1. Trans Radial Approach (TRA): Hands Up For This Technique?
Thomas H Maloney, MHA, RCIS
CRT 2011
Nurse & Technologist Symposium
February
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2. Presenter Disclosure Information
Within the past 12 months, the presenter or their spouse/partner have had a financial interest/arrangement or affiliation with the organization listed below.
Thomas Maloney MHA, RCIS
Company Name Relationship
Boston Scientific Corp Full Time Employee
Federal law restricts the use of devices named in this presentation to sale by or on the order of a physician. Please review all directions for use including indications, contraindications, warnings, precautions and adverse events prior to clinical use.
CRT 2011
Nurse & Technologist Symposium
February
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3. “Looking back, I’m struck that we in interventional cardiology have never simply accepted the limitations placed before us. We’ve tried to overcome them through creative thinking – and then subject the results of that creativity to the crucible of evidence-based medicine knowing that sometimes we’ll win, and sometimes we’ll lose, but always, we move forward.”
Don Baim MD

4. This is a Thing of the Past with TRA!
Image courtesy of Tom Maloney with patient permission
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5. Twenty-five year trends in PCI outcomes N=24,410 procedures at the Mayo Clinic
Singh M., et. al. Circulation 2007
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6. Complications of Contemporary PCI: Relative Importance of Bleeding
Elective PCI
Emergency CABG < 0.2%
Abrupt Closure/Acute ST <0.7%
Arrhythmia <0.01%
LST = % per year
Major/Minor TIMI bleeding >5%
Patel’s Atlas of Transradial Intervention: The Basics Copyright © 2007 by Tejas Patel MD
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7. Survival Free of Death from Any Causes and Myocardial Infarction
COURAGE
Survival Free of Death from Any Causes and Myocardial Infarction
1.0
Optimal Medical Therapy (OMT)
0.9
PCI + OMT
0.8
PCI does not improve mortality compared with medical therapy, but does improve Sx and quality of life
In this context, every effort should be made to make PCI safer and more comfortable for patients
0.7
Hazard ratio: 1.05
95% CI ( )
P = 0.62
0.6
0.5
0.0 1 2 3 4 5 6 7
Years
Number at Risk
Medical Therapy
PCI
Boden W., et al., N Engl J Med 2007
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8. (95% Confidence Interval)
Periprocedural Bleeding and Impact of 1-year Outcome
Independent Predictors of 1-year Mortality: Pooled ISAR Trials
Variable
Hazard Ratio
(95% Confidence Interval)
P Value
Bleeding within 30d
2.96 (1.96–4.48)
<0.001
Myocardial infarction within 30 days
2.29 (1.52–3.46)
Urgent revasc within 30 days
2.49 (1.16–5.35)
0.019
Age (yrs)*
2.27 (1.78–2.89)
Diabetes
1.47 (1.11–1.96)
0.008
Multivessel CAD
2.72 (1.58–4.67)
Elevated troponin†
1.77 (1.27–2.47)
Left ventricular ejection fraction
0.71 (0.60–0.85)
Creatinine level
1.10 (1.06–1.14)
*Calculated for a 10-year increase in age; †calculated for a 0.25-mg increase in concentration.
Retrospective study 5384 patients from study isar react, sweet,, smart 2, react 2
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Ndrepepa et al. J Am Coll Cardiol 2008 8

