Bleeding avoidance strategies, such as a transradial approach (TRA), should be considered especially for patients with high bleeding risk.3) However, PCI operators hesitate to choose conventional TRA for patients on dialysis because of the increased risk of radial artery occlusion (RAO) and general tendency to preserve possible hemodialysis access points for the future.
PCI & AimRadial 2018 | A Trans-Radial Approach of Cardiac Catheterization for Patients on Dialysis - Toshiki Kuno
1. A Trans-Radial Approach
of Cardiac Catheterization
for Patients on Dialysis
Department of Cardiology
Japanese Red Cross Ashikaga
Toshiki Kuno, MD, PhD,a,b Keita Hirano, MD,c Takayuki Abe, PhD,d Syohei
Imaeda, MD,a Kenji Hashimoto, MD,a, Toshinobu Ryuzaki, MD,a, Souichi
Yokokura, MD,a Tetsuya Saito,a, Hiroyuki Yamazaki, MD,a, Ryota Tabei, MD,a
Masaki Kodaira, MD, PhD,a Yohei Numasawa, MD, PhDa
aDepartment of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
bDepartment of Medicine, Mount Sinai Beth Israel Medical Center, New York, USA
aDepartment of Nephrology, Japanese Red Cross Ashikaga Hospital, Ashikaga,
Japan
dDepartment of Preventive Medicine and Public Health, Biostatistics at Center for
Clinical Research, Keio University School of Medicine, Tokyo, Japan
3. Case
83 F, 145cm, 40kg, BMI:19
DM, HT, ESRD on Dialysis
Prolonged chest pain (30min.)
ECG: TWI in precordial lead
FA both palpable, but very hard
Conventionally, diagnostic catheter through FA
performed, then, PCI if necessary with large size sheath
However, periprocedural puncture site bleeding risk is
extremely high
Department of Cardiology
Japanese Red Cross Ashikaga
4. Background
Periprocedural bleeding is the most common complication of PCI,
and associated with an increase risk of early and late mortality1)
Bleeding risk is high for patients on dialysis2)
Department of Cardiology
Japanese Red Cross Ashikaga
Bleeding avoidance strategies, such as a
transradial approach (TRA), should be considered
especially for patients with high bleeding risk.3)
However, PCI operators hesitate to choose
conventional TRA for patients on dialysis because
of the increased risk of radial artery occlusion
(RAO) and general tendency to preserve possible
hemodialysis access points for the future.
1): Karrowni et al. JACC Cardiovas Interv 2013;6:814-82
2): Numasawa et. al. PLoS One 2015;10:e0124399.
3): Numasawa et. al. Cardiovasc Interv Ther 2013 28:14
5. Background
Previous studies demonstrated that
2-year primary and secondary
patency rates of arteriovenous fistula
(AVF) were 51% and 64% 1)
Generally, RAO rates were 1%-10% 2)
Preservation of possible hemodialysis
access points for the future is
questionable because 5-year survival
rate of patients on dialysis is poor
(approximately 50%) 3)
1): Ahmed et. al. Am J Kid Dis 63 (3):464-78
2): Mamas et. al. Eurointervention 2014;10:824-83
3): Marui et. al. Am J Cardiol 2014;114:555-561.
Department of Cardiology
Japanese Red Cross Ashikaga
6. Hypothesis and aims
We considered that TRA would be beneficial for patients on
dialysis despite the risk of RAO, because it can reduce
bleeding complications and early mortality rates.
The aims of this study were to construct a TRA system and
to clarify the feasibility of TRA for patients on dialysis.
