How to optimize door-to-balloon for STEMI

1. How to optimize door-to-balloon for STEMI
Robert J Applegate, M.D.
Professor of Internal Medicine-Cardiology

2. Disclosures
Advisory Boards Abbott Vascular
Research Grants Abbott Vascular
Serruys, PW. PCR 2010
The Medicines Company
Wake Forest School of Medicine AimRADIAL 2014

3. How to optimize door-to-balloon for STEMI
Nodes of time “leaks” for DTB
Serruys, PW. PCR 2010
• Pre-hospital processes
• ED
• Catheterization lab prep
• Procedural
Wake Forest School of Medicine AimRADIAL 2014

4. How to optimize door-to-balloon for STEMI
Pre-hospital processes and ED
• Anything that reduces delays will reduce the
“pressure” on the radial procedure
Serruys, PW. PCR 2010
Wake Forest School of Medicine AimRADIAL 2014

5. How to optimize door-to-balloon for STEMI
• Prep for radial only
• Don’t prep femoral unless cardiogenic shock present
Serruys, PW. PCR 2010
Catheterization prep
Wake Forest School of Medicine AimRADIAL 2014

6. How to optimize door-to-balloon for STEMI
• Prep for radial only
• Don’t prep femoral unless cardiogenic shock present
• Have spasmolytics (iv diltiazem; verapamil; NTG)
available
• Use 6 fr, or “Slender” 6in5 sheath
• Be prepared for pathway issues-BAT
Serruys, PW. PCR 2010
Procedural
• Keep clock on DTB elapsed
Wake Forest School of Medicine AimRADIAL 2014

7. How to optimize door-to-balloon for STEMI
• Use EKG to focus culprit vessel PPCI
• Anterior or lateral STEMI-use 6 Fr LCA 0.071 guide (EBU)
• Perform culprit vessel PCI
• Shoot RCA, LV gram
• Inferior STEMI
• Shoot LCA first to help determine stent type
• 6 Fr 0.071 RCA guide
• Perform culprit vessel PCI
Serruys, PW. PCR 2010
Procedural
Wake Forest School of Medicine AimRADIAL 2014

8. How to optimize door-to-balloon for STEMI
• Anterior STEMI-per protocol
325 ASA, 600 clopidogrel,
5,000 units heparin
• Uncomplicated right radial
access-bivalirudin (+ prasugrel)
• 6 Fr 3.5 EBU guide
• LAD occluded proximally
Serruys, PW. PCR 2010
Anterior STEMI
Wake Forest School of Medicine AimRADIAL 2014

9. How to optimize door-to-balloon for STEMI
• LAD wired
Serruys, PW. PCR 2010
Anterior STEMI
Wake Forest School of Medicine AimRADIAL 2014

10. How to optimize door-to-balloon for STEMI
• PTCA with 2.5 x 12 mm balloon
• Significant thrombus present
Serruys, PW. PCR 2010
Anterior STEMI
Wake Forest School of Medicine AimRADIAL 2014

11. How to optimize door-to-balloon for STEMI
• Aspiration thrombectomy
performed
Serruys, PW. PCR 2010
Anterior STEMI
Wake Forest School of Medicine AimRADIAL 2014

12. How to optimize door-to-balloon for STEMI
• Stent with 3.0 x 18 DES
Serruys, PW. PCR 2010
Anterior STEMI
Wake Forest School of Medicine AimRADIAL 2014

13. How to optimize door-to-balloon for STEMI
• Final result with TIMI III flow
Serruys, PW. PCR 2010
Anterior STEMI
Wake Forest School of Medicine AimRADIAL 2014

14. How to optimize door-to-balloon for STEMI
• Inferior STEMI-per protocol
325 ASA, 600 clopidogrel,
5,000 units heparin
• Uncomplicated right radial
access-bivalirudin (+ prasugrel)
• 5 Fr multipurpose catheter
• Significant diffuse disease of
both LAD and LCX
Serruys, PW. PCR 2010
Inferior STEMI
Wake Forest School of Medicine AimRADIAL 2014

