Safety and efficacy of using a single transradial MAC guiding catheter for coronary angiography and intervention in patients with ST-elevation myocardial infarction (RAPID)

1. Department of Cardiology, Luhe hospital,Capital
Medical University
Jincheng Guo
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2. Disclosure
• Research grant
The capital health research and
development of special
2011-7071-01
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3. Background
15 45 75 105 135 165 195 225
15
12
9
6
3
0
Mortality (%)
Door to balloon time (minutes)
BMJ 2009;338:b1807 AimRADIAL 2014 3

4. Background
• Several strategies to improve D2B times prior to
catheterization laboratory (cath lab) arrival.
• Few recommendations in the cath lab, cath lab to
balloon(C2B) times.
• Transradial vs transfemoral improved clinical outcomes.
• longer C2B times and fluoroscopic times for transradial
approach
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5. Background
Trasnradial Strategies For Primary PCI In Cathlab
patients with STEMI
Radial access
NIRA NIRA
Primary PCI
IRA
GC?
GC
IRA
Diganostic MP
JL/R
NIRA+IRA
IRA：infarct-related artery; NIRA:non-infarct-related artery;
GC： guiding catheter L: JL R: JR MP: multipurpose
ECG-Guided CA
5
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6. What is the optimal guiding catheter for “a
single catheter technique”
Author year Journal Guiding cather study Sample
Youssef
AA, et al
2008 Eurointervention Ikari left (IL) 3.5 Prospective
observational
621
Roberts
EB, et al
2011 J Interv Cardiol Q guide atheter observational 57
Chow J,
et al
2012 J Interv Cardiol Ikari left retrospective
study
362
Moon KW,
et al
2012 J Interv Cardiol 6 Fr RM® 3.5 retrospective
study
31
Malaiapan
Y , et al
2013 Cardiovasc
Revasc Med
Kimny matched
cohort
106
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7. What is the ideal single guide catheter?
Q Curve Ikari left (IL) kimny
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8. What is the ideal single guide catheter for
us?
MAC guide catheter
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9. MAC3.5 guiding catheter for LCA
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10. Manipulation of the MAC guiding catheter for LCA
Natural position U shape curve
Push/ Counterclockwise pull
clockwise
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11. Manipulation of the MAC guiding catheter for RCA
clockwise Push and U shape form Engage and pull
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12. To investigate the safety and feasibilityof using a
single guiding catheter (MAC 3.5) for left and right
coronary angiography and intervention in patients
with STEMI
Objective
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13. Inclusion Criteria
• symptom onset within 12 hours before admission
• candidate for primary PCI
• no contraindications to antiplatelet and anticoagulant therapy
• lesions of native coronary artery.
Exclusion Criteria
No radial pulse palpable
Throm bolytic therapy
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14. Definitions of times and intervals
Time/interval Source/Definition
Cathlab arrival time Time that the patient was placed on the cathlab table
Prepare time Time from cath lab table to local anesthesia
Cannulation time time from local anesthesia to sheath insertion
Coronary time time from sheath insertion to first cineangiography recording
Time/Definitions interval of times and intervals
Source/Definition
Cathlab Cath lab=Catheterization arrival time lab, CA=coronary Time that angiography; the patient PCI=was percutaneous placed on the coronary cathlab intervention
table
Prepare time Time from cath lab table to local anesthesia
Cannulation time time from local anesthesia to sheath insertion
Coronary time time from sheath insertion to first cineangiography recording
Diagnostic time first cineangiography recording to completion of the last angiographic
Diagnostic time first cineangiography recording to completion of the last angiographic cine
acquisition
procedure time,CA Cannulation time+ coronary time+ diagnostic time
cine acquisition
procedure time,PCI Time from the end of diagnostic time to the end of PCI
procedure time,CA Cannulation time+ coronary time+ diagnostic time
procedure time,PCI Time from the end of diagnostic time to the end of PCI
Total procedure time Including CA and PCI procedure time
Cath lab door to balloon
time(C2B)
Total procedure time Including CA and PCI procedure time
Interval between the Cath lab arrival time and the first device was activated to
open the artery regardless of the type of device used.
