Using Procedural Approaches to Reduce Complications Related to Percutaneous Coronary Interventions

Percutaneous coronary intervention (PCI) is one of the most commonly performed cardiac procedures. Since its introduction over two decades ago, there has been a steady evolution in both devices and pharmacotherapy. Data from large registries have confirmed that periprocedural adverse events have decreased over time.¹ This trend mirrors that seen with acute coronary syndromes² and has made bleeding complications a clinical priority.^3,4 Several studies have shown that bleeding complications during treatment for ischemic heart disease are associated with an increased risk for death, MI, stroke, stent thrombosis, and increased costs.^5–8 Studies also indicate that a large proportion of bleeding complications in patients undergoing PCI is related to the vascular access site.^9,10 Therefore, strategies that address this issue may potentially reduce bleeding and vascular complications and improve PCI outcomes. This supplement is dedicated to the transradial approach to PCI and articles contained herein review and summarize the latest data regarding bleeding complications, technical aspects of transradial PCI, and elements fundamental to a successful transradial program. The issue leads off with a personal account of starting a program focused on the transradial approach by Dr. Jennifer Tremmel. Dr. Tremmel has long been involved with women’s health issues and, given that females are at higher risk for bleeding complications,¹¹ adopting the transradial approach seemed a natural fit. Her story of overcoming the operational challenges will serve as a template for operators considering starting their own program. In a similar vein, Dr. Mauricio Cohen provides an evidence-based summary of technical aspects that operators should keep in mind as they begin to perform transradial PCI. One important issue that will become the focus of the cardiology literature in the future is the impact of practice patterns on healthcare costs. Dr. Ronald Caputo provides a balanced view of how transradial PCI can affect resource use, including costs and length of stay. In addition to the cost impact, the transradial approach can influence clinical outcomes. Dr. John Vavalle reviews the association between using the radial artery for PCI and a reduced risk for bleeding. He also reviews whether this impacts harder clinical outcomes such as mortality. Finally, Dr. Craig Thompson provides a perspective on patients who potentially benefit the most from the transradial approach — those with acute ST-segment elevation myocardial infarction undergoing primary PCI. As reviewed in the article, applying the transradial approach to this population requires experience and technical expertise that should be gained in the elective population first. Dr. Thompson’s article provides recommendations on developing a strategy for transradial primary PCI. As the practice of PCI continues to evolve, it is incumbent on interventionalists to carefully review the evidence and apply the best practices. A body of literature now supports the role of transradial PCI in reducing bleeding and vascular complications without sacrificing procedure success. The purpose of this supplement is to provide operators with a basis for adopting transradial PCI. We hope that the articles contained in this issue are helpful to interventionalists whose collective goal is to provide the best care for their patients. — Sunil V. Rao, MD References 1. Singh M, Rihal CS, Gersh BJ, et al. Twenty-five-year trends in in-hospital and long-term outcome after percutaneous coronary intervention: A single-institution experience. Circulation 2007;115:2835–2841. 2. Fox KA, Steg PG, Eagle KA, et al. Decline in rates of death and heart failure in acute coronary syndromes, 1999–2006. JAMA 2007;297:1892–1900. 3. Rao SV, Eikelboom JA, Granger CB, et al. Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes. Eur Heart J 2007;28:1193–1204. 4. Doyle BJ, Rihal CS, Gastineau DA, Holmes DR Jr. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: Implications for contemporary practice. J Am Coll Cardiol 2009;53:2019–2027. 5. Rao SV, O'Grady K, Pieper KS, et al. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol 2005;96:1200–1206. 6. Manoukian SV, Feit F, Mehran R, et al. Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: An analysis from the ACUITY Trial. J Am Coll Cardiol 2007;49:1362–1368. 7. Eikelboom JW, Mehta SR, Anand SS, et al. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation 2006;114:774–782. 8. Rao SV, Kaul PR, Liao L, et al. Association between bleeding, blood transfusion, and costs among patients with non-ST-segment elevation acute coronary syndromes. Am Heart J 2008;155:369–374. 9. Kinnaird TD, Stabile E, Mintz GS, et al. Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions. Am J Cardiol 2003;92:930–935. 10. Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med 2006;355:2203–2216. 11. Alexander KP, Chen AY, Newby LK, et al. Sex differences in major bleeding with glycoprotein IIb/IIIa inhibitors: Results from the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) initiative. Circulation 2006;114:1380–1387.