1. How To Minimize Bleeding In The Cath Lab
Steven V. Manoukian, MD, FACC, FSCAI
Director of Cardiovascular Research,
Sarah Cannon Research Institute
Medical Director of Cardiovascular Services,
Hospital Corporation of America
Nashville, Tennessee

2. Disclosures
Relevant COI: None
Off-label: Yes

3. Outline Look at the patient for bleeding risk factors
Bleeding assessment
Think about the consequences of bleeding
Impact of bleeding
Do maximize risk : benefit while enhancing outcomes
Pharmacologic approaches (anticoagulation)
Non-pharmacologic approaches (radial, VCDs)

4. Bleeding and Mortality in ACS (ACUITY)
Manoukian SV et al. JACC 2007.

5. Predictors of Mortality in ACS (ACUITY)
Manoukian SV et al. JACC 2007.

6. Outcomes With / Without Bleeding in ACS (ACUITY)
Manoukian SV et al. JACC 2007.

7. Predictors of Bleeding in ACS (ACUITY)
Manoukian SV et al. JACC 2007.

8. Predictors of Bleeding in PCI (REPLACE-2)
Feit F et al. AJC 2007.

9. Bleeding Risk Score (R2, ACUITY, HORIZONS)
Mehran R et al. JACC INTV 2011.

10. Bleeding Risk Score (R2, ACUITY, HORIZONS)
Mehran R et al. JACC INTV 2011.

11. Bleeding Risk Score (R2, ACUITY, HORIZONS)
Mehran R et al. JACC INTV 2011.

12. Bleeding Avoidance: Bivalirudin in ACS (ACUITY)
Stone GW et al. NEJM 2006.

13. Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2H vs
Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2H vs. 18H, Periprocedural Myonecrosis
Fung AY et al. JACC 2009.

14. Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2-h vs
Bleeding Avoidance: Truncated GPI (BRIEF-PCI) Eptifibatide <2-h vs. 18-h, REPLACE-2 Bleeding Events
Fung AY et al. JACC 2009.

15. Bleeding Avoidance: Radial Proportion of PCI Cases Performed Via the Radial
593,094 PCIs sites. NCDR
Radial total = 1.32%
% of Cath Labs
Rao SV et al. JACC 2009.

16. Bleeding Avoidance: Radial Procedural Success and Bleeding Complications
593,094 PCIs sites. NCDR
Radial total = 1.32%
Rao SV et al. JACC 2009.

17. Bleeding Avoidance: Radial Outcomes by Access Site (ACUITY)
Hamon M et al. EuroIntervention 2009.

18. Bleeding Avoidance: Radial Bleeding by Access Site and Treatment (ACUITY)
Hamon M et al. EuroIntervention 2009.

19. Bleeding Avoidance: Vascular Closure Devices Major Access Site Bleeding (ACUITY)
Sanborn TA et al. Circ Cardiovasc Interv 2010.

20. Bleeding Avoidance: VCD + Bivalirudin Major ASB by VCD and Treatment (ACUITY)
Sanborn TA et al. Circ Cardiovasc Interv 2010.

21. Bleeding Avoidance: Vascular Closure Devices Predictors of Major ASB (ACUITY)
Sanborn TA et al. Circ Cardiovasc Interv 2010.

22. Bleeding Avoidance: Same-Day Discharge and No Readmission Penalty?
Elective PCI in Older (>65 years) Adults
Rao SV et al. JAMA 2011.

23. Conclusions Look at the patient for bleeding risk factors
Bleeding assessment
Age, gender, renal function, anemia, acuity of presentation
Think about the consequences of bleeding
Impact of bleeding
Associated with mortality, ischemic events, stent thrombosis
Do maximize risk : benefit while enhancing outcomes
Pharmacologic approaches (anticoagulation)
Bivalirudin and truncated regimens of GPI
Non-pharmacologic approaches (radial, VCDs)
Radial for sure
VCDs still require further study