1. Sunil V. Rao MD The Duke Clinical Research Institute The Durham VA Medical Center Duke University Medical Center Transradial PCI in Octogenarians: Caveats, Tips, and Tricks

2. Disclosures n Consultant, Honoraria l Sanofi-Aventis/BMS, The Medicines Company, Terumo Corporation, Astra Zeneca, Eli Lilly/Daiichi-Sankyo, Terumo n Research funding l Cordis Corporation, Momenta Pharmaceuticals, Portola Pharmaceuticals n Off-label uses l May be discussed in this presentation

3. Transradial PCI in elderly patients Issues n Comorbidities n Higher risk – ischemia, bleeding n Complex CAD n Calcification n Tortuous vasculature These issues are not specific to transradial!!

4. PCI-related outcomes N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI Klein LW, et. al. JACC 2002

5. PCI-related outcomes – Multivariable model N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI Klein LW, et. al. JACC 2002

6. Independent predictors of major bleeding in marker- positive acute coronary syndromes Moscucci, GRACE Registry, Eur Heart J. 2003 Oct;24(20):1815-23. Predictors of Major Bleeding in ACS ► Older Age ► Female Gender ► Renal Failure ► History of Bleeding ► Right Heart Catheterization ► GPIIb-IIIa Antagonists ► Older Age ► Female Gender ► Renal Failure ► History of Bleeding ► Right Heart Catheterization ► GPIIb-IIIa Antagonists

7. Risk Factors for Bleeding- Adjusted Analysis VariableOR95% CI  Square Female1.741.64-1.85319.3 Age (per 10 yrs)1.361.31-1.42223.6 GFR (per 10 ml/min decrease)1.111.10-1.13210.2 Prior PCI0.690.64-0.73128.9 Cardiogenic Shock1.871.66-2.10104.7 Emergent/Salvage PCI Urgent PCI 2.22 1.46 1.98-2.49 1.34-1.57 81.7 COPD1.311.23-1.3970.6 All p values <0.001 Mehta SR. Circulation: CI 2009

8. Access sites bleeding in “real-world” PCI patients Kinnaird et al Am J Cardio 2003 5.4%12.7%

9. Transradial PCI in Patients ≥ 75 years old N=307 pts randomized to radial vs. femoral Radial N=152 Femoral N=155 P-value Duration of Dx angio 18.115.00.009 Fluoro time (min)5.64.70.47 Crossover to other access 9%0.6% Major adverse events* 03.2%< 0.001 *Defined as death, MI, CVA, vascular complications requiring surgery, red cell transfusion, Hgb decrease > 3 g/dl Achenbach S, et. al. CCI 2008

10. Transradial PCI – Outcomes by Age N=593,094 pts in ACC-NCDR CathPCI Registry Rao SV, et. al. JACC:CI 2008

11. Transradial PCI – Outcomes by Age N=593,094 pts in ACC-NCDR CathPCI Registry Rao SV, et. al. JACC:CI 2008 While there is a trend toward less bleeding in the pts ≥ 75 years old With the radial approach, it does not reach statistical significance. This underscores the importance of non-access site bleeding

12. Bleeding and Outcomes 26,452 patients from PURSUIT, PARAGON A, PARAGON B, GUSTO IIb NST Adjusted hazard ratios for 30d Death Stratified by Procedure and Non-procedure related bleeds Bleeding severity Procedure Related Non-procedure Related Mild1.2 2.1* Moderate 3.7* 2.5* Severe 16.5* 10.9* *p<0.0001 Rao SV, et. al. AJC 2005

13. Excessive Dosing of Antithrombotics by Age Alexander KP, et. al. JAMA 2005

14. ACUITY PCI: Ischemic outcomes by age Patient age (years) P=.75 ≥75 P=.30 P=.77 P=.57 (n=1,346) (n=1,483)(n=1,454)(n=897) Percentage (%) Lopes RD, et. al. JACC 2009

15. ≥75 ACUITY PCI: Non-CABG bleeding by age Patient age (years) (n=897)(n=1,454)(n=1,483)(n=1,346) P=.007 P=.01 P=.03 P=.001 Percentage (%) Lopes RD, et. al. JACC 2009

16. Issues specific to transradial in elderly patients n Tortuosity of arm and chest vessels l Low threshold for angiography l Deep breath to direct wire l Get experience with other catheter curves n Complex PCI – few limitations with currently available 6Fr guiding catheters used via the transradial approach

23. Transradial PCI in the elderly Conclusions (1) n PCI-related ischemic outcomes have improved in older patients l High rates of procedure success l Low rates of peri-PCI ischemic events n Reducing bleeding risk is the priority n Transradial is associated with reduced bleeding risk, but… l Crossover to femoral may be higher l Non-access site related bleeding is important in older patients

24. n Strategies for reducing bleeding risk in older pateints include: l Transradial l Pharmacological therapies – appropriate dosing, alternative antithrombin strategies n Transradial tips/tricks l Low threshold for forearm/chest angiography l Deep breath to direct equipment l Use of other guide catheter curves l New technology coming Transradial PCI in the elderly Conclusions (2)