Transradial (TR) cardiac catheterization is effective and offers lower rates of vascular complications and bleeding compared with transfemoral cardiac catheterization. We sought to describe the safety and feasibility of TR cardiac catheterization in liver transplant candidates (LTCs). We retrospectively reviewed 1,071 consecutive cases of TR cardiac catheterization in 1,045 patients from May 2008 to December 2011 at a single institution. The primary end point was radial approach failure. Ten percent of TR cases (n = 107) were performed in LTCs and 90% (n = 964) were performed in non-LTCs. The LTC group had lower rates of cardiovascular diseases and cardiovascular risk factors. The LTC group had a significantly lower platelet count (75,000 vs 237,000/mm 3 , p <0.01), higher international normalized ratio (1.7 vs 1.1, p <0.01), and lower mean arterial pressure (78 vs 89 mm Hg, p <0.01). The mean Model for End-Stage Liver Disease score was 21 in LTCs. Percutaneous coronary interventions were performed in 4% of LTCs and 15% of non-LTCs (p <0.01). The radial approach failure rate was 10% in LTCs and 7% in non-LTCs (p = 0.15). In conclusion, radial approach failure was similar between the LTC and non-LTC groups. Despite significant differences in platelet count and international normalized ratio, there was no difference in the incidence of adverse events between the groups, suggesting that TR cardiac catheterization is safe and effective in LTCs.
Cardiovascular disease has a major impact on outcomes after liver transplantation (LT). However, the accuracy of noninvasive stress imaging for detecting coronary artery disease (CAD) is lower in liver transplant candidates (LTCs). Recent reports have demonstrated sensitivity as low as 13% for dobutamine stress echocardiography and 62% for single-photon emission computed tomography myocardial perfusion imaging for detecting CAD in LTCs. coronary computed tomography angiography has shown promise in risk stratification of patients with chest pain. However, in LTCs, who often have multiple risk factors for CAD, 92% had at least mild CAD on coronary computed tomography in 1 series, and coronary computed tomography had only a 13% true-positive rate in another series. Given the scarcity of LT donors, the high morbidity and mortality of LTCs with CAD, and the poor performance of noninvasive stress imaging techniques in LTC, cardiac catheterization plays a key role for risk stratification before LT. However, the risk of bleeding is a major concern in this population. Enthusiasm for a transradial (TR) approach to cardiac catheterization has increased in the past decade. Numerous studies have shown reductions in vascular complications, bleeding, and transfusion requirements when a TR approach is compared with a transfemoral (TF) approach. The purpose of this study is to describe the performance and safety of TR cardiac catheterization in LTCs.
Methods
We retrospectively reviewed all cases of TR cardiac catheterization at our institution from adoption of the TR approach until the time of this study. This included 1,071 consecutive cases of TR cardiac catheterization performed in 1,045 patients from May 2008 to December 2011. All cases were included in this analysis. Clinical, demographic, and procedural variables were collected by review of the medical records, procedure logs, digital angiograms, and the Social Security Death Index. Co-morbidities such as smoking status, hypertension, dyslipidemia, diabetes mellitus, CAD, congestive heart failure, and peripheral vascular disease were abstracted from the medical history and based on common definitions. All cases were performed at a single tertiary care academic medical center. The primary end point was overall radial approach failure, including both access failure and vascular failure. Access failure was defined as inability to cannulate the radial artery. Vascular failure was defined as inability to complete the procedure from a radial approach after successful radial artery cannulation. Reasons for vascular failure included radial artery loop, upper extremity arterial occlusive disease, tortuous vascular anatomy with inability to cannulate a coronary artery or bypass graft, and arterial spasm. Secondary end points included access failure, vascular failure, and adverse events. Adverse events including bleeding, digital ischemia, local vascular complications, contrast nephropathy, and death were prospectively recorded.
Comparisons between groups were performed with a chi-square test for categorical variables and a Welch’s t test for continuous variables. Welch’s t test was used because of the large discrepancy in sample sizes between the groups and major differences in variances from the sample means. p Values <0.05 were considered statistically significant. All analyses were completed using Stata version 12 software (StataCorp, College Station, Texas). The study was conducted in compliance with the Institutional Review Board at Northwestern University Feinberg School of Medicine.
Results
There were 1,071 TR cases included in the analysis. Ten percent of cases (n = 107) were performed in LTCs, and the remaining 90% (n = 964) were performed in non-LTCs. Baseline demographics are compared in Table 1 . There were several notable differences between the LTC and non-LTC groups. The LTC group had a higher proportion of men. The LTC group had lower rates of hypertension, dyslipidemia, CAD, congestive heart failure, and peripheral vascular disease. Systolic blood pressure, diastolic blood pressure, and mean arterial pressure were all significantly lower in LTCs at the time of cardiac catheterization. Body weight was also lower in LTCs, although there was no significant difference in height between the groups. Laboratory findings before cardiac catheterization showed a significantly lower platelet count and higher international normalized ratio (INR) in LTCs. Renal function was not significantly different between the groups. The mean Model for End-Stage Liver Disease score in the LTC group was 21.