Interval between the Cath lab arrival time and the first device was
activated to open the artery regardless of the type of device used.
Cath lab door to balloon
time(C2B)
Door to balloon time(D2B) Interval from initial presentation to cathlab arrive time+C2B
Door to balloon time(D2B) Interval from initial presentation to cathlab arrive time+C2B
Cath lab=Catheterization lab, CA=coronary angiography; PCI=percutaneous
coronary intervention
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15. Design
• DESIGN:
Prospective, randomized (1:1),
parallel group, Single-center
trial.
MAC group—MAC for left and right
Coronary angiography an
intervention
Control group--first underwent
coronary angiography with
diagnostic Tiger catheter followed
by guiding catheter selection for
intervention
360 patients enrolled between September
2011 and Dec 2013 in our center
MAC group
(N=180)
Control Group
(N=180)
Crossover
to Femoral
6 9
MAC group
(N=180)
Control Group
(N=180)
cathlab door to balloon time
Procedure time, fluoroscopic time,Door
to balloon time, MACE at 2 years
Intention-to-treat analysis
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16. Primay PCI protocol
access
sheath
Coronary
angiogarphy
Right raidal
Catheter
Tiger
MAC3.5
NIRA
IRA
RCA 2 projections
LCA 5 projections
RCA 1 projections
LCA
LAO+cranial
Cranial+caudal
LAO45
AP cra+cau
Wire
Hytrophilic Long
Long Hytrophilic
2 projections
anticoagulation heparin
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17. Table 1 baseline characteristics
MAC group(n=180) Control group(n=180) p value
age 63.23±12.07 62.47±12.25 0.702
male/female 135/45 136/44 0.903
Cardiovascular risk factors
diabetes mellitus, n(%) 50(27.8) 56(31.1) 0.488
hypertension, n(%) 74(41.1) 68(37.8) 0.458
hypercholesterolaemia, n(%) 61(33.9) 56(31.3) 0.574
Present smoking, n(%) 106(58.9) 96(53.3) 0.288
history of CAD, n(%) 18 (10.0) 26(14.4) 0.198
history of stroke, n(%) 19 (10.6) 23(12.8) 0.511
Previous MI, n(%) 5(2.8) 5(2.8) 1.000
Previous renal insufficiency, n(%) 5(2.8) 6(3.3) 0.752
Previous PCI, n(%) 11(6.1) 9(5.0) 0.636
Killip class on admission, n(%) 0.410
I~ II 165(91.7) 161(89.4)
III~ IV 15(8.03 19(10.6)
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18. Coronary angiography success rate
MAC 3.5
LCA(180)
RCA(180)
Failure(6)
success(174)
Failure(1)
success(179)
success(1)
Tiger
LCA(180)
RCA(180)
Failure(4)
success(176)
Failure(3)
success(177)
Tiger
JL4.0
success(5)
=
=
Tiger/AL2.0
JL4.0/4.5
MAC3.5 GC
JL4.0
success(1)
success(1)
success(2)
=
=
=
AL1.0
JR4.0
success(1)
success(1)
success(1)
=
=
=
= success(1)
SAL1.0 JR3.5
GC
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19. Table 2 Angiographic and procedural characteristics(1)
MAC group
(n=180)
Control group
(n=180)
p value
Target vessel， n(%) 0.070
Left main 1(0.6) 0(0)
LAD 76(42.2) 97(53.9)
LCX 26(14.4) 15(8.3)
RCA 77(42.8) 68(37.8)
Disease vessles，n(%)
0.270
single 59(32.8) 73(40.6)
double 63(35.0) 52(28.9)
triple 58(32.2) 55(30.6)
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20. Table 2 Angiographic and procedural characteristics(2)
MAC group(n=180) Control group(n=180) p value
Access site crossover 6(3.3) 9(5.0) 0.428