9. Impact of Transfusion on Risk of 30-day Mortality
24,112 ACS patients from GUSTO IIb, PURSUIT, PARAGON B
0.10
0.02
0.04
0.06
0.08
No. at Risk
Transfusion
No Transfusion
Randomization
2398
21 684 5 15 20
Log-rank P<.001 25 30 10
Day
2356
21 408
2317
21 248
2274
21 162
2237
21 102
2221
21 062
2189
20 884
Proportion Cumulative Mortality
Rao et al JAMA 2004;292:
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10. Site of Bleeding Complications in an Unselected Cohort of Patients Undergoing PCI
Rao, Cohen, Kandzari et al. J Am Coll Cardiol 2010;55:
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11. ICD – 9 Bleeding Description Among Transfused Patients Post PCI
N = 544 Bleeding Events
= 349 patients
~ 50%
Maloney TH et al. Abstract Presentation. Heart Matters Conference 2010 Richmond VA
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12. Outcome: Transfusion Patients vs. Non-Transfusion Patients
No Transfusion
(n=6,421)
Outcome
Clinically Apparent Bleeding (%)
34.8
3.8
Clinically Apparent Bleeding with Transfusion (%) NA
Inhospital Death (%)
11.0
0.8
Length of Stay (day)
(Mean ± SD)
11.7 ± 9.7
2.6 ± 2.7
Cost of Hospitalization (Mean ± SD)
$39,852 ± $32,283
$14,758 ± $8,503
Based on these figures a potential savings of $2.5MM could be realized by reducing groin related transfusions at Memorial Regional Medical Center alone!
Maloney TH et al. Abstract Presentation. Heart Matters Conference 2010 Richmond VA 12
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13. Effect of Radial Approach on Procedural Outcomes
1.0
Higher risk for any complication
Lower risk for any complication
Unadjusted
Adjusted for
patient differences
patient & procedure
differences
N = 593,094 PCI procedures
606 sites
Adjusted for center clustering in each model
Rao SV, et. al. JACC: CI 2008
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14. Association Between PCI Vascular Access Site and Outcomes
N=21 studies, 5600 patients
Rao SV, et. al. JACC: CI 2008
Rao SV, et. al. JACC: CI 2008
Jolly et al. Am Heart J 2009
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15. Brueck et al. J Am Coll Cardiol Intv 2009
Transradial Diagnostic and Interventional Studies Randomized Trial of Femoral vs Radial Access
Transradial (n = 512)
Transfemoral (n = 512)
p Value
Access failure
18 (3.5)
1 (0.2)
<0.0001
PCI
178 (34.8)
192 (37.5)
0.40
Procedural failure of PCI
6 (3.4)
1 (0.5)
0.06
Vascular closure device —
179 (93.2)
Median procedural time, min (IQR)
40.2 (24.3–50.8)
37.0 (19.6–49.1)
0.046
Median fluoroscopy time, min (IQR)
9.0 (3.9–10.7)
5.8 (1.7–7.5)
0.001
Median contrast amount, ml (IQR)
132 (80–160)
129 (90–160)
0.43
Median DAP, Gycm2 (IQR)
41.9 (22.6–52.2)
38.2 (20.4–48.5)
0.034
Access-related complications
3 (0.58)
19 (3.71)
0.0008
Cerebrovascular accidents
0 (0)
2 (0.39)
0.50
Brueck et al. J Am Coll Cardiol Intv 2009
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16. Potential Health Economic Benefits of Transradial Approach
Reduction in bleeding ($6300 avg cost/bleed¹)
No need for femoral vascular closure device
Fewer catheters needed when using specialty curves
Fewer hours needed for staffing (“sheath pulling”) based on my experience
Decreased nursing intensity post procedure based on my experience
Same-day PCI
¹Cohen DJ, et al. J Am Coll Cardiol. 2004;44:1792–1800. .
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17. 200 pts randomized to tr-PCI vs f-PCI
Quality of Life and Patient Preference:
Medical College of Ohio Experience
200 pts randomized to tr-PCI vs f-PCI
QOL metrics at baseline, 1 day, 1 week post PCI
Patients Strongly Preferred Radial Access (P<0.0001)
Costs  $2299 To $2010 (P<0.0001)
LOS  10.4 To 3.6 Hr (P<0.0001)
Less discomfort, back pain with improved walking ability reported
Strongly Prefer Radial
NO Preference
Strongly Prefer Femoral
Cooper CJ et al. Am Heart J 138:430, 1999
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18. Happy Patient Post Radial PCI
Image courtesy of Tom Maloney with patient permission
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19. % OF RADIAL FOR PCI ?
Bertrand OF, et al. JACC Cardiovasc Interv Dec 1;76(7):
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20. TRA PRACTICE IN THE FUTURE ?
68.4%
50%
Bertrand OF, et al. JACC Cardiovasc Interv Dec 1;76(7):
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21. Image courtesy of Google Images

22. Primary Outcome: Death, MI, stroke or major bleeding at 30 days
RIVAL study: RadIal Vs. femorAL access for coronary intervention
in patients with acute coronary syndromes study
Non STEACS and STEMI
(n=7000)
Intent to treat
Analysis
Randomization
Radial Access
(n=3500)
Femoral Access
(n=3500)
30 day follow up
30 day follow up
Primary Outcome: Death, MI, stroke
or major bleeding at 30 days

23. Protocol courtesy of Tom Maloney
MRMC Protocol
Protocol courtesy of Tom Maloney
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24. Nurse & Tech Obtaining Radial Artery Access
Arkansas Heart Hospital
“Our techs are now very adept at gaining radial access on their own”
Image courtesy of Cath Lab Digest
Cath Lab Digest Feb. 2011: Vol. 19, No.2: 24-6

25. Image courtesy of Tift Mann MD
Having nurses attuned to nonocclusive compression and rapid removal of hemostasis devices is now a very impt part of tr procedures
Image courtesy of Tift Mann MD
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26. Image courtesy of Kimberly Skelding MD
Tough patients, but lots to gain from this approach and it’s always interesting !
Image courtesy of Kimberly Skelding MD
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