O
R
Department of Cardiology
Japanese Red Cross Ashikaga
7. Method -study protocol-
This study was an ongoing, prospective, cohort study
Data of 88 consecutive patients on dialysis who underwent
cardiac catheterization (diagnostic angiography [DA] or PCI)
between December 2015 and December 2016 were analyzed
The institutional review board and nephrologist approved the
study design
Informed consent was obtained for all patients
Radial access was limited in the opposite side of AVF
P2Y12 inhibitor was restricted to clopidogrel
Department of Cardiology
Japanese Red Cross Ashikaga
8. Exclusion Criteria of TRA
Patients who did not agree the consent
Patients with weak or absent radial artery pulse
Patients on peritoneal dialysis with weak or absent radial
artery pulse on one side in order to preserve the other side
for future access
Recent AVF failure (within 6 months)
Trans femoral approach (TFA) preferred by operator (eg, for 8
Fr)
Nephrologist decision against TRA
Department of Cardiology
Japanese Red Cross Ashikaga
9. Assigned to TFA due to
Patients’ decline: 2
Weak or absent radial artery pulse: 10
Recent AVF failure: 4
Use of 8Fr: 1
Operators’ decision including
subclavian artery tortuosity: 7
Post bilateral AVF operation: 1
(a nephrologist’s decision)
History of radial artery injury: 1
(a nephrologist’s decision)
88 consecutive patients on dialysis who underwent
cardiac catheterization from 2015 Dec. to 2016 Dec.
TRA group
N=62 (70.5%)
TFA group
N=26 (29.5%)
10. TRA –study protocol–
Glidesheath Slender® (Terumo) which showed lower rates of RAO was
used for more than 6Fr1)
Radial artery diameter is measured
Bleedsafe® (Medikit) is used to hemostasis (DA 5 hours, PCI 7
hours)
Patent hemostasis2) which could decrease RAO, was attempted
Bleedsafe® was inflated for sheath removal. After removal, ulnar
artery was pressed
Pulse oximetor was placed to the index finger. If plethysmographic
signal returned, radial artery patency was confirmed.
If not, deflate 1cc each, with caution. If bleeding occurs, inflate again.Department of Cardiology
Japanese Red Cross Ashikaga
1): Mehran et. al. Circulation 2011;123:2736-2747.
2): Pancholy et. al. Catheter Cardiovasc Interv 2008;72:335
12. Baseline Characteristics
TRA group
% (N=62)
TFA group
% (N=26)
P value
Age (years) 71 [65, 80] 65 [62, 75] 0.050
Female 29.0% (18) 30.8% (8) 0.871
Hypertension 80.6% (50) 80.8% (21) 0.989
Diabetes mellitus 53.2% (33) 73.1% (19) 0.084
Diabetes mellitus with insulin 19.4% (12) 30.8 % (8) 0.244
Cerebral infarction 9.7% (6) 3.8% (1) 0.356
Peripheral artery disease 14.5% (9) 19.2% (5) 0.581
Hemodialysis 82.2% (51) 100% (26) 0.022
Peritoneal dialysis 17.7% (11) 3.8% (1) 0.083
Previous MI 11.2% (7) 15.4% (4) 0.596
Previous HF 19.4% (12) 38.5% (10) 0.059
Previous PCI 21.0% (13) 46.2% (12) 0.017
Department of Cardiology
Japanese Red Cross Ashikaga
13. Baseline Characteristics
TRA group
% (N=62)
TFA group
% (N=26)
P value
Catheterization indications
ST-elevation MI
Non ST-elevation MI
Unstable angina
Effort angina
Silent ischemia
Others
0.0% (0)
4.8% (3)
8.1% (5)
24.2% (15)
56.5% (35)
6.5% (4)
3.8% (1)
3.8% (1)
23.1% (6)
42.3% (11)
26.9% (7)
0.0% (0)
0.025
Left main trunk stenosis 4.8% (3) 3.8% (1) 0.838
3-vessel disease 17.7% (11) 34.6% (9) 0.085
Preprocedural aspirin 61.3% (38) 88.5% (23) 0.012