15. How to optimize door-to-balloon for STEMI
• 6 Fr 4.0 Rt Judkins guide
• RCA occluded proximally
Serruys, PW. PCR 2010
Inferior STEMI
Wake Forest School of Medicine AimRADIAL 2014

16. How to optimize door-to-balloon for STEMI
• RCA wired
• Balloon “dottered” to distal vessel
and back into guide
• PTCA performed with 2.5 x 12
balloon
Serruys, PW. PCR 2010
Inferior STEMI
Wake Forest School of Medicine AimRADIAL 2014

17. How to optimize door-to-balloon for STEMI
• Aspiration thrombectomy
performed x 3
Serruys, PW. PCR 2010
Inferior STEMI
Wake Forest School of Medicine AimRADIAL 2014

18. How to optimize door-to-balloon for STEMI
• Proximal stenosis (culprit) stented
with 3.5 x 18 DES
• Chest pain and ST elevation
resolving
• Diffuse distal disease left alone
Serruys, PW. PCR 2010
Inferior STEMI
Wake Forest School of Medicine AimRADIAL 2014

19. How to optimize door-to-balloon for STEMI
Tips and tricks for navigating challenging
Serruys, PW. PCR 2010
anatomy
Wake Forest School of Medicine AimRADIAL 2014

20. Radial Artery Issues-Forearm
• What is this?
Radial artery loop with
recurrent radial artery
• Any risks associated
with this?
Yes; difficult to navigate,
and can perforate
Wake Forest School of Medicine AimRADIAL 2014

21. Wake Forest School of Medicine
Radial Education-Nursing Staff
Brachial Artery
Recurrent
Radial Artery
Ulnar Artery
Radial Loop
Radial Artery

22. Radial Artery IsRsuaesd-Uiasle E ofd Cuocraontiaorny -WNiruer tsoi nNgav Sigtaateff Radial
Wake Forest School of Medicine
Loop/Tortuosity

23. Radial Artery Access-Radial Artery Perforation
Resistance with 0.035 J wire
Exchanged for 0.035 angled
hydrophilic wire
Resistance at same location
Sheath-o-gram
Perforation of radial artery
and or intramuscular
branch
Complete case, monitor sx
Serruys, PW. PCR 2010
Wake Forest School of Medicine AimRADIAL 2014

24. Radial Artery Access-Complete Resolution of Perforation
Radial traversed with 0.014
Coronary wire
Case completed with 5 Fr
Catheter
Angiogram demonstrates
Resolution of perforation
Serruys, PW. PCR 2010
Wake Forest School of Medicine AimRADIAL 2014

25. I wish I had(n’t) gone femoral
• Inferior STEMI
• Uncomplicated right radial
access
• Unable to advance catheters
• Unable to enter brachial artery
despite multiple efforts, angles,
etc
• Switched to femoral b/o DTB
concern
Wake Forest School of Medicine

26. I wish I had(n’t) gone femoral
• Significant LAD and LCX dz
• RCA occlusion
• MAC 3.0 guide
• Vessel wired, PTCA
Wake Forest School of Medicine

27. I wish I had(n’t) gone femoral
• Guide catheter and
guide wire spontaneously
dislodged from coronary
• After reintubation of RCA
dissection of vessel and
staining of sinus note
• Unable to wire vessel
• Right Judkin guide advanced and
vessel wired with difficulty
Wake Forest School of Medicine

28. I wish I had(n’t) gone femoral
• Patient became bradycardic, then
apneic, and finally arrested
• Unsuccessful resuscitation
• CTS did not believe ECMO or surgery
viable options
Wake Forest School of Medicine

29. How to optimize door-to-balloon for STEMI
Summary
• Commit to starting and ending PPCI using the radial
approach
• Keep a mental clock of the first EKG time to procedure
to gauge ability to complete DTB within 90 min
• Focus on culprit vessel PCI
Wake Forest School of Medicine AimRADIAL 2014