions

Phoenix, AZ

TIS-255-04082016

–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.

Terumo Medical Corporation Disclaimer

TIS-255-04082016

Why Transradial PCI for STEMI?

Perfusion Test and Patient Prep

Radial Access

Catheter Selection and

Manipulation

Hemostasis

Objective

TIS-255-04082016

4/10/2016

2

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

Kugelmass A, Cohen D, Brown MD, Simon A, Becker E, and Culler S. American Journal of Cardiology 2006; 97: 322-327

Vascular Access Complications

TIS-255-04082016

Reduction in Bleeding Complications

RIVAL

TRA n = 3507 TFA n =3514

STEMI radial showed 40% Reduction in primary outcome

STEMI/ACS radial showed 63% Reduction in Major Vascular

Complications

MORTAL

Retrospective analysis of 38,872 patients

TRA showed 50% Reduction in Transfusion Rate

TRA reduced 1yr Mortality from 3.9% to 2.8%

RIFLE-STEACS

STEMI TRA (n = 500) vs. TFA (n = 501)

62% Reduction of Access site bleeding complications with TRA

vs. TFA

*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 Inv estigation 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

•Randomised, Superiority trial

•8404 Patients, 74 Centers

•Co-primary End Points

•MACE

•NACE

•Secondary End Points

•Individual components of

Composite out comes

•All cause Mortality

•Stroke

•MI

•Bleeding

Results

•Radial garners superior outcomes

•Radial as compared with femoral

access reduces NACE through a

reduction of bleeding and all-cause

mortality

•Co-Primary 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

1J Cardiovasc Transl Res. 20 14 Feb;7(1):101-11. doi: 10.1007/s12265-013-9537-1.

Epub 2014 Jan 7

TIS-255-04082016

4/10/2016

3

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.

Transradial PCI for STEMI

Baklanov DV, Kaltenbach LA, Marso SP et al. J Am Coll Cardiol. 2013 Jan 2 9;61(4):420-6

TIS-255-04082016

Baklanov D V et al. Circ Cardiovasc Interv. 2013;6:347-353

This figure demonstrates the rate of percutaneous coronary intervention-associated

bleeding in 501,017 patients grouped by vascular access and anticoagulation.

Transradial and Bivalrudin

TIS-255-04082016

Common Hurdles with Transradial PCI for STEMI

Learning Curve

Length of Set

Up

Inability to use

Larger

Equipment

Support Staff

Resistance to

New Technique

Length of

Procedure

(Initially)

TIS-255-04082016

4/10/2016

4

Transradial Advantages

Benefits of radial access for all patients, especially STEMI

When to start performing radial STEMI?

Why to perform radial STEMI?

Discussing with your Cath Lab Staff in advance of radial

STEMI case

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

4/10/2016

5

Begin with the

arm adducted

90 degrees

To work from the

patient’s right, use

pillows, straps or

blankets to elevate

arm

Assess position for

patient comfort and

compliance prior to

prepping site

©2014 TERUMO MEDICAL

CORPORATION

©2014 TERUMO MEDICAL CORPORATION

©2014 TERUMO MEDICAL CORPORATION

Room Set up –Left Radial

TIS-255-04082016

Access the left radial with arm

positioned at 90 degrees to

patient

Position the arm near

patient’s left groin if working

from the patient’s right

©2014 TERUMO MEDICAL CORPORATION

©2014 TERUMO MEDICAL CORPORATION ©2014 TERUMO MEDICAL CORPORATION

Room Set up –Left Radial

TIS-255-04082016

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

Room Set up –Considerations

TIS-255-04082016

4/10/2016

6

Administering Heparin to Avoid RAO

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)

Comparison of the Effect of Intra-Arterial Versus

Intravenous Heparin on Radial Artery Occlusion After

Transradial Catheterization

Samir Pancholy: Volume 104, Issue 8, Pages 1083-1085 (15 October 2009)

TIS-255-04082016

Radial Artery Spasm

Vascular Trauma

(Access)

Friction as a result of

catheter movement

or sheath removal Patient Anxiety

The vessel grips

onto the

catheter/sheath

Difficulty of

advancement or

removal

Gives great pain to

the patient if the

system is forced out

What Happens

Reasons

Radial Artery Spasm occurs in 2%-6% of patients

Patel’s Atlas of Transradial Intervention, The Basics and Be yond © 2012 by Tejas Patel

TIS-255-04082016

Additional vasodilators if needed

Gentle Sedation

Spasmolotic Cocktail (Nitroglycerin 200-400mcg, Verapamil 2.5-

5mg). Consider alternate vasodilators/antispasmodic.

Use of Smaller sheaths and catheters

Use of Hydrophilic sheath to reduce friction

Patel’s Atlas of Transradial Intervention, The Basics and Be yond © 2012 by Tejas Patel

Radial Artery Spasm Prevention

TIS-255-04082016

4/10/2016

7

Antispasmotic Cocktail

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

©2014 TERUMO MEDICAL CORPORATION

TIS-255-04082016

OPTITORQUE™

Coronary 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

©2014 TERUMO MEDICAL CORPORATION

TIS-255-04082016

•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

HEARTRAIL™ Guide Catheters

©2014 TERUMO MEDICAL CORPORATION

TIS-255-04082016

4/10/2016

8

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

4/10/2016

9

ASPIRATION

THROMBECTOMY

TIS-255-04082016

TIS-255-04082016

EXTRA SUPPORT

WITH 6F

GUIDELINER

TIS-255-04082016

4/10/2016

10

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

4/10/2016

11

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

4/10/2016

12

TIS-255-04082016

DES 3.0X16

TIS-255-04082016

IKARI 3.5 L GUIDE

TIS-255-04082016

4/10/2016

13

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

4/10/2016

14

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

Rao SV, Bernat I, Bertrand OF. Eur Heart J. 2012 Oct; 33(20)2521-6

TIS-255-04082016

4/10/2016

15

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 5,000-

unit 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

Equivalent

Diameter

6 Fr

6 Fr Sheath 5 Fr Sheath

Equivalent

Lumen

6 Fr Glidesheath Slender is compatible with 6 Fr guiding catheter

while maintaining outer diameter of current 5 Fr sheath

©2014 TERUMO MEDICAL CORPORATION

TIS-255-04082016

4/10/2016

16

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

Pancholy S, et al Catheterization and Cardiovascular Interventions 72:335-340 2008

Conclusion

Patent hemostasis is successful

in significantly lowering the

incidence of radial artery

occlusion after TRA, without

compromising hemostatic efficacy

TIS-255-04082016

4/10/2016

17

Radial Hemostasis

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.

Impact of Two Different Hemostatic Devices on Radial

Artery Outcomes after Transradial Catheterization

Pancholy S. J Inv asive Cardiol 2009 Mar;21(3):101-4

TIS-255-04082016

Radial Hemostasis

At the conclusion of the procedure, a hemostasis device

is recommended for access site management

TIS-255-04082016

•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

Radial Hemostasis

TIS-255-04082016

4/10/2016

18

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