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Radial Approach:
     An International Journey !
      Olivier F. Bertrand, MD, PhD
      Associate-Professor of Medicine, Laval University
      Adjunct-Professor, Department of Mechanical Engineering, McGill University


      Quebec Heart-Lung Institute

                    DUKE TRANSRADIAL ADVANCED COURSE,
                             20 OCTOBER 2011




Friday, October 21, 2011
Disclosures
                    Research grants: Cordis, Eli-Lilly, Bristol-
                    Myers-Squibb,GE Healthcare, Sanofi-
                    Aventis, Eurocor
                    Consultant: Cordis, Astra-Zeneca,
                    Opsens
                    Research-Scholar from Quebec
                    Foundation for Health Research


Friday, October 21, 2011
The Past




Friday, October 21, 2011
Friday, October 21, 2011
COURTESY OF B FAURIE ANDJ MONSEGU, MD (PARIS, 2010)




                                                              ADAPTED FROM S RAO, 2011




Friday, October 21, 2011
PATIENT QUALITY OF LIFE




                           SF-36 ONE WEEK POST-CATH (N=200)

                                            COOPER C ET AL. AM HEART J 1999;138:430-6


Friday, October 21, 2011
PATIENT QUALITY OF LIFE




                                                     >
                                     SCIAHBASI A ET AL. INT J CARDIOL 2009;137:199-205


Friday, October 21, 2011
NURSING WORKLOAD




                                AMOROSO G ET AL. EUR J CARDIOVASC NURS 2005;4:234-41


Friday, October 21, 2011
MDs Quality of Life




Friday, October 21, 2011
N = 1107
       75 countries
       01-08-2010




                           BERTRAND OF ET AL. JACC INTV 2010;3:1022-31

Friday, October 21, 2011
CAPUTO R ET AL. CCI 2011 (IN PRESS)




Friday, October 21, 2011
Quebec Heart-Lung Institute




                                                                                    91-93% RADIAL FOR
                                                                                       ANGIO AND PCI

                             1ST PTCA ALL PCI OPERATORS ALL OPERATORS ALL OPERATORS
                               7 FR          6 FR            6 FR         5-6 FR
                           FEMORAL KIT 19G NEEDLE         ADHOC PCI SAME-DAY DISCHARGE
                                GB


                                                         ADAPTED FROM TIZON-MARCOS H. ET AL. (2009)

Friday, October 21, 2011
QHLI- RADIAL VS FEMORAL APPROACHES PER OPERATOR

                                             Radial (%)                  Femoral (%)
           100
                           16      14   12       10       9    8    8    7      7       6    5    2
                                                                                                  98
                                                                                       94    95
                                                               92   92   93     93
                                                 90       91
                                        88
                                   86
                       84

            75




            50




                                              VARIATION IN RADIAL USE IN STEMI
            25                                     AMONG 12 OPERATORS



              0
                       JR          SR   BN       CN       EL   GP   RL   LR     GB     JPD   OG   OB

Friday, October 21, 2011
“Radialist” Feeling After
                            Radial Access Failure...



Friday, October 21, 2011
TRA NOT A RELIGION!




                                       BERTRAND OF ET AL. JACC INTV 2010;3:1022-31

Friday, October 21, 2011
Published (Radial)

              160

                                                                                                                                                                       140
              140


              120


              100
                                                                                                                                                                85

                                                        Kiemeneij F
                 80


                                                                                                                                    54
                 60                                                                                                                               51     52
                            Campeau L                                                                   47                   49
                                                                                                                                           45


                 40
                                                                                                                      29
                                                                                   24                          26

                                                                            15                   17
                                                                                          14
                 20
                                                                      8
                            1      0      0      1      1      2

                   0
                           1989

                                  1990

                                         1991

                                                1992

                                                       1993

                                                              1994

                                                                     1995

                                                                            1996

                                                                                   1997

                                                                                          1998

                                                                                                 1999

                                                                                                        2000

                                                                                                               2001

                                                                                                                      2002

                                                                                                                             2003

                                                                                                                                    2004

                                                                                                                                           2005

                                                                                                                                                  2006

                                                                                                                                                         2007

                                                                                                                                                                2008

                                                                                                                                                                       2009
Friday, October 21, 2011
Meta-Analysis
           Ischemic outcomes: All-cause death and the
           combined incidence of Death-MI