Guiding catheter exchange 13(9.72) 19(9.86) 0.266
Pre-PCI TIMI flow, n(%) 0.354
0/1 146(81.1) 151(83.9)
2 10(5.6) 13(7.2)
3 24(13.3) 16(8.9)
Post-PCI TIMI flow, n(%) 0.704
0/1 8(4.4) 9(5.0)
2 15(8.3) 11(6.1)
3 157(87.2) 160(88.9)
CTFC ,frames
Pre-PCI 89.4±23.3 90.5±22.3 0.548
Post-PCI 31.6±20.9 30.2±21.5 0.518
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21. Table 2 Angiographic and procedural characteristics(2)
MAC group(n=180) Control group(n=180) p value
Pre-PCI TMP blush, n(%) 0.420
0 155(86.1) 156(86.7)
1 4(2.2) 7(3.9)
2 6(3.3) 2(1.1)
3 15(8.3) 15(8.3)
Post-PCI TMP blush, n(%) 0.643
0 24(13.3) 26(14.4)
1 37(20.6) 31(17.2)
2 45(25.0) 39(21.7)
3 74(41.1) 84(46.7)
Procedure success, n(%) 165(91.7) 165(91.7) 1.000
Stents per procedure 1.37±0.770 1.44±0.771 0.374
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22. Table 2 Angiographic and procedural characteristics(3)
MAC group(n=180) Control group(n=180) p value
Aspiration catheter, n(%) 164(91.1) 159(88.3) 0.386
GP IIb/IIIa, n(%)
tirofiban use 97(53.9) 88(48.9) 0.343
IABP support, n(%) 12(6.7) 10(5.6) 0.660
Contrast (ml) 103±37 110±41 0.163
Exchange guide catheter
LCA 12(6.7) 11(6.1) 0.829
RCA 1(0.6) 8(4.4) 0.018
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23. Table 3 treatment times
Time interval MAC group Control Group p
prepare time（min） 4.6±1.4 4.7±1.5 0.802
Cannulation time（min） 2.2±4.8 1.7±1.3 0.137
Coronary time（min） 2.6±4.8 2.8±2.9 0.704
Diagnostic time（min） 2.5±1.6 2.8±2.5 0.182
Procedure time, CA(min) 7.4±4.3 7.2±4.7 0.896
Procedure time, PCI(min) 24.8±10.7 28.7±12.0 0.003
Total procedure time 32.1±15.4 35.9±12.9 0.013
C2B（min） 17.1±5.5 19.2±5.6 <0.001
D2B（min） 87.1±39.4 85.6±35.0 0. 732
Fluorotime(min) 9.9±4.8 8.9±3.8 0.032
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24. time (min)
15
10
5
0
Control group
MAC group
NS
NS
NS
NS
NS
P=0.032
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25. Control group
MAC group
50
40
30
20
10
0
Procedure time (min)
P=0.003
PCI Total
C2B
P=0.004
P<0.001
D2B
150
100
50
0
NS
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26. Table 4 Clinical Outcomes during 30 days and two-Year Follow-Up
Variable MAC group (n=180)
control
group(n=180)
P value
The composite of MACE in
hospital and 30-days, n(%)
5(2.8) 4(2.2) 0.604
Cardiac death 4(2.2) 4(2.2)
Non-cardiac death 0 0
Re-MI 1(0.6) 0
TVR 1(0.6)
Stent thrombosis 0 0
Define
1(0.6) 0
probable
The composite of MACE at
24-months, n(%)
14(7.8) 12(6.7) 0.839
Cardiac death 6(3.3) 6(3.3)
Non-cardiac death 4(2.2) 3(1.7)
Re-MI 2(1.2) 1(0.6)
TVR 1(0.6) 1(0.6)
Stent thrombosis 1(0.6) 0
Define 1(0.6) 1(0.6)
Probable 0 0
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27. Percent survival
months
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28. Take home message
• A single transradial guiding catheter(MAC3.5 ) is
feasible in a majority of patients with STEMI and had
a shorter procedure time and fluoroscopic time .
• A learning curve for using MAC 3.5 might be
efficient .
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29. Thanks for
your attention！
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