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