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Sunil V. Rao MDThe Duke Clinical Research Institute
The Durham VA Medical CenterDuke University Medical Center
Transradial PCI in Octogenarians: Caveats,
Tips, and Tricks
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Disclosures
Consultant, Honoraria Sanofi-Aventis/BMS, The Medicines
Company, Terumo Corporation, Astra Zeneca, Eli Lilly/Daiichi-Sankyo, Terumo
Research funding Cordis Corporation, Momenta
Pharmaceuticals, Portola Pharmaceuticals Off-label uses
May be discussed in this presentation
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Transradial PCI in elderly patientsIssues
Comorbidities Higher risk – ischemia, bleeding Complex CAD Calcification Tortuous vasculature
These issues are not specific to transradial!!
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PCI-related outcomes N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI
Klein LW, et. al. JACC 2002
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PCI-related outcomes – Multivariable model N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI
Klein LW, et. al. JACC 2002
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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
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Risk Factors for Bleeding- Adjusted Analysis
Variable OR 95% CI Square
Female 1.74 1.64-1.85
319.3
Age (per 10 yrs) 1.36 1.31-1.42
223.6
GFR (per 10 ml/min decrease)
1.11 1.10-1.13
210.2
Prior PCI 0.69 0.64-0.73
128.9
Cardiogenic Shock 1.87 1.66-2.10
104.7
Emergent/Salvage PCIUrgent PCI
2.221.46
1.98-2.491.34-1.57
81.7
COPD 1.31 1.23-1.39
70.6
All p values <0.001 Mehta SR. Circulation: CI 2009
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Access sites bleeding in “real-world” PCI patients
TIMI Maj TIMI Min0
10
20
30
40
50
60
70
80
90
100
73.459
5.9
0.8
12.5
6.3
2.9
CVAGIRPHematoma
%
Kinnaird et al Am J Cardio 2003
5.4% 12.7%
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Transradial PCI in Patients ≥ 75 years oldN=307 pts randomized to radial vs. femoral
RadialN=152
FemoralN=155
P-value
Duration of Dx angio
18.1 15.0 0.009
Fluoro time (min) 5.6 4.7 0.47
Crossover to other access
9% 0.6%
Major adverse events*
0 3.2% < 0.001
*Defined as death, MI, CVA, vascular complications requiring surgery, redcell transfusion, Hgb decrease > 3 g/dl
Achenbach S, et. al. CCI 2008
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Transradial PCI – Outcomes by AgeN=593,094 pts in ACC-NCDR CathPCI Registry
< 75 yrs ≥ 75 yrs < 75 yrs ≥ 75 yrs0
0.5
1
1.5
2
2.5
3
3.5
0.47
2.05
0.13
0.44
1.42
2.99
0.62
1.00
r-PCIf-PCI%
Bleeding Complications
Vascular Complications
Rao SV, et. al. JACC:CI 2008
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Transradial PCI – Outcomes by AgeN=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 oldWith the radial approach, it does not reach statistical significance.This underscores the importance of non-access site bleeding
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Bleeding and Outcomes
26,452 patients from PURSUIT, PARAGON A, PARAGON B, GUSTO IIb NST
Adjusted hazard ratios for 30d DeathStratified by Procedure and Non-procedure related bleeds
Bleeding severity
Procedure Related
Non-procedure Related
Mild 1.2 2.1*
Moderate 3.7* 2.5*
Severe 16.5* 10.9*
*p<0.0001Rao SV, et. al. AJC 2005
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Excessive Dosing of Antithrombotics by Age
LMW Heparin UF Heparin GP IIb/IIIa0
10
20
30
40
50
60
70
12.5
28.7
8.512.5
3733.1
16.5
38.5
64.5
< 65 yrs 65-75 yrs >75 yrs
% E
xces
sive
Dos
e
Alexander KP, et. al. JAMA 2005
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<55 55-64 65-740
2
4
6
8
10
12
14
6.57.1
9.0
11.0
7.0
8.6 8.6
12.2
Heparin(s) + GP IIb/IIIa Bivalirudin
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)
Perc
enta
ge (%
)
Lopes RD, et. al. JACC 2009
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<55 55-64 65-740
2
4
6
8
10
12
14
4.3
5.76.7
12.3
1.7
3.0
4.2
6.1
Heparin(s) + GP IIb/IIIa Bivalirudin
≥75
ACUITY PCI: Non-CABG bleeding by age
Patient age (years)
(n=897)(n=1,454)(n=1,483)(n=1,346)
P=.007P=.01
P=.03
P=.001
Perc
enta
ge (%
)
Lopes RD, et. al. JACC 2009
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Issues specific to transradial in elderly patients
Tortuosity of arm and chest vessels Low threshold for angiography Deep breath to direct wire Get experience with other catheter curves
Complex PCI – few limitations with currently available 6Fr guiding catheters used via the transradial approach
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Transradial PCI in the elderlyConclusions (1)
PCI-related ischemic outcomes have improved in older patients High rates of procedure success Low rates of peri-PCI ischemic events
Reducing bleeding risk is the priority Transradial is associated with reduced bleeding
risk, but… Crossover to femoral may be higher Non-access site related bleeding is important in
older patients
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Strategies for reducing bleeding risk in older pateints include: Transradial Pharmacological therapies – appropriate dosing,
alternative antithrombin strategies Transradial tips/tricks
Low threshold for forearm/chest angiography Deep breath to direct equipment Use of other guide catheter curves New technology coming
Transradial PCI in the elderlyConclusions (2)