| Variable | LTC | p Value | |
|---|---|---|---|
| Yes (n = 107) | No (n = 964) | ||
| Age (yrs) | 61 ± 8 | 60 ± 13 | 0.19 |
| Men | 72 (67) | 543 (57) | 0.04 |
| Diabetes mellitus | 42 (39) | 314 (33) | 0.18 |
| Hypertension | 50 (47) | 687 (72) | <0.01 |
| Dyslipidemia | 20 (19) | 491 (51) | <0.01 |
| Previous CAD | 14 (13) | 254 (26) | <0.01 |
| Congestive heart failure | 8 (7) | 235 (24) | <0.01 |
| Coronary artery bypass surgery | 1 (1) | 45 (5) | 0.07 |
| Lower extremity arterial disease | 2 (2) | 90 (9) | 0.01 |
| Aneurysmal vascular disease | 2 (2) | 60 (6) | 0.07 |
| Cerebrovascular disease | 6 (6) | 82 (9) | 0.29 |
| Any peripheral vascular disease | 10 (9) | 188 (20) | 0.01 |
| Smoking exposure (pack years) | 17 ± 23 | 13 ± 24 | 0.15 |
| Height (in) | 67 ± 4 | 68 ± 22 | 0.39 |
| Weight (kg) | 92 ± 25 | 98 ± 32 | 0.01 |
| Systolic blood pressure (mm Hg) | 106 ± 22 | 120 ± 24 | <0.01 |
| Diastolic blood pressure (mm Hg) | 60 ± 12 | 69 ± 14 | <0.01 |
| Mean arterial pressure (mm Hg) | 78 ± 15 | 89 ± 15 | <0.01 |
| Platelet count (10 3 /mm 3 ) | 75 ± 46 | 223 ± 76 | <0.01 |
| INR | 1.7 ± 0.5 | 1.1 ± 0.2 | <0.01 |
| Creatinine (mg/dl) | 1.7 ± 1.6 | 1.4 ± 4.1 | 0.15 |
| Model for End-Stage Liver Disease | 21.4 ± 8.7 | ||
Differences in procedural characteristics between the 2 groups are listed in Table 2 . All procedures in LTCs were performed under elective circumstances for preoperative evaluation before LT. In non-LTCs, approximately 1/5 of cases were performed for acute coronary syndromes. Concomitant right-sided cardiac catheterization was more common in LTCs, whereas percutaneous coronary intervention was more common in non-LTCs. The LTC group had significantly lower exposure to fluoroscopy, contrast dye, and intra-arterial heparin. Nearly all cases in both groups were performed using a 5Fr arterial sheath.
| Variable | LTC | p Value | |
|---|---|---|---|
| Yes (n = 107) | No (n = 964) | ||
| Left-sided cardiac catheterization | 58 (54) | 760 (79) | <0.01 |
| Left- and right-sided cardiac catheterization | 49 (46) | 185 (19) | <0.01 |
| Left- and right-sided cardiac catheterization with biopsy | 0 (0) | 19 (2) | 0.14 |
| Indication | |||
| Acute coronary syndrome | 0 (0) | 203 (21) | <0.01 |
| Elective | 103 (96) | 554 (58) | <0.01 |
| Cardiomyopathy | 4 (4) | 187 (19) | <0.01 |
| Arrhythmia | 0 (0) | 20 (2) | 0.13 |
| Any percutaneous coronary intervention | 4 (4) | 142 (15) | <0.01 |
| Coronary artery intervened | |||
| Left anterior descending | 2 (2) | 67 (7) | 0.04 |
| Left circumflex | 1 (1) | 33 (3) | 0.16 |
| Right | 1 (1) | 54 (6) | 0.04 |
| Medications and exposures | |||
| Verapamil (mg) | 2.5 ± 0.5 | 2.6 ± 1.0 | 0.42 |
| Nitroglycerin (μg) | 108 ± 63 | 106 ± 51 | 0.82 |
| Heparin (U) | 1,915 ± 1,160 | 2,400 ± 790 | <0.01 |
| Contrast dye (ml) | 72 ± 34 | 102 ± 61 | <0.01 |
| Fluoroscopy time (minutes) | 8.0 ± 5.0 | 11.1 ± 8.6 | <0.01 |
| Sheath size | |||
| 4Fr | 1 (1) | 7 (1) | 0.81 |
| 5Fr | 96 (96) | 851 (92) | 0.66 |
| 6Fr | 3 (3) | 65 (7) | 0.11 |
The overall TR approach failure rate was similar between the 2 groups. There were no differences in the rates of access failure, vascular failure, or any of the individual components of vascular failure between the LTC and non-LTC groups ( Table 3 ). Adverse events and death were rare in both groups. There was 1 recorded adverse event related to TR access in the LTC group, which was the development of a small hematoma. Nine adverse events were recorded in the non-LTC group. There was no difference in the adverse event rate between the groups ( Table 4 ). Periprocedural blood product transfusion was required in 3 LTCs compared with 1 non-LTC. Each of the 3 LTCs had transfusions started before cardiac catheterization for bleeding prophylaxis. At 1 month, there were 2 deaths in the LTC group and 11 deaths in the non-LTC group. None of the deaths were related to procedural complications.
| Variable | LTC | p Value | |
|---|---|---|---|
| Yes (n = 107) | No (n = 964) | ||
| Death (<30 days) | 2 (2) | 11 (1) | 0.51 |
| Any adverse event | 1 (1) | 9 (1) | 0.99 |
| Small hematoma | 1 | 0 | |
| Hematoma >4 cm | 0 | 1 | |
| Infected wrist | 0 | 1 | |
| Digit ischemia | 0 | 1 | |
| Contrast nephropathy | 0 | 2 | |
| Intraoperative hypotension | 0 | 1 | |
| Stroke | 0 | 1 | |
| Facial swelling | 0 | 1 | |
| Dissection | 0 | 1 | |
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