Bertrand OF 201110

Radial Approach:
An International Journey !
Olivier F. Bertrand, MD, PhD
Associate-Professor of Medicine, Laval University
Adjunct-Professor, Department of Mechanical Engineering, McGill University

Quebec Heart-Lung Institute

DUKE TRANSRADIAL ADVANCED COURSE,
20 OCTOBER 2011

Friday, October 21, 2011

Disclosures
Research grants: Cordis, Eli-Lilly, Bristol-
Myers-Squibb,GE Healthcare, Sanoﬁ-
Aventis, Eurocor
Consultant: Cordis, Astra-Zeneca,
Opsens
Research-Scholar from Quebec
Foundation for Health Research


The Past


COURTESY OF B FAURIE ANDJ MONSEGU, MD (PARIS, 2010)

ADAPTED FROM S RAO, 2011


PATIENT QUALITY OF LIFE

SF-36 ONE WEEK POST-CATH (N=200)

COOPER C ET AL. AM HEART J 1999;138:430-6


PATIENT QUALITY OF LIFE

>
SCIAHBASI A ET AL. INT J CARDIOL 2009;137:199-205


NURSING WORKLOAD

AMOROSO G ET AL. EUR J CARDIOVASC NURS 2005;4:234-41


MDs Quality of Life


N = 1107
75 countries
01-08-2010

BERTRAND OF ET AL. JACC INTV 2010;3:1022-31


CAPUTO R ET AL. CCI 2011 (IN PRESS)


Quebec Heart-Lung Institute

91-93% RADIAL FOR
ANGIO AND PCI

1ST PTCA ALL PCI OPERATORS ALL OPERATORS ALL OPERATORS
7 FR 6 FR 6 FR 5-6 FR
FEMORAL KIT 19G NEEDLE ADHOC PCI SAME-DAY DISCHARGE
GB

ADAPTED FROM TIZON-MARCOS H. ET AL. (2009)


QHLI- RADIAL VS FEMORAL APPROACHES PER OPERATOR

Radial (%) Femoral (%)
100
16 14 12 10 9 8 8 7 7 6 5 2
98
94 95
92 92 93 93
90 91
88
86
84

75

50

VARIATION IN RADIAL USE IN STEMI
25 AMONG 12 OPERATORS

0
JR SR BN CN EL GP RL LR GB JPD OG OB


“Radialist” Feeling After
Radial Access Failure...


TRA NOT A RELIGION!



Published (Radial)

160

140
140

120

100
85

Kiemeneij F
80

54
60 51 52
Campeau L 47 49
45

40
29
24 26

15 17
14
20
8
1 0 0 1 1 2

0
1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Meta-Analysis
Ischemic outcomes: All-cause death and the
combined incidence of Death-MI

Bleeding included both standardized and study-
specific definitions. Most definitions involved fatal or
intracranial bleeding, bleeding associated with Hb
drop ≥ 3 g/dl or ≥ 5 g/dl, or access-related bleeding
requiring transfusion or surgery

Transfusion rates

Early (≤ 30 days)


Studies Selection

TOTAL OF 761,919
PATIENTS


Impact on Bleeding
RANDOMIZED

OR 0.21 (95% CR I: 0.15-0.28) OR 0.27 (95% CR I: 0.08-0.47)

OBSERVATIONAL


Impact on Transfusion

RANDOMIZED

OR 0.19 (95% CR I: 0.09-0.30)
OBSERVATIONAL

OR 0.25 (95% CR I: 0.01-1.07)


Impact on Death (Early)

RANDOMIZED

OR 0.52 (95% CR I: 0.40-0.63)

OBSERVATIONAL

OR 0.80 (95% CR I: 0.49-1.23)


EHJ 2005


JACC 2009


JACC 2011:...PRESENT BUT NO RECOMMENDATION


EHJ-SEP 2011
STILL NO RECOMMENDATION !!


CCI 2011 (IN PRESS, NOVEMBER ISSUE)


RADIATION AND EXPERIENCE

NEILL J. ET AL. AM J CARDIOL 2010;106:936-40


JACOB S ET AL. BMC PUBLIC HEALTH, 2010;10:537


NO LEADED GLASSES
CATHPAX

NO LEAD APRON
DOSIMETER = OUTPUT

FACTOR 10
<<
<<
<<
<< RADPAD
<<
COURTESY J ARSENAULT, 2011


S RAO, 2011


EASY-Bivalirudin To Reduce Bleeding (B2B)
Patients at high risk of non-access site bleeding ie ≥
2 risk-factors: Age > 70, female, CKD, recent GI or
organ bleeding, anemia, diabetes, prior GPI/Tnk.
≃ 2500 Transradial PCI

HEPARIN BIVALIRUDIN

1ST END-POINT: DEATH, MI, URGENT REVASCULARIZATION,
BARC BLEEDING 2,3,5 AT 30 DAYS FU


FUNDING FOR RADIAL TRIALS RESEARCH ??


TRA PRACTICE IN THE FUTURE ?

50%



Supporting the adoption of transradial access

theradialist.org redesigned

50% RADIAL IN 5 YEARS


Supporting the adoption of transradial access

Facebook


Conclusion: Think Different!
Transradial practice is already used worldwide
Use will likely continue to increase signiﬁcantly
over next few years
Physicians = Education, EBM (Publications !!)
Health systems = Cost reduction
Patients = Qol, better outcomes
Still ways for improvement (RAO...)


IT IS NOT ABOUT YOU!!
IT IS ABOUT THE PATIENT AND
BETTER OUTCOMES...

“Great invention and I’d love to invest, but I can’t
spend time to learn how to use it and I never
have trouble getting places when I have to
anyway. I’ll just stick with what I’m doing…”

ADAPTED FROM I GILCHRIST


EHJ 2010...STILL NO RECOMMENDATION !!


ANTITHROMBOTIC REGIMENS AND RESIDUAL BLEEDING RISK

HAMON ET AL. EUROINTERVENTION, 2009


0
1
2

0
20
40
60
80
100
120
140
160

1989

1
1989
1990

0
1990
1991

0
1991
1992

1
1992
1993

1
1993
1994

2
1994
1995

8
1995 1996
1996 1997

15
1997 1998

24
1998 1999

14
2000
1999

17
2001
2000
47
Randomized Trials (Radial vs Femoral)

2002
2001
26

2003
2002
29

2004
2003
49

2005
2004
54

2006
2005 2007
45

2006 2008
51

2007 2009
52

2010
2008
85

2011
2009
140

0
2
4
6
8
10
12
14

1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
Observational Studies (Radial vs Femoral)

2004
2005
2006
2007
2008
2009
2010
2011

Objectives

To conduct a systematic review and
meta-analysis of all observational
studies and randomized trials
comparing TRA to FA for PCI


PI: S. RAO, M. KRUCOFF


JOLLY S ET AL. LANCET 2011, 377:1409-20


Bertrand OF 201110

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