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Transradial approach in myocardial · PDF file Conclusions Routine transradial primary PCI can be safely and successfully performed on up to 70% of acute ST-elevation myocardial infarct

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  • 239Acta Cardiol 2011; 66(2): 239-245 doi: 10.2143/AC.66.2.2071257

    Address for correspondence:

    Wei-Hsian Yin, MD, PhD, Division of Cardiology, Cheng-Hsin General Hospital, No. 45, Cheng-Hsin Street, Pei-Tou, Taipei, Taiwan, R.O.C. E-mail: [email protected]; [email protected]

    Received 21 April 2010; revision accepted for publication 24 November 2010.

    INTRODUCTION

    Transradial angioplasty and stenting are safe and effective methods of percutaneous coronary intervention (PCI) when compared with conventional transfemoral intervention1,2. During the past decade, many reports regarding the feasibility and efficacy of transradial cor- onary intervention in the setting of acute myocardial infarction (MI) have been encouraging3-13.

    Although there is concern that the difficulties in obtaining vascular access owing to the smaller size of the radial artery and in learning the technique of trans- radial intervention lead to delay in reperfusion2,14-18, a

    Transradial approach in myocardial infarction

    Hsu-Lung JEN1,2, MD, PhD; Wei-Hsian YIN1,3, MD, PhD; Kuan-Chun CHEN1,4, MD; An-Ning FENG1, MD; Shih-Ping MA1, RN; Chin-Feng CHENG1, RN; Mason Shing YOUNG1, MD 1Division of Cardiology, Department of Internal Medicine, Cheng-Hsin General Hospital; 2Institute of Clinical Medicine; 3Faculty of Medicine, and 4Institute of Emergency and Critical Care Medicine, National Yang-Ming University, School of Medicine, Taipei, Taiwan.

    Objective This study investigates the feasibility, effi cacy, and safety of routine primary percutaneous coronary intervention via transradial approach in patients with acute ST-elevation myocardial infarction.

    Methods and results From 2005 to 2007, 122 consecutive patients with acute ST-elevation myocardial infarction within 12 hours, including those experiencing cardiogenic shock, were eligible for primary transradial PCI if the radial artery pulse could be felt. Effi cacy, safety, and major adverse cardiac events regarding mortality, recurrent non-fatal myocardial infarction, and revascularization were recorded. Eighty-fi ve of 122 patients underwent transradial PCI, and 37 had transfemoral PCI. Older women, haemodynamic instability, and the presence of severe chronic kidney disease (stages 4 and 5) or end-stage renal disease were signifi cantly related to choice of transfemoral approach (P < 0.05). Glycoprotein IIb/IIIa inhibitors were used more often in patients who underwent transradial PCI than in those who underwent transfemoral PCI (37% vs 16%; P = 0.043). The incidence of major bleeding com- plications requiring blood transfusion was signifi cantly higher in the transfemoral group (P = 0.004). A similar procedural success rate was achieved in both groups (P = 0.737). During follow-up of 580 days, the total major adverse cardiac events were similar in both groups (P = 0.299).

    Conclusions Routine transradial primary PCI can be safely and successfully performed on up to 70% of acute ST-elevation myocardial infarction patients and, compared with transfemoral approach, is associated with a signifi cantly reduced rate of major bleeding complications.

    Keywords Acute myocardial infarction – PCI – transradial approach – transfemoral approach.

    major advantage of the transradial approach in PCI is that vascular access site complications related to the use of fibrinolytic drugs, antiplatelets, and glycoprotein IIb/ IIIa inhibitors, are significantly lower than those of a transfemoral approach19-23.

    In view of the fact that the transradial approach considerably reduces vascular access site complication and is less uncomfortable for the patient, we have adopted this technique as routine for PCI in our institu- tion since November 1997. Primary PCI via the trans- radial approach has been the preferred method for all acute MI patients since 2005 when all physicians in our institution had already done transradial PCI for more than 300 cases.

    In this study, we retrospectively analysed our experi- ences with primary PCI in acute ST elevated MI, clas- sifying patients according to whether we used a transra- dial or a transfemoral approach from 2005 to 2007. Approximately 1000 PCI procedures were done in the hospital each year, and more than 80% of them, via a transradial approach. The efficacy, safety, and clinical outcomes of both methods were analysed accordingly.

