Transradial Intervention and Guide Catheter Selection

Transcription

Transradial Intervention and Guide Catheter Selection
38 RCTs
18,000 pts
Transradial Intervention
and Guide Catheter
Selection
Procedure With A Purpose
David E. Kandzari, MD
Director, Interventional Cardiology and
Interventional Cardiology Research
Piedmont Heart Institute
Atlanta, Georgia
[email protected]
Disclosure
Transradial Catheterization
Perception, Belief…
Should radial access become the default choice for PCI?
www.theheart.org, May 25, 2009
Yes
51%
N=666 respondents
No 49%
Transradial Catheterization
Opportunity for Education
What is the main reason not to use the radial approach?
www.crtonline.org, May 14, 2009
Lack of Complex
training/
Comfort
PCI
knowledge
with TF
32%
36%
32%
Transradial Catheterization
Opportunity for Education
The solution to this problem….
Is not introducing another!
Transradial Guiding Catheter Considerations
1.  What impact does guiding catheter selection
have on TRI procedural outcomes?
2.  Which guiding catheters are appropriate for TR
PCI?
3.  What are existing limitations of TR PCI guiding
catheters? Are there TR specific guiding
catheters?
4.  Can complex PCI be performed with existing
guiding catheters?
5.  Practical suggestions related to guiding
catheters and procedural success
Transradial Guiding Catheter Considerations
1.  What impact does guiding catheter selection have on
TRI procedural outcomes?
2.  Which guiding catheters are appropriate for TR PCI?
3.  What are existing limitations of TR PCI guiding
catheters? Are there TR specific guiding catheters?
4.  Can complex PCI be performed with existing guiding
catheters?
5.  Practical suggestions related to guiding catheters
and procedural success
Contemporary Comparative Trials Evaluating Transradial PCI
Agostini et al. JACC 2004
Meta-analysis: 3 224 patients/12 randomized trials
Significant decrease in access site complications; increase in procedural
failure
Chase et al. Heart 2008
38 872 procedures in 32 822 patients in British Columbia were analysed
(1999 to 2005)
Tr-PCI associated with halving of transfusion rate; significant reductions in
30-day and 1-year mortality
Rao et al. JACC Interv 2008
No differences in procedural success between tr-PCI and f-PCI
Significantly decreased bleeding in high-risk subgroups
Brueck et al. JACC Interv 2009
Higher procedural failure and time with tr-PCI
Significantly lower access complications with tr-PCI
Understanding Mechanisms and Predictors of TR
PCI Procedural Failure
Meta-Analysis of 12 RCTs TR vs TF (≤6 Fr), N=3,224
—  Procedural Failure, 7.2% TR vs 2.4% TF, P<0.001
—  Mechanisms of Failure?
Radial artery access
Arterial Spasm
Anatomical limitations
Inability to cannulate target vessel
Inadequate guide support
Agostoni et al. JACC 2004
Understanding Mechanisms and Predictors of TR
PCI Procedural Failure
2,100 TR PCI Procedures (≤6 Fr)
•  Procedural Failure 4.7%
•  Number of Guiding Catheters
—  RCA: 1.2±0.6 Success vs 1.4±0.6 Failure, P=0.003
—  LCA: 1.2±0.6 Success vs 1.6±1.0 Failure, P<0.0001
—  TR Failures: Operators used 6 and 7 catheters for RCA
and LCA, respectively, before crossover to TF
Dehghani et al. JACC Intv 2009
Understanding Mechanisms and Predictors of TR
PCI Procedural Failure
TR PCI Procedural Failures (N=98)
• 
Failure of arterial access
Inadequate arterial puncture
• 
• 
13 (13)
Failure to advance catheter into ascending aorta
Radial artery spasm
33 (34)
Radial artery loop/tortuosity
10 (10)
Radial artery dissection
6 (6)
Radial artery stenosis
1 (1)
Failure to complete PCI due to lack of guide support
Subclavian tortuosity
18 (18)
Inadequate guide back up support
17 (17)
Dehghani et al. JACC Intv 2009
Transradial Guiding Catheter Considerations
1.  What impact does guiding catheter selection have on
TRI procedural outcomes?
2.  Which guiding catheters are appropriate for TR PCI?
3.  What are existing limitations of TR PCI guiding
catheters? Are there TR specific guiding catheters?
4.  Can complex PCI be performed with existing guiding
catheters?