           Bleeding included both standardized and study-
           specific definitions. Most definitions involved fatal or
           intracranial bleeding, bleeding associated with Hb
           drop ≥ 3 g/dl or ≥ 5 g/dl, or access-related bleeding
           requiring transfusion or surgery

           Transfusion rates

           Early (≤ 30 days)

Friday, October 21, 2011
Studies Selection




                                         TOTAL OF 761,919
                                            PATIENTS




Friday, October 21, 2011
Impact on Bleeding
                                                            RANDOMIZED




                            OR 0.21 (95% CR I: 0.15-0.28)         OR 0.27 (95% CR I: 0.08-0.47)


      OBSERVATIONAL


Friday, October 21, 2011
Impact on Transfusion

                                                            RANDOMIZED




                            OR 0.19 (95% CR I: 0.09-0.30)
    OBSERVATIONAL

                                                                   OR 0.25 (95% CR I: 0.01-1.07)


Friday, October 21, 2011
Impact on Death (Early)

                                                           RANDOMIZED




                           OR 0.52 (95% CR I: 0.40-0.63)

    OBSERVATIONAL

                                                                 OR 0.80 (95% CR I: 0.49-1.23)


Friday, October 21, 2011
EHJ 2005




Friday, October 21, 2011
JACC 2009




Friday, October 21, 2011
JACC 2011:...PRESENT BUT NO RECOMMENDATION




Friday, October 21, 2011
EHJ-SEP 2011
                           STILL NO RECOMMENDATION !!




Friday, October 21, 2011
CCI 2011 (IN PRESS, NOVEMBER ISSUE)




Friday, October 21, 2011
Friday, October 21, 2011
RADIATION AND EXPERIENCE




                              NEILL J. ET AL. AM J CARDIOL 2010;106:936-40

Friday, October 21, 2011
JACOB S ET AL. BMC PUBLIC HEALTH, 2010;10:537

Friday, October 21, 2011
NO LEADED GLASSES
      CATHPAX



  NO LEAD APRON
                                                      DOSIMETER = OUTPUT




                                   FACTOR 10
                                      <<
                                      <<
                                      <<
                                      <<                                   RADPAD
                                      <<
      COURTESY J ARSENAULT, 2011




Friday, October 21, 2011
S RAO, 2011

Friday, October 21, 2011
EASY-Bivalirudin To Reduce Bleeding (B2B)
                   Patients at high risk of non-access site bleeding ie ≥
                   2 risk-factors: Age > 70, female, CKD, recent GI or
                   organ bleeding, anemia, diabetes, prior GPI/Tnk.
                              ≃ 2500 Transradial PCI



                           HEPARIN                BIVALIRUDIN

                     1ST END-POINT: DEATH, MI, URGENT REVASCULARIZATION,
                              BARC BLEEDING 2,3,5 AT 30 DAYS FU




Friday, October 21, 2011
Friday, October 21, 2011
Friday, October 21, 2011
FUNDING FOR RADIAL TRIALS RESEARCH ??

Friday, October 21, 2011
TRA PRACTICE IN THE FUTURE ?




                           50%




                                                    BERTRAND OF ET AL. JACC INTV 2010;3:1022-31

Friday, October 21, 2011
Supporting the adoption of transradial access


                            theradialist.org redesigned


                           50% RADIAL IN 5 YEARS




Friday, October 21, 2011
Supporting the adoption of transradial access

                                       Facebook




Friday, October 21, 2011
Conclusion: Think Different!
                  Transradial practice is already used worldwide
                  Use will likely continue to increase significantly
                  over next few years
                  Physicians = Education, EBM (Publications !!)
                  Health systems = Cost reduction
                  Patients = Qol, better outcomes
                  Still ways for improvement (RAO...)

Friday, October 21, 2011
IT IS NOT ABOUT YOU!!
                            IT IS ABOUT THE PATIENT AND
                                 BETTER OUTCOMES...



