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Nolan J - AIMRADIAL 2015 - Radialists and femoral access

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Radialists perform better femoral percutaneous coronary intervention (PCI)

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Nolan J - AIMRADIAL 2015 - Radialists and femoral access

  1. 1. RADIALISTS PERFORM BETTER FEMORAL PCI Jim Nolan University Hospital of North Staffordshire
  2. 2. WHY DOESN’T EVERYBODY USE RADIAL ACCESS • Learning curve • Extended Procedural duration • Increased nursing input • Patient preference • Impaired Procedural success and applicability • Increased cost of radial specific kit • Radiation exposure • If they do they will lose the ability to do safe TFA
  3. 3. RADIAL ENVIRONMENT • Small calibre vessel • Spasm risk • Anatomical variation • Advanced guide catheter techniques • Skilled high volume TRA operators are highly proficient interventionists ( as are their teams )
  4. 4. FEMORAL ENVIRONMENT
  5. 5. FACTORS THAT MAY ACT TO INCREASE TFA COMPLICATIONS IN RADIAL CENTERS • Fewer TFA procedures • Reduced exposure to technique for operators in training and daily practice • Reduced institutional experience with post TFA care
  6. 6. ACCESS SITE PRACTICE EVOLUTION IN THE UK
  7. 7. FACTORS THAT MAY ACT TO REDUCE TFA COMPLICATIONS IN A RADIAL CENTER •When a TRA operator has to perform a TFA case it is done with maximum attention to puncture, haemostasis and aftercare •TRA operators performing TFA frequently use guidance for the puncture •Limited use of VCDs
  8. 8. VACD – DEVICE FAILURE RATE (Sesana et-al, JIC 2000, n = 827) 9 11 0 2 4 6 8 10 12 COLLAGEN PLUG SUTURE FAILURERATE(%)
  9. 9. VCD META ANALYSIS – RANDOMISED + OBSERVATIONAL (Nikolsky et-al, JACC 2004, n = 37,066)
  10. 10. COMPLICATIONS IN VCD MA (Biancari et-al, Am Heart J 2010, n=7528)
  11. 11. HOW CAN WE INVESTIGATE THE SAFETY OF TFA IN RADIAL CENTERS
  12. 12. PATIENTS UNDERGOING PCI FROM THE FEMORAL ROUTE BY DEFAULT RADIAL OPERATORS Ihsan M. Rafie, MD; Muez M. Uddin, MD; Nicholas Ossei-Gerning, MD; Richard A. Anderson, MD; Timothy D. Kinnaird*, MD Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom Eurointervention 2014
  13. 13. CARDIFF STUDY • 1352 PCI procedures performed by default radial operators over 12 month period • TFA used when operator felt it to be technically and clinically appropriate ( skilled TFA operators) • ACUITY based definition of TFA related complications ( included haematomas that were not associated with Hb fall and required no intervention) • TFA utilised in 351 (25.2%) cases
  14. 14. WHAT TYPE OF PATIENT HAD TFA IN THE CARDIFF STUDY • Female gender (41% v 21%) • Older (65 v 63) • Lower BMI (80% v 84%) • Shorter stature (167 v 171) p < 0.001 for all comparisons
  15. 15. WHAT TYPE OF PROCEDURE WAS DONE VIA TFA IN THE CARDIFF STUDY?
  16. 16. RESULTS IN TFA CASES • 44 patients (12.5%) had femoral vascular complication (ACUITY definition) • 22 of these ( 6.25%) were haematomas with no intervention required • 22 (6,25%) had TFA complication that required some form of intervention
  17. 17. The use of radial access decreases the risk of vascular access-site-related complications at a patient level but is associated with an increased risk at a population level: the radial paradox Lorenzo Azzalini, MD, MSc; E. Marc Jolicoeur*, MD, MSc, MHS Interventional Cardiology Division, Dept. of Medicine, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
