Dr Savvas S Constantinides, MBChB, MD, FRCP Consultant Interventional Cardiologist American Medical Center, Nicosia, Cyprus

Radial access in the elderly

Dehgani P et al. J Am Coll Cardiol Intv 2009; 2: 1057-64

‘You are going nowhere near my groin!’

Why bother? Higher incidence of peri-procedural events Higher incidence of access-site related bleeding complications Higher incidence of comorbidities Higher incidence of mobility problems e.g. chronic back pain, urinary frequency/incompetence/retention: early ambulation very important!

Why is it a bother? More advanced atherosclerosis – often more complex cases (LMS, bifurcations, SVGs etc) Tortuous aorta, subclavian and radial arteries Advanced vessel calcification, more difficult radial and coronary access (rotablation) Inadequate patient co-operation due to poor hearing/vision/mental comprehension being more common Comorbidities more common: diabetes, renal failure, stroke

What is the evidence? Feasible? Safe?

Transradial in young vs old What is the evidence? Transradial in young vs old

Delache N et al. ‘Direct Angioplasty for Acute Myocardial Infarction in Elderly Patients using Transradial Approach’. Am J Geriatr Cardiol. 1999 Prospective study 46 patients >70 years old with AMI included -ve Allen test, thrombolysed patients excluded Failed right transradial approach in 4 pts (9%) PCI not necessary in 2 (4%) Remaining 40 (87%) successful PCI Conclusion: TRA feasible and highly successful in elderly patients.

Procedure success in 195 pts < 70 y.o. Vs 83 pts > 70y.o. Caputo RP et al: ‘Transradial cardiac catheterization in elderly patients’ Catheter Cardiovasc Interv. 2000 Nov;51 (3):287-90 Procedure success in 195 pts < 70 y.o. Vs 83 pts > 70y.o. Elderly pts less likely to be selected for TRA (46% Vs 61%). Elderly pts more often female (40% Vs 24%) and had smaller body surface area (1.9 Vs 2.0 m2) Same procedural success Similar procedure related variables (procedure time, amount of contast, number of catheters)

To assess safety, feasibility and efficacy of TRA in elderly Valsecci O et al: ‘Safety and feasibility of transradial coronary angioplasty in elderly patients’ Ital Heart J 2004 Dec; 5(12):926-31 To assess safety, feasibility and efficacy of TRA in elderly 1125 (<70 n=802 Vs >70 n=323) consecutive patients TRA single operator Radial and branchiocephalic anatomical toruosity more common in elderly (35.3 Vs 17.3%, p<0.05) Equal procedural success rate (97.5 Vs 98.7%, p=NS) No difference in cannulation and total procedural time No difference in access site bleeding (0.4 Vs 0%), 30 day asymptomatic loss of radial pulse (1.5 Vs 1.4%, p=NS). No forearm ischaemia in either group.

No difference in vascular complications Molinari G te al. ‘Safety and efficacy of the percutaneous radial artery approach for coronary angiography and angioplasty in the elderly’ J Invasive Cardiol. 2005 Dec;17 (12): 651-4 850 patients – 600 < 70 (70.5%) Vs 250 > 70 (29.5%) who underwent transradial coronary angiography and/or PCI No difference in procedure duration, X-ray time and number of catheters used No difference in vascular complications Stroke or TIA n=3 (1.2%) Vs n=1 (0.2%), p=0.08

Zheng et al. Chin Med J 2008; 121 (12): 1126-29

Transradial Vs transfemoral in the old What is the evidence? Transradial Vs transfemoral in the old

Rao SV et al. J Am Coll Cardiol Interv 2008; 1: 379-86

Secco G.G. et al. ‘Transradial Versus Transfemoral Approach for Primary Percutaneous Coronary Interventions in Elderly Patients’ J Invasive Cardiol 2013; 25(5): 254-6 283 consecutive elderly (>75) patients undergoing Primary PCI 177 (61%) TRA Vs 106 (39%) TFA Door-to-balloon 103 Vs 110 min (p=NS) Time of arterial puncture 10.6 Vs 12.1 min (p<0.01) Time of balloon inflation 19.6 Vs 24.2 min (p<0.01) Access site haematoma 1.7 Vs 8.5% (p<0.01) Access site bleeding 1.1 Vs 4.7% (p=NS)

Jean-Pierre Dery et al. J Am Coll Cardiol 2010; 55: A209 E1975

S. Constantinides et al. ‘Transradial approach for Coronary Angiography and Intervention in Octogenarians’ Cath Cardiovasc Intervent 2015; 85: S1-S176 Retrospective analysis of 108 consecutive octogenarians having undergone coronary angiography (45%) or PCI (55%) over a 2 year period 83% (n=90) transradial – 17% (n=18) tranfemoral Mean age 82.7 years (range 80-93) 39% (n=42) urgent, 11% (n=12) previous CABG, 4% (n=4) cardiogenic shock Only 2.2% (2/90) of transradial procedures switched to femoral due to extreme subclavian tortuosity and radial spasm No major vascular complications

Case Example 80 year old fragile Danish female tourist , 160cm and 55kgs Risk factors: smoking, DM, HTN and dyslipidemia Admitted to another centre with severe dyspnoea, reduced level of consciousness and restlessness The patient was in pulmonary oedema with an admitting ECG showing ST depression inferolaterally. Elevated cardiac enzymes. Mechanical ventilation instituted Echo EF 35-40%. Inferolateral hypokinisia, apical akinisia. Mild to moderate AS gradient 35mmHg. Following 48 hours of extubation and improvement she developed reccurrent chest pain and dyspnoea. She was transferred to our facility for coronary angiography

Coronary angiogram via right radial 5F sheath

Coronary angiogram via right radial 5F sheath

PCI RCA, LMS/LCx, mid-LAD

PCI RCA, LMS/LCx, mid-LAD

PCI RCA, LMS/LCx, mid-LAD

Final LCA PCI result

Conclusions Transradial approach for the elderly is not only feasible but safer than the transfemoral in experienced hands. Difficulties may include calcification, tortuosity/spasm and other comorbodities: consider Lt Vs Rt radial approach. If treated with patience and respect, vast majority of cases (>95%) can be successfully completed transradially irrespective of the age.

Transradial approach for the old?

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