Transradial Approach for Percutaneous Intervention in Acute Myocardial Infarction

ABSTRACT: Transradial intervention (TRI) approach has emerged as an alternative and competitive method compared with transfemoral intervention (TFI) approach for percutaneous coronary intervention (PCI) in simple to complex coronary disease. TRI, when performed by operators experienced with this technique, appears to have comparable efficacy and procedural resource utilization compared with TFI. However, vascular access complications, specifically major and minor bleeding, can be reduced with TRI. Patients with acute myocardial infarction (AMI) are at the highest risk for periprocedural bleeding for a variety of reasons, and may derive the greatest benefit from TRI. This review article will discuss potential advantages for TRI in the setting of AMI, barriers, and development of a TRI AMI program. J INVASIVE CARDIOL 2009;21(Suppl A):25A–27A Key Words: Transradial, radial, vascular, intervention, myocardial infarction, stent
Transradial intervention (TRI) approach for percutaneous coronary intervention (PCI) has emerged as an alternative to transfemoral intervention (TFI) in many settings and serves as a default access strategy for operators experienced in this technique. The radial artery is the preferred approach arm, compared with the brachial artery because, in most patients, the hand can remain perfused in the case of radial artery occlusion via the ulnar artery and a patent palmar vascular arch. This is not the circumstance with brachial access; the brachial artery serves as an end blood supply to the forearm and hand via the radial and ulnar arteries and its occlusion can be devastating. In addition, vascular compression and hemostasis are more consistent in the radial distribution and wrist compared with the upper arm post-PCI. TRI can be used successfully in many complex coronary lesion subsets, including left main disease, bifurcations, multivessel disease, chronic total occlusion, thrombotic, and calcified lesions.^1–11 The efficacy of TRI seems comparable to TFI when used by experienced operators. The learning curve includes proper patient selection, radial access assessment, troubleshooting arm vessel anomalies,¹² guidecatheter selection and engagement, augmentation of guide support, and adjunctive device selection. With-TRI specific experience, the operator can eff-ectively utilize this approach in most patients if desired, and maintain the femoral approach as a crossover technique as needed. In this setting, efficacy appears comparable between TRI and TFI. Although vascular complications exist with both approaches, the mechanism of the complications often differs between the radial and femoral routes. TRI in the appropriate settings seems to reduce major and minor bleeding.^13–19Bleeding and Adverse Events in Myocardial Infarction Periprocedural blood loss, as defined by TIMI and GUSTO criteria, as well as blood transfusion are associated with higher rates of death and recurrent ischemia in the short- and long-term in patients with AMI and acute coronary syndrome.^20,21 Elderly patients, women, and patients with very high or very low body surface area have higher rates of vascular adverse events post-PCI as well.^22–24 It is noteworthy that patients with myocardial infarction are at the highest risk for bleeding for multiple reasons, but particularly related to anticoagulant/antiplatelet/thrombolytic status and the emergent nature of their procedures. It is also troublesome that bleeding complications in this patient subset are much more likely to be associated with repeat ischemia as well as short- and long-term adverse cardiac events, including mortality. Major and minor bleeding, which can be particularly life threatening in the clinical setting of AMI or acute coronary syndrome are lower with TRI. Bleeding events do still occur and remain associated with poorer outcome and therefore cannot be trivialized even with TRI approach,²⁵ but TRI appears to have a different vascular adverse event profile compared with TFI in terms of the nature and frequency of events. Radial artery occlusion (RAO) is found in ~5% of cases during the post-TRI follow-up period,²⁶ and a much higher percentage of patients may experience long-standing impairment of radial artery vasomotor tone of uncertain significance. It is not currently clear if newer coated sheath designs, improved compression techniques, and increased operator experience have contributed to a reduction in RAO over time. In addition, radial artery access with inadequate compression technique is prone to pseudoaneursym formation, as is the femoral artery, but with much lower apparent frequency.²⁷ Finally, a critical ischemic limb complication involving a dominant hand may be a catastrophic life event for a patient, though these complications in the lower extremity can be equally serious and impairing. It is unclear if systematic utilization of TRI for myocardial infarction can compress morbidity and mortality in this clinical patient subset by virtue of reduction in vascular complications, but preliminary data are encouraging. Transradial PCI in Acute Myocardial Infarction Ochiai and colleagues performed an observational pilot investigation to determine if risk stratified AMI patients could experience reduced bleeding complications and earlier mobilization with TRI and primary stenting.