5.  Practical suggestions related to guiding catheters
and procedural success
Transradial Guiding Catheter Shape Selection
Left Coronary Artery
Right Coronary Artery
Left Radial
Standard catheters
Right Radial
XB/EBU ↓0.5
Amplatz L
Ikari Left
SVG
Left radial: Standard guiding catheters
JR 5>4
Amplatz R/L
Ikari Left or Right
Right radial: Amplatz, Ikari Left, JR, XBR
LIMA
JR 3.5/4, IMA
Transradial Guiding Catheter Shape Selection
Extra Back Up Catheters
Transradial Guiding Catheter Shape Selection
Bypass Grafts
Transradial Guiding Catheter Shape Selection
Bypass Grafts
Ikari Guide Catheters
Fcosθ = fcosθ’ + λ
λ
θ’ θ
fcosθ ’ + λ
Fmax = ―――――
cosθ
Maximum backup force is
acheved if
θ=90 degree;�θ’= 0 degree;
or� λ is large
Ikari et al. J Invasive Cardiol 2005 ;17:636-41
Ikari Left Guide Catheters
A
A
B
B
Curve A to fit angle of brachiocephalic artery
Straight portion (20 mm) B to generate strong back-up force
supported by opposite side of aorta wall
Ikari Left Guide Catheters
Comparison with Judkins Left
Judkins
Judkins
Ikari
Transradial Guiding Catheter Shape Selection
Ikari Left
Relationship Between Back Up Support and
Static Friction (Resistance)
15mm
25mm
35mm
45mm
Relationship Between Back Up Support and
Static Friction (Resistance)
E
*
A
*
*
B
*
C
D
E
Transradial Guiding Catheter Shape Selection
Ikari Left ‘Power Position’
Ikari Right Guide Catheters
IR: Ikari Right
A
A
B
Curve A to fit angle of brachiocephalic artery
Straight portion B to generate strong back-up force supported by
opposite side of aorta wall.
B
Ikari Right Guide Catheters
Judkins
Judkins
Ikari
Transradial Guiding Catheter Shape Selection
Ikari Right
Ikari Right and Left Guide Catheters for RCA
Judkins-R
Ikari-R
Ikari-L for RCA
The area of contact on the contralateral aorta of IR & IL for RCA is greater than the JR.
Therefore, IR & IL for RCA generate greater backup force than the JR.
Ikari Right and Left Guide Catheters for RCA
Judkins-R
Ikari-R
Ikari-L for RCA
Judkins-R is forced to an aerial PCI, because backup force is insufficient.
However, Ikari-R & Ikari-L produce greater backup force, these enable stable PCI
Transradial Guiding Catheter Shape Selection
Ikari Right or Left for RCA
Ikari Right
Ikari Left
Transradial Guiding Catheter Considerations
1.  What impact does guiding catheter selection have on
TRI procedural outcomes?
2.  Which guiding catheters are appropriate for TR PCI?
3.  What are existing limitations of TR PCI guiding
catheters? Are there TR specific guiding catheters?
4.  Can complex PCI be performed with existing guiding
catheters?
5.  Practical suggestions related to guiding catheters
and procedural success
Distribution of Radial Artery Diameter
Female
Male
6Fr
7Fr
8Fr
Saito S, et al. Catheter Cardiovasc Interv 1999; 46: 173-8.
Guide Catheter Size for TR PCI:
Smaller, Bigger…Better?
