Abstract
Background
STEMI and unstable acute coronary syndromes are associated with widespread adrenergic activation which may increase radial artery (RA) spasm, requiring cross-over to the femoral artery (FA) during percutaneous coronary intervention (PCI). We assessed the incidence of failed trans-radial artery PCI in emergency cases compared with non-emergency cases.
Methods
PCI procedures performed by default radial artery operators were assessed in our centre over a 25 month period. Those who had both RA and FA access were identified to assess if the double punctures were elective or due to failure of the RA approach. Cross-over rates were compared between emergency and non-emergency cases.
Results
680 cases of PCI were performed, 153 in an emergency setting. In non-emergency cases 403/527 (76.5%) were performed via the RA. In the emergency setting 139/153 (90.8%) were completed by the RA. Previous CABG with multiple arterial conduits was the most common reason for elective FA PCI in both groups. The RA to FA cross-over rate was low with no significant difference between the emergency and non-emergency groups (emergency 1.4%, non-emergency 1.2%, p = 1.0). In both groups there was no significant difference between RA and FA procedures in terms of fluoroscopy times (emergency: mean 13.1 ± 7.9 min vs 16.1 ± 16.1 min, p = .25, non-emergency: 16.6 ± 10.3 min vs 18.7 ± 13.6 min, p = .07) or contrast volumes (emergency: mean 231 ± 126 ml vs 229 ± 102 ml, p = .77, non-emergency: 223 ± 85 ml vs 237 ± 91 ml, p = .15).
Conclusions
The vast majority of PCI can be successfully performed via the RA. Cross-over rates to the FA are low and are not more common in emergency patients.
1
Introduction
In recent years vascular access via the radial artery has become increasingly favoured for diagnostic coronary angiography and percutaneous coronary intervention (PCI). Several trails have identified lower major bleeding rates and vascular access site complications with radial access when compared with femoral artery access in a wide range of elective and emergency cases .
Trans-radial PCI can be more technically challenging than the trans-femoral approach however, with radial artery spasm and subclavian tortuosity distinct challenges specific to the radial route. These problems can occasionally require abandoning the trans-radial route and crossing over to the femoral artery in a small subset of patients. The recently published RIVAL study has underlined that radial artery approach is safe and efficacious in both elective and emergent cases of PCI . The RIVAL study was also notable for the subgroup analysis that suggested that patients with ST-elevation myocardial infarction (STEMI) had better clinical outcomes when primary PCI (PPCI) was performed via the radial route suggesting that radial PCI should be the default access site for the emergency management of STEMI . However, STEMI is associated with widespread increased levels of urinary and plasma catecholamines, and this is most marked in the first 24 h, during which PPCI has the largest prognostic benefit . This hyper-adrenergic state may increase the propensity to vasospasm in the radial artery through activation of ά-adrenoceptors and therefore in patients with STEMI there may be an increase in incidence of radial artery spasm, leading to a higher incidence of failed radial PPCI procedures.
We sought to assess the incidence of radial to femoral “cross-over” rates in our centre over a twenty-five month period. We also sought to assess if the incidence of failed trans-radial PCI was higher during emergency cases of PCI compared with non-emergency cases, as might be expected given the elevated adrenergic and neurohormonal milieu.
2
Methods
Our centre has an electronic database detailing all demographic and peri-procedural information related to PCI procedures. The database is completed prospectively during each individual procedure. From this database we analysed all successful PCI procedures performed in our centre by default radial artery proceduralists over a twenty-five month period from January 2009 to February 2011. The centre has 5 interventional cardiologists who perform approximately 1200 PCIs per year. Four of the 5 operators are currently default radial artery operators with a staggered transition from the femoral artery occurring from approximately 2007. Only those operators who had been performing default radial artery PCI for a minimum of 1 year at the start of the study period were included in the analysis.