  18. 18. INFLUENCE OF RADIAL ACCESS ON BLEEDING AND VASCULAR COMPLICATIONS – META ANALYSIS OF RANDOMISED TRIALS (Jolly et-al,lancet,2011, n=10,000+)
  19. 19. META-ANALYSIS OF RCT COPARING RADIAL v FEMORAL ACCESS IN STEMI PATIENTS UPDATED TO INCLUDE RIFLE (Mamas et-al,Heart 2011,n=3978) OR for mortality = 0.53 (95% CI 0.38-75); P<0.001 for radial
  20. 20. BRITISH CARDIOVASCULAR INTERVENTION SOCIETY • BCIS established in 1998 to promote and monitor PCI activity in UK • Collects data on all PCI performed in UK via central electronic database ( 113 patient ,procedural and outcome variables ) • Robust mortality data using NHS number • Linked to NHS central register • Legal requirement for every death in UK to be recorded
  21. 21. PCI OUTCOMES ACCORDING TO CLINICAL SYNDROME AND ACCESS SITE (n=433,000 JACCI 2014) 0.1 1 Favours TRA Favours TFA Access site complication 0.20 (0.13-0.29) p<0.001 Bleed 0.53 (0.43-0.66) p<0.001 MACE 0.71 (0.65-0.78) p<0.001 30-Day Mortality 0.69 (0.62-0.77) EMERGENCY Access site complication 0.24 (0.19-0.30 p<0.001 Bleed 0.40 (0.31-0.52) p<0.001 MACE 0.85 (0.77-0.94) p<0.001 30-Day Mortality 0.85 (0.76-0.96) p=0.01 URGENT Access site complication 0.22 (0.17-0.29) p<0.001 Bleed 0.24 (0.15-0.39) p<0.001 MACE 1.04 (0.92-1.18) p=0.53 30-Day Mortality 0.78 (0.57-1.03) p=0.77 STABLE Figure 3. Forest plot of log odds ratio of outcomes following multivariate logistic regression Variables included in analysis: Age, sex, prior MI, prior CABG, prior PCI, diabetes, hyperlidaemia, hypertension, peripheral vascular disease, previous stroke, smoking, pre- procedural ventilation, use of circulatory support and pre-procedural shock.
  22. 22. UK BCIS PPCI N=46,128 PPCI 39% TRA TRA for PPCI increased from 12% to 49% Mamas M, JACC Cardiovasc Interv. 2013; 6: 698-706 TRM 2013
  23. 23. ACCES SITE RELATED OUTCOMES IN CARDIOGENIC SHOCK (AHJ,2014, n=7,231)
  24. 24. WHO STILL DOES TFA IN UK ?
  25. 25. GEOGRAPHICAL DISTRIBUTION OF TRA IN UK
  26. 26. WHAT TYPE OF OPERATORS DO TFA IN UK? Kinnaird T et al, O Heart 2014
  27. 27. CLOPIDOGREL USE IN STEMI PCI
  28. 28. UK FEMORAL OPERATORS • Old guys based in south • Low volume operators • Slow to modify practice
  29. 29. EVALUATION OF TFA ACCESS SITE PRACTICE IN MAJORITY RADIAL CENTERS • Years 2006 to 2010 • Single access site recorded • TRA or TFA
  30. 30. P=0.007 P=0.26 P=0.6
  31. 31. ARE RADIAL CENTERS BETTER AT EVERYTHING?
  32. 32. WHAT DOES BCIS TELL US • TRA benefits seen in RCT translate into clinical practice • Radial centers do better radial PCI • No increase in TFA complications in radial centers • TFA procedures performed in a TRA center were associated with an observed reduction in mortality at 30 days • In MVA OR 0.86, 95% CI 0.76-0.99, p=0.032
  33. 33. Limitations • Observational data • Unmeasured confounders • Data collected in an evolutionary period (operators have TFA background) • May not apply to TFA cases in very high volume TRA centers ( case mix effects )
  34. 34. CONCLUSIONS • Radial centres do better femoral PCI • Radial centres do better radial PCI • Radial centres do better PCI

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