radial approach - role of patent haemostasis 2 · sunil rao. jacc: cardiovascular interventions,...
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RadialAccessRoleofPatentHaemostasis
AlunHarcombeConsultantCardiologist
ACI2015
Inherentconflictofinterest:
SpeakingatinvitationofVascularPerspectives
InfluenceofaccesssiteselectiononPCI-relatedadverseeventsinpatientswithSTEMI:meta-analysisofrandomised controlledtrials
MamasAMamas,Karim Ratib,HelenRoutledge,Farzin Fath-Ordoubadi,LudwigNeyses,YvesLouvard,DouglasGFraser,JimNolan.Heart2012;98:303-311.
Radial Versus Femoral Access for Primary Percutaneous Interventions in ST-Segment Elevation Myocardial Infarction Patients : A Meta-Analysis of
Randomized Controlled Trials
Karrowni et al JACC: Cardiovascular Interventions, Volume 6, Issue 8, 2013, 814 - 823
SheathSizeandClinicalApproachInter-relationship
Complications
Sheathsize
Interventional options
Sheath size Interventional options5F 1balloon
1stent6F 2balloons
1stent1balloon1.5mmburr
7F 2balloons2stentsCorsair, trapballoon1.75mmburr
8F Corsair + trapballoon+micro-catheteroranchorballoonorCrossBoss2.0mmburr
ComparativeradialsizeMeanrightradialarterydiameter• Texas(35yrs) 2.22± 0.35mm• Pakistan 2.3± 0.4mm• Chinese 2.38± 0.56mm• Singapore 2.45± 0.45mm• Korea 2.60± 0.41mm
VelascoA.JInvasiveCardiol.2012Jul;24(7):339-41 Yoo Betal.Int JCardiol.2005;101(3):421-427.Ashraf Tetal.JPakMedAssoc.2010;60(10):817-819. YanZXetal.CircJ.2010;74(4):686-692.Loh YJetal.AsianCardiovasc Thorac Ann.2007;15(4):324-326
FromAM,Gulati R,PrasadA,Rihal CS.CatheterCardiovasc Interv.2010;76:911–916.
Sheathvs GuideSize
Whatwewanttoavoid
Radialarteryocclusion(RAO)
LeipzigUltrasoundStudy• November2009toAugust2011• 455patientsmean65.3yearsof
age(62.2%male)• Transradial access5F(n 153)or
6F(n 302)• Duplexsonography pre-discharge• PatientswithsymptomaticRAO
givenlow-molecular-weightheparin(LMWH)
Uhlemann etal. JACC:CARDIOVASCULARINTERVENTIONS,VOL.5,NO.1,JANUARY2012:36– 43
• RAO:5-Fsheaths13.7%
• 6-Fsheaths 30.5% (p <0.001).
• 42.5%ofpatientswithRAOimmediatelysymptomatic;another7%within4days.
• 59%withRAOtreatedwithLMWH.
• Recanalization rateshigherinLMWHcomparedwithconventionaltherapy:55.6%vs.13.5%,(p <0.001)aftermeanof14days.
Clearly Reduce Risk Likely Reduce Risk Limited Effect
Anticoagulation* Enoxaparin† Sheath length
Patent hemostasis Hydrophilic sheaths Sheathless guide catheters
Sheath diameter < arterial diameter
Routine use of spasmolyticdrugs
Limiting the number of times the same radial artery is accessed
Limited duration of arterial compression
*Studiedstrategiesincludeunfractionated heparin70U/kgupto5,000Uandbivalirudin 0.75mg/kgbolusfollowedby1.75mg/kg/h infusionduringprocedure.†Studiedstrategyincludesenoxaparin 60mgviatheradialarterialsheath.
SunilRao.JACC:CARDIOVASCULARINTERVENTIONS,VOL.5,NO.1,JANUARY2012:44– 6
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SunilRao.JACC:CARDIOVASCULARINTERVENTIONS,VOL.5,NO.1,JANUARY2012:44– 6
PatentHaemostasis:EffectonRAO200720102010200820092011
Sowhatispatenthaemostasis?• Controlledmethodofcompressingarterialpuncturesitewithoutpreventingbloodflow– Manual– Compressionbandages– Helix– Otherdevices– eg TRband,Radistop
Helix– Pressureindicator
Summary• Radialidealforreducedaccesssitecomplications
• Increasinglycomplexproceduresdemandlargersheathsandguides
• Largersheathsmeanmoreradialocclusion
• InbesthandsusingPatentHaemostasisratesofocclusioncanbereducedtominimalincidence(butnotzero)
Thankyou
References
• Sanmartin M,GomezM,Rumoroso JR,etal.Interruptionofbloodflowduringcompressionandradialarteryocclusionaftertransradial catheterization.CatheterCardiovasc Interv 2007;70:185–9.
• Rathore S,StablesRH,Pauriah M,etal.Impactoflengthandhydrophiliccoatingoftheintroducersheathonradialarteryspasmduringtransradial coronaryintervention:arandomizedstudy.JAmCollCardiol Intv 2010;3:475– 83.
• Plante S,CantorWJ,GoldmanL,etal.Comparisonofbivalirudin versusheparinonradialarteryocclusionaftertransradial catheteriza- tion.CatheterCardiovasc Interv 2010;76:654–8.
• Pancholy S,CoppolaJ,PatelT,Roke-ThomasM.Preventionofradialarteryocclusion-patenthemostasis evaluationtrial(PROPHETstudy):arandomizedcomparisonoftraditionalversuspatencydocumentedhemostasis aftertransradial catheterization.CatheterCardiovasc Interv 2008;72:335–40.
• Cubero JM,LombardoJ,Pedrosa C,etal.Radialcompressionguidedbymeanarterypressureversusstandardcompressionwithapneumaticdevice(RACOMAP).CatheterCardiovasc Interv 2009;73:467–72.
• Bernat I,BertrandOF,Rokyta R,etal.Efficacyandsafetyoftransientulnar arterycompressiontorecanalize acuteradialarteryocclusionaftertransradial catheterization.AmJCardiol 2011;107:1698–701.
• 2007