Only cases of PCI were considered and these included emergency and non-emergency cases. Emergency cases were defined as PPCI for STEMI, Rescue PCI and PCI performed for patients suffering cardiac arrest requiring intubation and ventilation. Non-emergency cases included elective or semi-elective cases comprising patients undergoing PCI for the management of stable angina or Acute Coronary Syndromes (ACS) without ongoing pain or persistent ST segment elevation on the ECG. Only cases of successful PCI were included in the analysis. This included cases where only balloon angioplasty and/or thrombus aspiration were used with a decision made not to subsequently insert a coronary stent. Instances where vessels could not be wired (eg chronic total occlusions) or devices could not be tracked and/or deployed due to tortuosity or calcification of the coronary arteries were not considered successful PCI and were excluded from the analysis.
All patients who had both radial and femoral arterial punctures were identified. These patients had their case notes examined to assess if the double punctures were performed electively or had been necessitated due to technical difficulties related to the trans-radial route.
Radial access was defined as successful insertion of an arterial sheath in the radial artery. Cases where radial punctures were attempted but unsuccessful requiring a femoral arterial puncture were not identified as a cross-over.
2
Methods
Our centre has an electronic database detailing all demographic and peri-procedural information related to PCI procedures. The database is completed prospectively during each individual procedure. From this database we analysed all successful PCI procedures performed in our centre by default radial artery proceduralists over a twenty-five month period from January 2009 to February 2011. The centre has 5 interventional cardiologists who perform approximately 1200 PCIs per year. Four of the 5 operators are currently default radial artery operators with a staggered transition from the femoral artery occurring from approximately 2007. Only those operators who had been performing default radial artery PCI for a minimum of 1 year at the start of the study period were included in the analysis.
Only cases of PCI were considered and these included emergency and non-emergency cases. Emergency cases were defined as PPCI for STEMI, Rescue PCI and PCI performed for patients suffering cardiac arrest requiring intubation and ventilation. Non-emergency cases included elective or semi-elective cases comprising patients undergoing PCI for the management of stable angina or Acute Coronary Syndromes (ACS) without ongoing pain or persistent ST segment elevation on the ECG. Only cases of successful PCI were included in the analysis. This included cases where only balloon angioplasty and/or thrombus aspiration were used with a decision made not to subsequently insert a coronary stent. Instances where vessels could not be wired (eg chronic total occlusions) or devices could not be tracked and/or deployed due to tortuosity or calcification of the coronary arteries were not considered successful PCI and were excluded from the analysis.
All patients who had both radial and femoral arterial punctures were identified. These patients had their case notes examined to assess if the double punctures were performed electively or had been necessitated due to technical difficulties related to the trans-radial route.
Radial access was defined as successful insertion of an arterial sheath in the radial artery. Cases where radial punctures were attempted but unsuccessful requiring a femoral arterial puncture were not identified as a cross-over.
3
Results
In the study period 680 cases of PCI were performed. Of these 153 were emergency cases of primary PCI (PPCI) with the remaining cases performed for the management of stable angina or ACS without ST elevation. The demographic details of the patients included in the study are identified in Table 1 . Rates of obesity (BMI > 25) were similar between the two groups.
| Emergency patients | Non-emergency patients | |
|---|---|---|
| No. | 153 | 527 |
| Gender | ||
| Male | 114 (74.5%) | 391 (74.1%) |
| Female | 39 (25.5%) | 136 (25.8%) |
| Age (years) mean (SD) | 67.1 (12.9) | 70.1 (11.8) |
| Height (cm) mean (SD) | 170.7 (11.5) | 171.0 (9.4) |
| Weight (kg) mean (SD) | 82.0 (17.9) | 82.3 (18.3) |
| BSA (m²) mean (SD) | 2.0 (0.3) | 1.9 (0.2) |
| Fluoroscopy Time (min) mean (SD) | 13.4 (8.9) | 17.2 (11.4) |
| Contrast volume (ml) mean (SD) | 221.5 (77.7) | 227.6 (87.1) |
| Ejection Fraction (%) mean (SD) | 44.0 (8.9) | 55.2 (11.2) |
| Access site | ||
| Radial | 139 (90.8%) | 403 (76.2%) |
| Femoral | 14 (9.2%) | 120 (23.0%) |
| Brachial | 0 (0%) | 4 (0.8%) |
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