Anticoagulation Strategies for Transradial Diagnostic and Interventional Cases

1. Anticoagulation Strategies for
Transradial Diagnostic and
Interventional Cases
Tift Mann, MD, FACC

2. Disclosure Statement of Financial Interest
I, Tift Mann, DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could be
perceived as a real or apparent conflict of
interest in the context of the subject of
this presentation.

3. Heparin must be administered for all
transradial procedures
100
2mo radial occlusion
80
71%
60
40
24%
20
4%
0
No Heparin UFH 2000-3000 UFH 5000
Spaulding et al CCVD 39:365 (1996)

4. Bernat et al, AJC 2011

5. IA vs IV heparin:
No difference in incidence of RAO
Pancholy. Am J Cardiol 2009; 104: 1083

6. Bivalirudin vs heparin:
No difference in RAO
Plante et al. CCVI 2010; 76:654

7. What anticoagulation strategy should be
used for ad hoc TRI?
1. Increase the total heparin dose
to 80-100 units/kg
2. Switch to bivalirudin

8. Transitioning to bivalirudin in ad hoc
transradial procedures:
divide the heparin dose
• Divided dosing with unfractionated heparin
should provide the same protection against post-
procedure radial occlusion as the standard 5000
unit single dose if diagnostic only procedure .
• The safety profile of bivalirudin should not be
altered if it is given after an initial reduced
heparin dose should PCI be required.

9. Transitioning to bivalirudin in ad hoc
transradial procedures
Venkatesh K et al. JIC 2006;18:120

13. Does TRI and Bivalirudin combination
reduce
all procedure-related bleeding?

14. Site of Bleeding Complications in Patients
Undergoing PCI
Rao, et al. J Am Coll Cardiol 2010;55:2187-2195

15. R I V A L
Site of Non-CABG Major Bleeds
(RIVAL definition)
*Sites of Non Access site Bleed: Gastrointestinal (most common site), ICH,
Pericardial Tamponade and Other

16. Eurovision: Bivalirudin monotherapy in PCI
Bleeding Outcomes
Femoral Radial P-value
(n=1353) (n=580)
Major Bleeding 1.7% 1.2% 0.4216
Minor Bleeding 4.8% 1.9% 0.0026
Thrombocytopenia 0 0
Any bleeding 8.0% 4.5% 0.0055
Access Site Bleed 3.6% 1.0% 0.0017
Non-Access Site Bleed 1.6% 0.9 0.1897
Hamon et al, TCT 2011

17. EArly Discharge After Transradial
Stenting of CoronarY Arteries in
High–Bleeding-Risk Patients Using
Bivalirudin to Reduce Bleeding
EASY-B2B Study
Pts with increased bleeding risk
undergoing TR PCI randomized to
Heparin vs Bivalirudin
Bertrand et al

18. R I V A L
Definition: Major Bleeding
 Fatal
 > 2 units of Blood transfusion
 Hypotension requiring inotropes
 Requiring surgical intervention
 ICH or Intraocular bleeding leading to
significant vision loss

19. R I V A L
Definition: Major Vascular Access Site
Complications
•Large hematoma
• Pseudoaneurysm requiring closure
• AV fistula
• Other vascular surgery related to the access site
• Blood txf 1 unit

20. R I V A L
“Other” Outcomes
Radial Femoral
(n=3507) (n=3514) HR 95% CI P
% %
Major Vascular
Access Site 1.4 3.7 0.37 0.27-0.52 <0.0001
Complications
ACUITY Non-CABG
1.9 4.5 0.43 0.32-0.57 <0.0001
Major Bleeding

21. R I V A L
Results stratified by
High*, Medium* and Low* Volume Radial Centres
*High (>146 radial PCI/year/ median operator at centre), Medium (61-146), Low (≤60)
Tertiles of Radial PCI Centre Volume/yr HR (95% CI) p-value
Primary Outcome Interaction
High 0.021
Medium
Low
Death, MI or stroke
High 0.013
Medium
Low
Non CABG Major Bleed
High
Medium 0.538
Low
Major Vascular Complications
High 0.019
Medium
Low
Access site Cross-over
High 0.003
Medium
Low
0.25 1.00 4.00 16.00
Radial better Femoral better

22. Risk of death for up to 1 year:
transfemoral vs. transradial access site
Adjusted OR (95% CI)
0.78 (0.64-0.96)
P= 0.018
From SCAAR registry, EuroPCR, 2011

23. What is the strategy for patients on
coumadin undergoing TR procedures?

24. Transradial access in the fully
anticoagulated patient
N=66
No major bleeding
Hildick-Smith et al CCVI 58:8,2003

25. TR Access in pts receiving coumadin
INR 2.4 INR 1.4
Sanmartin et al. Rev Esp Cardiol. 2007;60:988

26. CONCLUSION:
Transradial access provides a
safety margin for interventional
procedures

27. Radial vs. Femoral Access
MAJOR BLEEDING DEATH / MI / STROKE
Jolly et al. Am Heart J 2009

28. Abciximab in pts with transradial access
N=504 N=501
Bertrand et al. Circ 2006;114:2636

29. Risk of death for up to 30 days:
transradial vs. transfemoral access site (male vs. female)
Favors Radial Favors Femoral
OR 95% CI
0.66 (0.51-0.86), p=0.002
0.78 (0.64-0.97), p=0.022

30. Risk of death for up to 30 days:
transradial vs. transfemoral access site (by age)
Favors Radial Favors Femoral
OR 95% CI
0.59 [ 0.45-0.78]
0.70 [0.53-0.93]
1.12 [0.78- 1.61]
0.84 [0.50-1.42]

31. Results
Outcome
Transfemoral Transradial P value OR Adjusted OR
(%) (%) (95 % CI) (95 % CI)
N = 21 339
Measured Variable:
30 day mortality event/N (%) 667/15290 (4.4) 193/6049 (3.2) <0.001 0.72 (0.61-0.85) 0.57 (0.46-0.72)
1 year mortality event/N (%) 982/13446 (7.3) 260/4175 (6.2) 0.018 0.84 (0.73-0.97) 0.78 (0.64-0.96)
Male: 30 day mortality/N (%) 120/4396 (2.7) 373/10797 (3.5) 0.022 0.78 (0.64-0.97)
Female: 30 day mortality/N(%) 73/1653 (4.4) 294/4493 (6.5) 0.002 0.66 (0.51-0.86)
Any reported bleeding event/N(%) 495/14953 (3.3) 88/5866 (1.5) <0.001 0.45 (0.35-0.56) 0.43 (0.31-0.61)
Serious bleeding event/N (%) 335/14953 ( 2.2) 58/5866 (1.0) <0.001 0.44 (0.33-0.58) 0.43 (0.32-0.57)
Hospital stay Days mean(SD) 5.2 (6.3) 4.8 (5.1) <0.001
From SCAAR registry, EuroPCR, 2011

32. Anticoagulation Strategies for
Transradial Diagnostic and
Interventional Cases
Tift Mann, MD, FACC
TCT 2011