²⁷ Fifty-six patients with Killip class I or II and a positive Allen’s test were treated by operators with more than 30 cases of elective TRI experience. Successful stent delivery was achieved in all patients and successful stenting with normalized outflow in 97% of patients. No major vascular complications occurred in this experience. Philippe et al¹⁹ observed similar results in their experience of 119 consecutive patients with AMI having primary PCI via radial (64 patients) or femoral (55 patients) approach with adjunctive abciximab. Hospital length of stay was higher in the TFI group compared with TRI (5.9 versus 4.5 days, respectively, p = 0.05). There were no vascular complications in the TRI group, but 3 (5.5%) in the TFI group (p = 0.04). They did observe longer radiation exposure times in the TRI cohort. Cruden and associates¹³ expanded on these registry observations in 287 patients having rescue PCI in patients with unsuccessful thrombolysis for AMI. In this retrospective analysis, procedural success was similar for TRI and TFI (98% versus 93%, p = 0.3). However, vascular complications (0% versus 13%, p p 28 in the TEMPURA clinical trial, randomized 149 patients with AMI n = 77) or TFI (n = 72). Procedural success (96.1% TRI versus 97.1% TFI, p = NS) and adverse cardiac events (5.2% TRI versus 8.3% TFI, p = NS) were similar between these groups. Severe bleeding was seen in 3% of patients with TFI and none with TRI. In the RADIAL AMI pilot trial, Cantor and colleagues²⁹ randomized 50 patients having primary or rescue PCI to TRI or TFI approaches. No major bleeding or transfusion was required in either group. Procedure time slightly favored TFI over TRI (this is in contrast with slightly better TRI procedure times in the Saito series). Final TIMI flow, contrast, and fluoroscopy time were similar for TRI and TFI. It should be noted that patients in all of these investigations were well selected. Many patients with severe cardiogenic shock, hemodynamic instability, and/or thready or nonpalpable radial pulse were often not included. Furthermore, and very importantly, the operators in all these studies had significant TRI experience in the elective setting of 30 to 100 (and often more) cases. The Transradial Acute Myocardial Infarction Program No formalized guidelines exist regarding development of TRI AMI program, but it is reasonable to assume that this should be an outgrowth of standard elective TRI. Leading to AMI applications for TRI, the operator and support staff should have experience managing well selected, non complex patients in the elective setting to develop skill and experience with this method. This elective experience should be extended to more complex scenarios including 5/6 Fr bifurcation techniques, calcification, and vascular/coronary tortuosity. The operator can then become more accustomed to technique modification and device choices that are suited for these situations in a more controlled environment before encountering these circumstances in patients who are less stable and when time to perfusion is critical. The number of cases to achieve these competencies will be variable by operator and program, but it should be recognized that a minimum of 30 to 100 TRI cases per operator is supported by the citations from this manuscript (and the majority of operators in these cited reports likely had more TRI experience). Room preparation and patient setup are keys in AMI TRI. Arm boards for the access site should be placed close to femoral position to mimic the TFI approach. Many operators shift a standard femoral window drape so the right femoral window is over the right radial (for right TRI) and the left femoral window is overlying the right femoral artery (for femoral crossover or IABP/hemodynamic support device placement). This method works well for non-obese patients. An alternate method is to use towel drapes for the desired radial access site and standard femoral window drape for the legs. Although the preparation time is slightly prolonged to prepare provisional femoral access, it is typically justified to minimize this activity when femoral access is needed during the case. This delay may be offset by the ability to access the radial without needing fluoroscopic guidance (i.e., while the staff is completing room setup). Whatever the preparation choices for the program, this should be standardized to truncate door-to-balloon time. Trans-radial sheaths, access kits, and diagnostic and interventional catheters should be immediately available. When setup is standardized and gear is immediately available, room-to-coronary engagement time should be comparable to transfemoral technique, and therefore reduce barriers for TRI approach on the basis of perceived prolongation of procedure and/or door-to-balloon time. Diagnostic angiography should be performed in the non-infarct vascular distribution, follwed by angiography with a guide catheter for the infarct-related distribution (XB, EBU, or equivalents for the left coronary, Judkins right 4, Amplatz left 1 for the right coronary, or per operator practice or discretion). Another potential advantage to TRI for primary PCI is that dedicated radial guide catheters that are designed for both the RCA and LCA can be used (e.g., Kimny). Guide catheter anchoring support, deep seating, or other augmentation may be utilized as needed. Thrombectomy, PTCA, or direct stenting can then be performed and PCI completed in usual fashion. Vascular hemostasis can be achieved in typical transradial fashion using a variety of specialized radial closure devices. The specifics of radial PCI technique are beyond the scope of this manuscript; however, active guide catheter support augmentation may be particularly important in myocardial infarction. First, guide catheter selection is incredibly important. If the guide catheter is a poor fit for support, it should be exchanged for a better choice. Often, forcing a poor guide catheter choice for complex anatomy is associated with increased procedural difficulty. Second, multiple wires (often three or more) to enhance coaxial orientation and modify vascular architecture and support can be beneficial when device delivery is difficult. Finally, a wire and monorail balloon in a sidebranch (sidebranch anchor balloon technique) can be used to improve device delivery. Other methods for anchoring and guide augmentation exist, but the aforementioned techniques should be standard for the transradial interventionalist. Conclusion In conclusion, TRI can be an effective alternative approach to TFI in patients with myocardial infarction. This technique can be accomplished safely and effectively in the hands of an experienced operator and staff. Patient and room preparation and operator experience with elective complex transradial intervention are the starting basis for developing a transradial acute myocardial infarction program. The potential benefits of this approach include reduced vascular complications in this high-risk subset, improved patient comfort, and earlier ambulation. References 1. Cheng CI, Wu CJ, Fang CY, et al. Feasibility and safety of transradial stenting for unprotected left main coronary artery stenoses. 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