Preprocedural thienopyridine 38.7% (24) 73.1% (19) 0.003
Preprocedural warfarin 3.2% (2) 7.7% (2) 0.359
Radial artery diameter (mm) 2.5±0.5 -
Department of Cardiology
Japanese Red Cross Ashikaga
14. Procedural data
TRA group
% (N=62)
TFA group
% (N=26)
P value
Arterial sheath size
4Fr
5Fr
6Fr
7Fr
8Fr
12.9% (8)
1.6% (1)
71.0% (44)
14.5% (9)
0.0% (0)
11.5% (3)
3.8% (1)
34.6% (9)
42.3% (11)
7.7% (2)
0.004
Glidesheath Slender® 83.9% (52) -
PCI
Procedural information
Intra aortic balloon pump
Drug eluting stent
Rotational atherectomy
38.7% (24)
4.1% (1)
87.5% (21)
16.7% (4)
73.1% (19)
0.0% (0)
63.2% (12)
47.4% (9)
0.003
0.368
0.060
0.029
Department of Cardiology
Japanese Red Cross Ashikaga
15. Procedural data
TRA group
% (N=62)
TFA group
% (N=26)
P
value
Patent hemostasis 62.3% (33) -
Radial artery spasm 1.6%(1) -
Severe arterial
tortuosity affecting
catheterization
manipulation
6.5% (4) 3.8% (1) 0.630
Procedural success 98.4% (61) 100% (26) 0.515
Radial artery occlusion
(24 hours/30 days)
6.5% (4)/6.5% (4) -
Department of Cardiology
Japanese Red Cross Ashikaga
Of patients with RAO, 2 patients underwent PCI with 7 Fr Glidesheath
Slender and radial artery diameters were 2.1 mm and 3.3 mm. In the other 2
patients, 6 Fr Glidesheath Slender was inserted for DA and radial artery
diameters were 1.5 mm and 2.2 mm.
16. Patients’ outcomes
TRA group
% (N=62)
TFA group
% (N=26)
P value
Puncture site bleeding 0.0% (0) 3.8% (1) 0.120
Puncture site hematoma 1.6% (1) 0.0% (0) 0.515
Hand ischemia 0.0% (0) -
Pseudo-aneurysm 0.0% (0) 3.8% (1) 0.120
Puncture site related
intervention/surgery
0.0% (0) 3.8% (1) 0.120
Transfusion 0.0% (0) 3.8% (1) 0.120
In-hospital mortality/30-day
mortality
0.0% (0)
/0.0% (0)
0.0% (0)
/0.0% (0)
1): Mehran et. al. Circulation 2011;123:2736-2747.
Puncture site bleeding: hemoglobin drop >3.0 g/dL; need for transfusion;
procedural intervention/surgery 1)
Puncture site hematoma: for TFA:>10cm, for TRA:>2cm
17. Discussion
It is well known that patients on dialysis have high bleeding risk for
PCI 1)
The advantages of TRA are patients’ comfort, decrease bleeding
risk, and improve patients’ outcomes2,3)
The current American Heart Association statement includes a class
III recommendation for the routine use of vascular closure devices
(VCD) to reduce the incidence of vascular complications 4)
And our previous study did not reveal decrease of bleeding events5)
In our study, we did not reveal major endpoints such as puncture
site bleeding due to limited number of patients
Department of Cardiology
Japanese Red Cross Ashikaga
1): Numasawa et. al. PLoS One 2015;10:e0124399.
2): Numasawa et. al. Cardiovasc Interv Ther 2013 28:148
3): Karrowni et al. JACC Cardiovas Interv 2013;6:814-823
4): Patel et. al. Circulation 2011;123:2736-2747.
5): Kuno et. al. AsiaIntervention 2017;3:70-80.
18.
19. Discussion
In our study, the rate of RAO was 6.5%, which was relatively high,
but within the range of previous studies
Patent hemostasis was not effective in our study
Downsizing sheath is considered to be effective according to the
vessel size1)
The long compression time could be one of the reasons behind
RAO in the current study 2)
Ulnar compression to recanalize RAO after band removal could be
effective3)
Department of Cardiology
Japanese Red Cross Ashikaga
1): Mamas et. al. Eurointervention 2014;10:824-832.
