Pyne C 201110
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This document discusses building a successful transradial intervention (TRI) program for ST-segment elevation myocardial infarction (STEMI) patients. It highlights that TRI can reduce vascular complications and mortality compared to transfemoral approach. While procedural failures may be higher initially with TRI, outcomes improve significantly with operator experience. The document reviews data demonstrating reduced death rates with TRI in STEMI patients and lower transfusion needs. It provides guidance on volume thresholds for transitioning to TRI as primary approach and emphasizes that with experience, reperfusion times can be comparable between TRI and transfemoral approach.
Pyne C 201110
- 1. Building a Successful TRI STEMI Program Christopher Pyne M.D. Lahey Clinic Medical Center Burlington, Massachusetts U.S.A.
- 2. Disclosure • Modest consulting arrangement with Terumo
- 3. Fundamentals of TRI in STEMI • Reduction in vascular complications and mortality • Increase in procedure failures – heavily dependent on volume • Volume requirements for a default STEMI program are unknown.
- 4. Impact of TRI on Death in RIVAL n= Radial Femoral P= Death Death STEMI 1958 1.3 3.2 .026 ALL 7021 1.3 1.5 .5 • STEMI death and overall MACE were significantly reduced in the radial arm, despite no significant reduction in major bleeding. Jolly: Lancet DOI 10.1016; April 2011
- 5. TRI will reduce Transfusion rates in STEMI Radial Radial n = 220 Femoral Femoral n= 856 Etiology Umber of patients with transfusions 10 9 CABG 11 8 7 IABP/VAD 5 Percent 6 GI Bleed 1 Patients 5 Transfused 4 Other 3 3 2 1 0 Non CABG Transfusion rates for STEMI Etiologies of RBC Transfusion in Radial Patients @ Lahey Clinic over 4 years. STEMI patients Kahan AHA 2010
- 6. Potential Disadvantages of TRI in STEMI • Increase procedural failure and crossover to the femoral approach • Potential for D2B delays • Need for large vessel support
- 7. TRI in STEMI questions: • Are there procedural volume prior to default STEMI therapy with TRI • Are there time limits at which the approach should be abandoned?
- 8. Selected TRI STEMI D2B and Crossover data Study Patients Crossover to Reperfusion randomized femoral times Brasselet et al 114 12% Not reported Heart 2007 Rival 7021 7.6% No D2B times Lancet 2011 Procedure times the same Cantor et al 50 4% TRI 6 minutes AHJ 2005 slower Chotor et al 240 0% TRI 11 minutes Cardiol Journ 2009 slower
- 9. Decisions on Transitioning to Primary PCI are volume related Likely anywhere form 50 – 100 successful non-STEMI Radial PCI should be completed prior to considering a default radial STEMI program. Ball et al: Circ Cardio Interv 2011;4:336-341
- 10. Impact of Learning Curve on STEMI Re-Perfusion Times in a Single Center Early Radial: Pre - 2008 Late Radial: 2008 - 09 Conversion to default approach after several years of TRI experience. With experience – TRI times comparable to femoral times Frelich SCAI Scientific sessions: 2009
- 11. Institutional Volume and Crossover Rates in RIVAL Center Median Crossover Volume Operator Case Rate Volume Low < 60 8.8% Medium 60 - 142 9.7% High > 142 4.4% Overall Femoral crossover rate of 2.0 % Jolly: Lancet DOI 10.1016; April 2011
- 12. You Can Learn LRA Faster LRA Fluoro. times RFRA Fluoro. times • TALENT investigators compared trainees and experienced operators for fluoroscopy times . • Divided trainees into volume stages and compared Left vs. Right • Fellows equaled attendings @ 300 cases on the left – did not equal them on the right Schiahbasi A: Am Journ of Cardiol 2011;108:185-188
- 13. Etiologies of failure in operators learning TRI Cause 0 -50 51-100 101 -150 151 – 300 Control cases cases cases cases Spasm 15 5 1 1 4 Subclavian Tortuosity 7 0 2 1 1 Poor guide support 8 1 2 0 0 Failed puncture 6 1 0 0 0 Radial Loop 4 1 0 0 0 Roughly 40 % of TRI failures for new operators are side specific. Ball et al: Circ Cardio Interv 2011;4:336-341
- 14. Left approach yields high success in STEMI – in high risk failure pts. Left (50) Right (85) P= Age (yrs.) 69.7 60 <.001 % Female 40 20 .01 Height (cm.) 169 173 .02 Crossover 0 1.2 .45 rate RTB (Min.) 31 30 .73 Larsen: CCI DOI 10.1002/22843: 2011
- 15. “Rough” STEMI approach @ Lahey: Larsen ACC 2010
- 16. TRI in Shock 65 y.o. , 340 lbs, ASMI, borderline hemo-dynamics, Cr. 4
- 17. Impella assisted TRI cont. Bell et al, CCI: DOI 10.1002: 2011
- 18. “Physicians can approach high risk and hemodynamically unstable patients through the radial approach confident that lower extremity support devices can quickly be employed if felt necessary to patient management. Bell et al, CCI: DOI 10.1002: 2011
- 19. Evolution to Default STEMI at Lahey: • Long lag time of single operator low risk program • Marked ramp – up of STEMI with new operators. Waxman and Iqtidar: SCAI 2011
- 20. TRI Success and time conclusions: • Early operators will see high crossover rates and D2B delays • Improved operator and lab experience will generate competitive quality metrics. Single Center STEMI D2B times: TRI vs. Femoral. Pancholy CCI 75:991-995 (2010)
- 21. Case Presentation • 58 yo male – presents with IMI • Stable hemo-dynamics • S/P CABG – 11 years ago – LIMA to LAD – SVG to D1 – SVG to OM – RCA not grafted – Rx with DES 4 years prior • Left radial approach selected
- 22. Native Vessels
- 23. 2Patent Grafts
- 24. Closed OM - SVG • Ongoing ST changes with pain • No realistic chance @ acute native CTO • Plan: – Thrombectomy – Stenting – Heavy anticoag/anti- platet
- 25. SVG PCI
- 26. Embolic protection with 2B – 3A receptor blockade
- 27. Final Result • Sheaths out • No bleeding or T- fusion: – ACT > 350 – 24 hours of 2B/3A – Prasugrel • Uneventful course
- 28. TRI in STEMI Conclusions: • Use of TRI in STEMI can improve outcomes • TRI can reduce bleeding • TRI will have higher procedural failures, but these will improve with operator experience • All types of MI can be performed – shock is not an absolute contra-indication.
- 29. TRI in STEMI Conclusions: • Specific numbers for experience, failure rates, and perfusion delays to guide training do not exist. • It is likely that mentoring and supportive environments will shorten the learning curve for individual operators