Remaining Challenges and Opportunities for Improvement In Percutaneous Transradial Procedures Sunil V. Rao MD The Duke Clinical Research Center Duke University Medical Center The Durham VA Medical Center

Disclosures Consultant ZOLL, Terumo Medical, The Medicines Company Research funding Ikaria, sanofi-aventis Off-label uses may be discussed

Remaining challenges and opportunities for improvement Radial procedure technique Radial access site bleeding Radial artery injury and occlusion Increased radiation exposure Radial procedure implementation Transradial primary PCI

Radial artery access site bleeding Patent hemostasis 2000u UFH 5000u UFH

Predictors of radial access site bleeding Odds Ratio 95% CI Female sex 4.40 2.49 – 7.81 CrCL < 60 ml/min 3.26 1.10 – 8.67 Procedure duration > 1 hr 2.95 1.12 – 8.31 Sheath size ≥ 6F 5.34 1.44 – 34.65 Non-occlusive hemostasis ?? Bertrand OF, et. al. AHJ 2009 Tizón Marcos H, et. al. AHJ 2009

Bertrand OF, et. al., Circulation 2006

Radial artery injury Yonetsu T, et. al. EHJ 2010

Titrate to least necessary pressure Slide courtesy of Samir Pancholy MD

Anticoagulation Patent hemostasis UFH 70-100 u/kg No UFH 70 u/kg No Or Bivalirudin No UFH 50u/kg Yes UFH 70-100 u/kg Yes UFH 5000 u Yes + Ulnar compression Rao SV. JACC Intv 2012

Collateralization in UE is more than we think Extensive interosseous collaterals Dynamic recruitable non-visible circuits.

Recruitable circulation JACC Vol. 46, No. 11, 2005 December 6, 2005:2013–7

Abnormal Allen’s = ischemia? JACC Vol. 46, No. 11, 2005 December 6, 2005:2013–7

Hand ischemia following TRI Normal pre-procedure Allen’s test Rhyne D, Mann T. CCI 2010

Radiation exposure Rao SV, Bernat I, Bertrand OF. EHJ 2012

Minimizing Radiation Don’t fluoro the J-wire going up the arm unless there is resistance Don’t fluoro catheter exchanges Use Fluoro-Save as much as possible Operator experience matters1 Left radial may also help Distance Shorter procedures (less subclavian tortuosity)2 1Kuipers G, et. al. JACC Intv 2012 2Sciahbasi A, et. al. Circ Intv 2011

Radial vs. Femoral in STEMI N=3347 pts from randomized, case-control, and cohort studies incl. RIVAL Mortality Procedure time (min) Joyal D, et. al. AJC 2012

RIFLE STEACS – results 30-day NACE rate p = 0.003 p = 0.029 p = 0.026 21.0 17.3 p = 0.029 p = 0.026 13.6 12.2 11.4 10.0 9.3 7.8 7.2 Net Adverse Clinical Event (NACE) = MACCE + bleeding Major Adverse Cardiac and Cerebrovascular event (MACCE) = composite of cardiac death, myocardial infarction, target lesion revascularization, stroke Bleeding Academic Research Consortium (BARC) = bleeding definition adopted 17

RIFLE STEACS – results 30-day MACCE rate p = 0.020 p = 1.000 p = 0.604 9.2 7.2 5.2 p = 1.000 p = 0.604 p = 0.725 1.8 1.3 1.4 1.5 1.2 1.2 0.7 0.6 0.8 18

Issues unique to Primary PCI Most important – the team MUST have experience with radial diagnostic and interventional cases Success of transradial primary PCI is dependent almost entirely on the cath lab staff Barbeau test can be checked within seconds of arriving in lab The set-up is the rate-limiting factor Do NOT do transradial primary PCI until you have at least 1 year of experience with “radial first” elective PCI, 100 cases, and a femoral crossover rate ≤ 4% Access – can obtain access without fluoroscopy Always prep groins for quick bailout, adjunctive devices (IABP, Pacemaker) Catheters – same approach as femoral (diagnostic catheter for non-involved coronary, guide for IRA)

Algorithm for transradial primary PCI ASA + Clopidogrel pre-treatment Exclude pts with absent pulses/abnormal Barbeau test* Prep Radial and both groins (LRA for pts > 75 y.o. or height ≤ 165 cm) ≤ 3 min for radial access 6F sheath/5F diagnostic catheter(s) Bivalirudin bolus and drip started when catheter is in ascending Ao; Bailout 2b3a as needed 6F guide catheter Total time from sheath to engaging IRA ≤ 15 min; total time from access to crossing lesion ≤ 25 min Sheath removed at end of case Bailout to femoral for failure

Summary There is growing interest in and adoption of radial approach It should not be viewed as a gimmick – we need good science to support its use Remaining challenges Radial artery access site bleeding – early recognition and treatment are key RAO – anticoagulation, sheath size, and non-occlusive hemostasis are key (drug-eluting sheaths?) Recognize the importance of reducing radiation exposure Don’t let the “irrational exuberance” for transradial primary PCI affect patient outcomes