                       “Great invention and I’d love to invest, but I can’t
                       spend time to learn how to use it and I never
                       have trouble getting places when I have to
                       anyway. I’ll just stick with what I’m doing…”

                                                                    ADAPTED FROM I GILCHRIST

Friday, October 21, 2011
EHJ 2010...STILL NO RECOMMENDATION !!




Friday, October 21, 2011
Friday, October 21, 2011
ANTITHROMBOTIC REGIMENS AND RESIDUAL BLEEDING RISK




                                                 HAMON ET AL. EUROINTERVENTION, 2009


Friday, October 21, 2011
0
                                                                                               1
                                                                                                               2




                                  0
                                          20
                                                          40
                                                                    60
                                                                          80
                                                                                 100
                                                                                       120
                                                                                             140
                                                                                                         160




Friday, October 21, 2011
                                                                          1989




                                      1
                           1989
                                                                          1990




                                      0
                           1990
                                                                          1991




                                      0
                           1991
                                                                          1992




                                      1
                           1992
                                                                          1993




                                      1
                           1993
                                                                          1994




                                      2
                           1994
                                                                          1995




                                          8
                           1995                                           1996
                           1996                                           1997




                                              15
                           1997                                           1998




                                                    24
                           1998                                           1999




                                              14
                                                                          2000
                           1999

                                               17
                                                                          2001
                           2000
                                                               47
                                                                                                                   Randomized Trials (Radial vs Femoral)




                                                                          2002
                           2001
                                                    26




                                                                          2003
                           2002
                                                         29




                                                                          2004
                           2003
                                                                49




                                                                          2005
                           2004
                                                                     54




                                                                          2006
                           2005                                           2007
                                                               45




                           2006                                           2008
                                                                    51




                           2007                                           2009
                                                                    52




                                                                          2010
                           2008
                                                                               85




                                                                          2011
                           2009
                                                                                                   140
0
                                      2
                                          4
                                              6
                                                  8
                                                      10
                                                           12
                                                                14




Friday, October 21, 2011
                           1989
                           1990
                           1991
                           1992
                           1993
                           1994
                           1995
                           1996
                           1997
                           1998
                           1999
                           2000
                           2001
                           2002
                           2003
                                                                     Observational Studies (Radial vs Femoral)




                           2004
                           2005
                           2006
                           2007
                           2008
                           2009
                           2010
                           2011
Objectives

              To conduct a systematic review and
              meta-analysis of all observational
              studies and randomized trials
              comparing TRA to FA for PCI



