Growing segment of the population Higher prevalence of CAD Background Growing segment of the population Higher prevalence of CAD More severe CAD (multivessel, calcification) Co-morbidity factors (renal insuffisency, PAD) High Risk Sub-groups The radial approach in octogenarians Stefano Rigattieri, Yves Louvard, Martial Hamon Trans-radial cardiovascular interventions, M Hamon & EP Mc Fadden Chapter 15, Text book, ESM Editions 2003; in press Massy 2003 The Octoplus study group Y. Louvard, H. Benamer, P. Garot, D. Hildick-Smith, C. Loubeyre, T. Lefevre, R. Sabatier, G. Grollier, M. Hamon Martial Hamon Caen, France

High Risk Sub-groups Rationale Technical issues Interventions Results Invasive strategies in octogenarians Difficult anatomy Interventions Results Massy 2003 Martial Hamon Caen, France Complex PCI/TRI Highlighting Important issues hamon-m@chu-caen.fr

enhanced benefit in the elderly Stent Invasive Rationale Aged (n=301) Nonaged (n=5885) Coronary stenting: MACE   * * Invasive Strategies & related issues *           Chauhan MS et al. JACC 2001; 37:856-62 ( p<0.001) *   GPIIb/IIIa blockers: enhanced benefit in the elderly GPIIb/IIIa INV (%) CON (%) OR Death 5.3 5.9 0.88 Death or MI 8.8 13.6 0.61 Death,MI,or Re-   Hosp for ACS 17.1 21.7 0.75 Bach et al. Circulation. 2001; Abstract: AHA. P=0.017 Age > 65 ( n = 962, avg = 73 yrs ) 95% CI 0.54-1.03 0.51-1.53 0.41-0.92 Time study (300 patients, 80 yrs) Invasive Stent GPIIb/IIIa       Three VD: 60% Left main stem: 14% Revasc.:74% (PCI:72%) Time Investigators. Lancet 2001;358:951-957

Radial Technical issues Spasm Haematoma Quick and adequate single puncture Short sheath, 5F Radial Cannulation

Loops Subclavian artery Aorta Catheter Brachial artery Brachial artery Spasm Haematoma Delayed Loops Technical issues Subclavian artery Aorta access Never forced Fluoroscopic guidance Hydrophilic wire Alternative approach Catheter Manipulation Brachial artery (Proximal) Brachial artery (Distal) Radial artery

Aorta Catheter access 1. Right subclavian artery Spasm Haematoma Stroke 1. Right subclavian artery 2. Brachiocephalic trunk 3. Right common carotid artery 4. Right vertebral artery 5. Right internal thoracic artery 3 4 1 2 Technical issues Exchange wire (260 cm) J tip, 0.032" Fluoroscopic guidance   5 Ascending aorta elongation Aorta access Catheter Manipulation Advanced age Hyperstension

Catheter Three vessel disease male patient of 83 yrs Complex PCI/TRI 30° 60° 90° Three vessel disease male patient of 83 yrs ACS, 5 Fr TRI, 48 hrs hospit. Catheter Manipulation

Success of TRA Success of TRA 100 80 60 40 20 Femoral 396 Radial 2072 Year 2001 All procedures Success of TRA 100 80 60 40 20 Success of TRA Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Department of Interventional Cardiology University Hospital of Caen, Normandy, France

Impact An attempt to obtain zero access site complication 2.7% 1.1% Others Leeches Transfusions Surgery 3,0 2.7% Highlighting Important issues 2,5 2,0 P<0.000005 P<0.03 % 1,5 1.1% 1,0 0.3% 0.2% 0,5 0,0 n=1269 n=1108 n=396 n=2072 Impact Femoral Radial Femoral Radial 2000 2000 2001 2001 Department of Interventional Cardiology University Hospital of Caen, Normandy, France Randomized studies: Access Study, Kiemeneij F. J Am Coll Cardiol 1997 Carafe study, Louvard Y. Catheter Cardiovasc Interv 2001

Preliminary results (n=288, 83 yrs, 54% male, ACS 48%) Radial (n=137) Femoral (n=141) p Cross-over (%) 11.7 9.5 ns Angio. Duration (min) 18 ± 11 16 ± 11 X-ray Duration (min) 6 ± 5 4 ± 3 0.000 PCI success (%) 96.8 94.7 PCI X-ray duration 10 ± 8 11 ± 10 PCI duration (min) 28 ± 18 33 ± 23 Primary end-point (%) 1.4 5.9 Haematoma > 3 cm (%) 2.2 11.4 0.004 Highlighting Important issues Octoplus Randomised study The Octoplus study group Y. Louvard, H. Benamer, P. Garot, D. Hildick-Smith, C. Loubeyre, T. Lefevre, R. Sabatier, G. Grollier, M. Hamon