3, 4 and 5 Fr Guiding Catheters
Accessability
Mizuno et al. CCI 2010;75:985-988
Takeshita et al. CCI 2010;75:735-739
Mizuno et al. CCI 2010;75:985-988
Hamon et al. CCI 2002:55;340-343
7 Fr and 8 Fr Guiding Catheters
Gioia G, et al. CCI 2000;51:234 –238
Wu SS, et al. J Invasive Cardiol 2000;12:605–609
Complications
Procedural
Failure
Advanced Guiding Catheter Technologies
Asahi Eaucath
7.5 Fr Sheathless Hydrophilic Guiding Catheter
Smaller outer diameter < 6Fr sheath, Inner diameter > 7 Fr guide
Catheter external diameter: 2.49mm (5.5 Fr)
6F Sheath external diameter: 2.62 mm
Mamas MA et al, CCI 2008;72:357‒364; Liang et al. CCI 2010;75:222-224
Advanced Guiding Catheter Technologies
Asahi Eaucath
Liang et al. CCI 2010;75:222-224
Complex PCI with 6 Fr Guiding Catheters
Procedural Outcomes with Ikari Catheter
N=601
Angiographic Characteristics
Left main
5.6%
Bifurcation
17.4%
Multivessel PCI
32.9%
CTO
16.3%
ACC/AHA Class B2/C Lesion
89.3%
Right and left in same procedure (same catheter)
98.1%
Procedural and In-Hospital Outcomes
Device success
96.6%
Procedure success
98.2%
Ali A, et al. EuroInterv. 2007;3:475-481
Transradial Catheterization and Intervention
Complex Lesion Treatment with 6 Fr Guiding Catheters
100%
100%
95%
95%
75%
75%
75%
95%
Stent
Stent
Stent
Stent
Transradial vs Transfemoral Left Main PCI
Procedural and Clinical Complications
Transradial
N=353
Transfemoral
N=468
P value
97%
96%
0.57
MACE
4.0%
3.2%
0.57
TIMI Major Bleeding
0.6%
2.8%
0.02
Hospital stay (days)
8.5±5.9
9.9±5.9
0.001
Procedural and In-Hospital Outcomes
Procedural success (%)
Late Clinical Outcomes (Mean 17 mos)
Cardiac Death
1.4%
1.7%
0.74
Non-fatal MI
4.0%
2.6%
0.26
LM specific TLR
5.7%
5.8%
0.95
MACE
10.2%
9.2%
0.63
Yang, Kandzari et al., JACC Interv In Press
Effect of TR- vs TF- Primary PCI on Bleeding, Time to
Revascularization and 1-Year Outcomes
P<0.001
P<0.001
Door to Balloon Time (min)
Radial
Femoral
P Value
123±63
129±81
NS
P<0.001
P<0.007
P=NS
In-Hospital
Arzamendi et al. Am J Cardiol 2010
1-Year
Transradial Guiding Catheter Considerations
1.  What impact does guiding catheter selection have on
TRI procedural outcomes?
2.  Which guiding catheters are appropriate for TR PCI?
3.  What are existing limitations of TR PCI guiding
catheters? Are there TR specific guiding catheters?
4.  Can complex PCI be performed with existing guiding
catheters?
5.  Practical suggestions related to guiding catheters
and procedural success
Transradial Guiding Catheter Suggestions
• 
Advancing guiding catheter to ascending aorta
Hydrophilic wires
Exchange with extra support wire
4 Fr support catheter within catheter
• 
Engaging coronary artery
Advance catheter and rotate over wire deep into
aortic cusp of interest
• 
Maintaining guide support
Second wire (ideal for ostial lesions)
Guideliner mother-and-child catheter extension
Anchor balloon technique
Transradial Guiding Catheter Suggestions and Solutions
Transradial Guiding Catheter Suggestions and Solutions
Transradial Guiding Catheter Suggestions and Solutions
Transradial Guiding Catheter Suggestions and Solutions
Guiding Catheter Selection in Transradial PCI
•  Guiding catheter engagement and support represent
significant barriers to transradial procedural success (more
than we might think!)
•  In most instances, knowledge of guide catheter selection and
technique enable successful PCI
•  Complex PCI is achievable with existing equipment
•  Development of TR specific guiding catheters and sheathless
guiding catheters is evolving
•  Keep familiar with the literature and evolving technique and
technology
•  Share your successes and failures
•  Train cath lab staff
•  Standardize protocols to include equipment selection
Ongoing Trials Evaluating the Transradial Approach
ClinicalTrials.gov
Identifier
Comparison
Sample Size
Outcomes
NCT01014273
Radial vs. femoral approach
to PCI in UA, NSTEMI,
STEMI
7,000
30-day death, MI,
stroke, or major bleeding
NCT00815997
4- vs. 6-F guide catheter for
transradial PCI
160
Radial artery patency 2
days post-procedure
NCT00329979
Radial vs. femoral diagnostic
catheterization in severe
aortic stenosis
152
Acute brain injury
assessed by diffusionweighted brain MRI
NCT00597324
Transradial catheterization in
patients with normal and
abnormal Allen test results
180
30-day levels of capillary
lactate in the thumb of
instrumented hand
NCT00821106
Right radial vs. left radial
approach for diagnostic and
interventional procedures
1,500
NCT00638586
Radial vs. femoral access for
PCI
160
Fluoroscopy time and
patient radiation dose
Post-procedure anxiety,
pain, satisfaction