Friday, October 21, 2011
PI: S. RAO, M. KRUCOFF




Friday, October 21, 2011
JOLLY S ET AL. LANCET 2011, 377:1409-20


Friday, October 21, 2011
JOLLY S ET AL. LANCET 2011, 377:1409-20


Friday, October 21, 2011
JOLLY S ET AL. LANCET 2011, 377:1409-20


Friday, October 21, 2011
JOLLY S ET AL. LANCET 2011, 377:1409-20


Friday, October 21, 2011
JOLLY S ET AL. LANCET 2011, 377:1409-20


Friday, October 21, 2011
JOLLY S ET AL. LANCET 2011, 377:1409-20


Friday, October 21, 2011
Friday, October 21, 2011
Friday, October 21, 2011

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Bertrand OF 201110

  • 1. Radial Approach: An International Journey ! Olivier F. Bertrand, MD, PhD Associate-Professor of Medicine, Laval University Adjunct-Professor, Department of Mechanical Engineering, McGill University Quebec Heart-Lung Institute DUKE TRANSRADIAL ADVANCED COURSE, 20 OCTOBER 2011 Friday, October 21, 2011
  • 2. Disclosures Research grants: Cordis, Eli-Lilly, Bristol- Myers-Squibb,GE Healthcare, Sanofi- Aventis, Eurocor Consultant: Cordis, Astra-Zeneca, Opsens Research-Scholar from Quebec Foundation for Health Research Friday, October 21, 2011
  • 5. COURTESY OF B FAURIE ANDJ MONSEGU, MD (PARIS, 2010) ADAPTED FROM S RAO, 2011 Friday, October 21, 2011
  • 6. PATIENT QUALITY OF LIFE SF-36 ONE WEEK POST-CATH (N=200) COOPER C ET AL. AM HEART J 1999;138:430-6 Friday, October 21, 2011
  • 7. PATIENT QUALITY OF LIFE > SCIAHBASI A ET AL. INT J CARDIOL 2009;137:199-205 Friday, October 21, 2011
  • 8. NURSING WORKLOAD AMOROSO G ET AL. EUR J CARDIOVASC NURS 2005;4:234-41 Friday, October 21, 2011
  • 9. MDs Quality of Life Friday, October 21, 2011
  • 10. N = 1107 75 countries 01-08-2010 BERTRAND OF ET AL. JACC INTV 2010;3:1022-31 Friday, October 21, 2011
  • 11. CAPUTO R ET AL. CCI 2011 (IN PRESS) Friday, October 21, 2011
  • 12. Quebec Heart-Lung Institute 91-93% RADIAL FOR ANGIO AND PCI 1ST PTCA ALL PCI OPERATORS ALL OPERATORS ALL OPERATORS 7 FR 6 FR 6 FR 5-6 FR FEMORAL KIT 19G NEEDLE ADHOC PCI SAME-DAY DISCHARGE GB ADAPTED FROM TIZON-MARCOS H. ET AL. (2009) Friday, October 21, 2011
  • 13. QHLI- RADIAL VS FEMORAL APPROACHES PER OPERATOR Radial (%) Femoral (%) 100 16 14 12 10 9 8 8 7 7 6 5 2 98 94 95 92 92 93 93 90 91 88 86 84 75 50 VARIATION IN RADIAL USE IN STEMI 25 AMONG 12 OPERATORS 0 JR SR BN CN EL GP RL LR GB JPD OG OB Friday, October 21, 2011
  • 14. “Radialist” Feeling After Radial Access Failure... Friday, October 21, 2011
  • 15. TRA NOT A RELIGION! BERTRAND OF ET AL. JACC INTV 2010;3:1022-31 Friday, October 21, 2011
  • 16. Published (Radial) 160 140 140 120 100 85 Kiemeneij F 80 54 60 51 52 Campeau L 47 49 45 40 29 24 26 15 17 14 20 8 1 0 0 1 1 2 0 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Friday, October 21, 2011
  • 17. Meta-Analysis Ischemic outcomes: All-cause death and the combined incidence of Death-MI Bleeding included both standardized and study- specific definitions. Most definitions involved fatal or intracranial bleeding, bleeding associated with Hb drop ≥ 3 g/dl or ≥ 5 g/dl, or access-related bleeding requiring transfusion or surgery Transfusion rates Early (≤ 30 days) Friday, October 21, 2011
  • 18. Studies Selection TOTAL OF 761,919 PATIENTS Friday, October 21, 2011
  • 19. Impact on Bleeding RANDOMIZED OR 0.21 (95% CR I: 0.15-0.28) OR 0.27 (95% CR I: 0.08-0.47) OBSERVATIONAL Friday, October 21, 2011
  • 20. Impact on Transfusion RANDOMIZED OR 0.19 (95% CR I: 0.09-0.30) OBSERVATIONAL OR 0.25 (95% CR I: 0.01-1.07) Friday, October 21, 2011