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  • H.-L. Jen et al.240

    were done according to the standard methods. Use of thrombectomy devices and glycoprotein IIb/IIIa antag- onists was at the discretion of the physician. Cardiac markers (creatine kinase, creatine kinase MB, and tro- ponin) were analysed every 6 hours for the first 24 hours after having the PCI. Use of post-procedural heparin was discouraged. After the procedure, all patients received daily aspirin 100 mg and clopidogrel 75 mg for at least 9 months unless contraindicated.

    Vascular access site haemostasis

    For the transradial approach, the arterial access sheaths were removed immediately after the transradial procedures, and haemostasis was achieved by radial compression with a pressure clamp. The clamp was removed within 2 to 3 hours if haemostasis was achieved and changed to a pressure dressing. The pressure dress- ing was removed within 12 hours after the intervention.

    For the transfemoral approach, the arterial access sheaths were removed 4 to 6 hours after the procedure, regardless of the use of glycoprotein IIb/IIIa inhibitors. Haemostasis was achieved by manual compression for 20 to 30 minutes, subsequently followed by a pressure bandage and sandbag application for another 8 to 12 hours. No closure devices were used in the present study.

    Study endpoints and defi nitions

    Endpoints were recorded from the start of the pro- cedure to at least 6 months’ follow-up. After discharge, all patients were routinely checked at regular outpatient visits. Clinical information regarding safety and efficacy endpoints was provided by the cardiologists in charge.

    The primary safety endpoints of this study were defined as the incidence of major bleeding complications requiring blood transfusion, including vascular access site bleeding and other major bleeding (intracranial or gastrointestinal bleeding), and major adverse cardiac events including mortality, recurrent non-fatal MI, and any revascularization procedure during the follow-up.

    The primary efficacy endpoint was defined as the procedural success rate (achievement of successful rep- erfusion). Successful reperfusion was defined as achieve- ment of a residual diameter stenosis of < 30% with Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow at the end of PCI.

    Data analysis

    Statistical analyses were performed with SPSS software for Windows (Statistical Product and Service Solutions, version 12.0, SSPS Inc, Chicago, IL, USA). Continuous variables are expressed as mean ± SD. The

    METHODS

    Study population

    We retrospectively reviewed 141 consecutive patients with STEMI, within 12 hours from onset of chest pain, who underwent primary PCI in Cheng-Hsin General Hospital between June 2005 and June 2007. Among them, 19 were excluded because of mechanical compli- cations, left main disease, or severe multivessel disease requiring emergency surgical intervention. The remain- ing 122 patients were recruited for the present study. The diagnosis of STEMI was made in the presence of both prolonged chest pain lasting more than 30 minutes, unresponsiveness to nitroglycerin and electrocardio- graphic (ECG) changes matching the electrocardio- graphic criteria of STEMI. Electrocardiographic criteria of STEMI are ST elevation of ≥ 1 mm in ≥ 2 contiguous ECG leads.

    In our institution, all patients with acute STEMI, including those with cardiogenic shock, were considered eligible for primary transradial PCI if the radial artery pulse could be felt. Should 1 radial access fail but the vascular access time was still < 5 minutes, we usually chose the opposite radial access. However, the left and right groin sites also were prepared before the procedure in case radial approach should fail. We avoided perform- ing primary transradial PCI on those patients with a feeble or absent radial pulse, an abnormal Allen test, a small-sized radial artery that precluded the use of a 6-French introducer, an abnormality of the artery that caused coronary cannulation failure, or vascular access time > 5 minutes. If the patient was under chronic hae- modialysis or had severe chronic kidney disease (stage 4 or 5) and was considered a candidate for future hae- modialysis, we avoided the transradial approach so as to preserve the radial artery for future autogenous radi- ocephalic arteriovenous fistula. The final decision between the radial and the femoral approach was nev- ertheless left to the discretion of the physician. The ethical committee of the hospital approved the study protocol.

    Primary PCI procedures, anticoagulant, and antiplatelet regimen

    All patients undergoing primary PCI were pretreated with aspirin (300 mg) and clopidogrel (300 mg). In both transradial and transfemoral groups, the arterial access was done using an appropriate introducer. Subsequent to the arterial puncture and sheath insertion, heparin 5000 to 10 000 IU intravenous was administered, with a target activated clotting time of 250 to 300 seconds, or 200 to 250 seconds for patients receiving glycoprotein IIb/IIIa inhibitors. Transradial and transfemoral PCI

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