RADIAL OR BUST The only choice for vascular access Jim Nolan University Hospital of North Staffordshire United Kingdom

CONFLICTS OF INTEREST

ARTERIAL ACCESS – WHY AM I INTERESTED (Heart 1995, Am Heart J 1997) % Major Vasacular Complications % %

BRACHIAL CUT DOWN COMPLICATIONS

NEURO-ANATOMY OF THE FEMORAL TRIANGLE

FEMORAL ACCESS PRACTICE Two weeks at UHNS

FEMORAL ACCESS COMPLICATIONS

ACTIVE RETROPERITONEAL BLEED

FEMORAL VASCULAR COMPLICATIONS IN CONTEMPORARY UK PRACTICE (Berry et-al, AJC 2004, n = 311)

MAJOR VASCULAR COMPLICATIONS 1 RPH, 3 Pseudo-aneurysms 3 GA emergency surgery 13 units of blood Total of 61 extra days in hospital

ANTITHROMBOTIC THERAPY AND FEMORAL COMPLICATIONS 17.5 % 5.9 2.2 1.1 DIAGNOSTIC POPULATION Berry 2004 ANGINA PCI POPULATION Moutralescot 2005 MI/REO-PRO PCI POPULATION Otavio 2004 RESCUE PCI Dauermau 2000

VACD – DEVICE FAILURE RATE (Sesana et-al, JIC 2000, n = 827)

VCD META ANALYSIS – RANDOMISED + OBSERVATIONAL (Nikolsky et-al, JACC 2004, n = 37,066)

DOES IT ALL MATTER? COMPLICATIONS OF PCI IN CONTEMPORARY PRACTICE (Heart 2005, n = 3071) %

DOES IT ALL MATTER? MEDICO-LEGAL CASES ARISING FROM CARDIAC CATHETERISATION PROCEDURES (1992-2002 - MDU)

NEURO-ANATOMY OF THE WRIST

VASCULAR COMPLICATIONS (uhns transradial programme) Heart 2003 RADIAL FEMORAL (n=1000) (n=727) TRANSFUSION 0 (0%) 4 (0.6%) VASCULAR INTERVENTION 1 (0.1%) 6 (0.8%) INFECTION 2 (0.2%) 2 (0.3%) 3 (0.3%) 12 (1.7%)

RADIAL VS FEMORAL ACCESS – RCT meta analysis (Agostoni et-al JACC 2004) number 279 152 600 112 142 200 210 420 371 149 Grinfield Mann ACCESS BRAFE Mann Cooper CARAFE Gorge Moriyama OCTOPLUS TEMPURA MACE Procedural success Procedural success 1999-2003 Access site complications

ARE RADIAL CASES TOO HARD TO DO (Rao et al, JACCI 2008)

DOES EVERYBODY BENEFIT FROM RADIAL ACCESS (Rao et-al JACCI 2008)

DOES EVERYBODY BENEFIT FROM RADIAL ACCESS (Rao et-al JACCI 2008)

DOES EVERYBODY BENEFIT FROM RADIAL ACCESS (Rao et-al JACCI 2008)

IS PCI RELATED BLEEDING A BAD THING (MORTAL study, Heart 2008, n=38,872)

DOES PREVENTION OF ACCESS SITE BLEEDING IMPROVE OUTCOME (MORTAL study, Heart 2008, n=38,872)

VASCULAR COMPLICATIONS – ECONOMIC IMPACT (Nowamagbe et-al, JACC 1995, n = 1,012 CAVEAT-1) LENGTH OF STAY HOSPITAL COSTS COST ($) LOS (DAYS)

TRANSRADIAL APPROACH PATIENT PREFERENCE

TRANSRADIAL APPROACH NURSING PREFERENCE (Amoroso, EJCVN, 2005, n = 260) Cath lab Ward Femoral Radial Femoral Radial

RADIATION EXPOSURE IS IMPORTANT Skin injury due to cardiac intervention

RADIATION EXPOSURE IS IMPORTANT Accessory pathway ablation 3 weeks 5 months 6.5 months

OPERATORS ALSO GET RADIATION INDUCED SKIN INJURY

UHNS RADIATION EXPOSURE STUDY Mean fluoroscopy time and patient and operator radiation doses (Heart 2007) P=NS P=NS P<0.05

UHNS RADIATION EXPOSURE STUDY Mean procedure duration (min) and time to ambulation (min) (Heart 2007) P<0.0001 P<0.005

PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004 TLD BADGE READINGS - UHNS

Mont Blanc Summit Ridge September 2007

TRANSRADIAL APPROACH THE LEARNING CURVE Lefevre TCT 2003 Puncture failure, spasm, different guide manipulation

“…the radial approach has become increasingly popular with the potential advantage of a greater opportunity for same day discharge” “…shorter bed rest and hospital stay when the radial approach is used” “…the use of the radial approach is likely to increase”

RADIAL Vs FEMORAL PCI (BCIS DATABASE)

THE RADIAL ARTERY Reduces access site bleeding Impact on mortality Efficient Preferred by patients Endorsed by BCIS Taken up by increasing numbers of UK interventionists THE ONLY CHOICE FOR VASCULAR ACCESS

THANKS TO MARK GUNNING