  • 21. Impact on Death (Early) RANDOMIZED OR 0.52 (95% CR I: 0.40-0.63) OBSERVATIONAL OR 0.80 (95% CR I: 0.49-1.23) Friday, October 21, 2011
  • 24. JACC 2011:...PRESENT BUT NO RECOMMENDATION Friday, October 21, 2011
  • 25. EHJ-SEP 2011 STILL NO RECOMMENDATION !! Friday, October 21, 2011
  • 26. CCI 2011 (IN PRESS, NOVEMBER ISSUE) Friday, October 21, 2011
  • 28. RADIATION AND EXPERIENCE NEILL J. ET AL. AM J CARDIOL 2010;106:936-40 Friday, October 21, 2011
  • 29. JACOB S ET AL. BMC PUBLIC HEALTH, 2010;10:537 Friday, October 21, 2011
  • 30. NO LEADED GLASSES CATHPAX NO LEAD APRON DOSIMETER = OUTPUT FACTOR 10 << << << << RADPAD << COURTESY J ARSENAULT, 2011 Friday, October 21, 2011
  • 31. S RAO, 2011 Friday, October 21, 2011
  • 32. EASY-Bivalirudin To Reduce Bleeding (B2B) Patients at high risk of non-access site bleeding ie ≥ 2 risk-factors: Age > 70, female, CKD, recent GI or organ bleeding, anemia, diabetes, prior GPI/Tnk. ≃ 2500 Transradial PCI HEPARIN BIVALIRUDIN 1ST END-POINT: DEATH, MI, URGENT REVASCULARIZATION, BARC BLEEDING 2,3,5 AT 30 DAYS FU Friday, October 21, 2011
  • 35. FUNDING FOR RADIAL TRIALS RESEARCH ?? Friday, October 21, 2011
  • 36. TRA PRACTICE IN THE FUTURE ? 50% BERTRAND OF ET AL. JACC INTV 2010;3:1022-31 Friday, October 21, 2011
  • 37. Supporting the adoption of transradial access theradialist.org redesigned 50% RADIAL IN 5 YEARS Friday, October 21, 2011
  • 38. Supporting the adoption of transradial access Facebook Friday, October 21, 2011
  • 39. Conclusion: Think Different! Transradial practice is already used worldwide Use will likely continue to increase significantly over next few years Physicians = Education, EBM (Publications !!) Health systems = Cost reduction Patients = Qol, better outcomes Still ways for improvement (RAO...) Friday, October 21, 2011
  • 40. IT IS NOT ABOUT YOU!! IT IS ABOUT THE PATIENT AND BETTER OUTCOMES... “Great invention and I’d love to invest, but I can’t spend time to learn how to use it and I never have trouble getting places when I have to anyway. I’ll just stick with what I’m doing…” ADAPTED FROM I GILCHRIST Friday, October 21, 2011
  • 41. EHJ 2010...STILL NO RECOMMENDATION !! Friday, October 21, 2011
  • 43. ANTITHROMBOTIC REGIMENS AND RESIDUAL BLEEDING RISK HAMON ET AL. EUROINTERVENTION, 2009 Friday, October 21, 2011
  • 44. 0 1 2 0 20 40 60 80 100 120 140 160 Friday, October 21, 2011 1989 1 1989 1990 0 1990 1991 0 1991 1992 1 1992 1993 1 1993 1994 2 1994 1995 8 1995 1996 1996 1997 15 1997 1998 24 1998 1999 14 2000 1999 17 2001 2000 47 Randomized Trials (Radial vs Femoral) 2002 2001 26 2003 2002 29 2004 2003 49 2005 2004 54 2006 2005 2007 45 2006 2008 51 2007 2009 52 2010 2008 85 2011 2009 140
  • 45. 0 2 4 6 8 10 12 14 Friday, October 21, 2011 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Observational Studies (Radial vs Femoral) 2004 2005 2006 2007 2008 2009 2010 2011
  • 46. Objectives To conduct a systematic review and meta-analysis of all observational studies and randomized trials comparing TRA to FA for PCI Friday, October 21, 2011
  • 47. PI: S. RAO, M. KRUCOFF Friday, October 21, 2011
  • 48. JOLLY S ET AL. LANCET 2011, 377:1409-20 Friday, October 21, 2011
  • 49. JOLLY S ET AL. LANCET 2011, 377:1409-20 Friday, October 21, 2011
  • 50. JOLLY S ET AL. LANCET 2011, 377:1409-20 Friday, October 21, 2011
  • 51. JOLLY S ET AL. LANCET 2011, 377:1409-20 Friday, October 21, 2011
  • 52. JOLLY S ET AL. LANCET 2011, 377:1409-20 Friday, October 21, 2011
  • 53. JOLLY S ET AL. LANCET 2011, 377:1409-20 Friday, October 21, 2011