2): Pancholy et. al. Catheter Cardiovasc Interv 2012;79:78
3): Bernat et. al. Am J Cardiol 2011;107:1698-701.
20. Future Perspective
Multicenter Randomized Trial, if possible
Distal radial puncture for patients on dialysis should be
tried
Department of Cardiology
Japanese Red Cross Ashikaga
21. Case
Discuss the benefit and the risk of TRA with Patients
Angiography showed LAD proximal 99% with Calcification
PCI performed with 7Fr Glidesheath® (Rotablator and stenting)
No complications such as bleeding and RAO
22. Which do you prefer, TRA or TFA,
for patients on dialysis?
OR
Department of Cardiology
Japanese Red Cross Ashikaga
23. Conclusion
We constructed the system of TRA for
patients on dialysis
Department of Cardiology
Japanese Red Cross Ashikaga
24. Thank you for your attention
Questions?
Toshiki.Kuno@mountsinai.org
kuno-toshiki@hotmail.co.jp
Department of Cardiology
Japanese Red Cross Ashikaga
25. Radial artery occlusion (RAO)
–definition–A pulse-oximeter sensor was placed over the index finger. Radial
and ulnar arteries were compressed; subsequently, the radial
artery was released.
When plethysmographic signal returned, radial artery patency was
confirmed.
This test was performed on the next day after the procedure. If
RAO was suspected, ultrasonography with duplex Doppler was
performed to observe the absence of blood flow, after which RAO
was confirmed.
These patients were examined at 30 days post procedure because
RAO rates at 30 days were reportedly lower than those detected
at 24 hours 1)
1): Pancholy et. al. Catheter Cardiovasc Interv 2008;72:335
Department of Cardiology
Japanese Red Cross Ashikaga
28. Procedural data
TRA group
% (N=62)
TFA group
% (N=26)
P value
Arterial sheath size
4Fr
5Fr
6Fr
7Fr
8Fr
12.9% (8)
1.6% (1)
71.0% (44)
14.5% (9)
0.0% (0)
11.5% (3)
3.8% (1)
34.6% (9)
42.3% (11)
7.7% (2)
0.004
Glidesheath Slender® 83.9% (52) -
Femoral vein sheath insertion 9.7% (6) 34.6% (9) 0.005
PCI
Procedural information
Intra aortic balloon pump
Drug eluting stent
Bare metal stent
Drug coated balloon
Balloon angioplasty
Intravascular ultrasound
Rotational atherectomy
38.7% (24)
4.1% (1)
87.5% (21)
0.0% (0)
12.5% (3)
4.2% (1)
95.8% (23)
16.7% (4)
73.1% (19)
0.0% (0)
63.2% (12)
0.0% (0)
5.3% (1)
36.8% (7)
89.5% (17)
47.4% (9)
0.003
0.368
0.060
0.417
0.865
0.416
0.029
Hemoglobin change after a
procedure (g/dl)
-0.2 [-0.6, 0.5] -0.45 [-1.2, 0.0] 0.043
Closure device - 11.5% (3)
29. Procedural data
TRA group
% (N=62)
TFA group
% (N=26)
P
value
Patent hemostasis 62.3% (33) -
Radial artery spasm 1.6%(1) -
Severe arterial tortuosity
affecting catheterization
manipulation
6.5% (4) 3.8% (1) 0.630
Procedural success 98.4% (61) 100% (26) 0.515
Radial artery occlusion
(24 hours/30 days)
6.5% (4)
/6.5% (4)
-
30. Patients’ outcomes
TRA group
% (N=62)
TFA group
% (N=26)
P value
Puncture site bleeding 0.0% (0) 3.8% (1) 0.120
Puncture site hematoma 1.6% (1) 0.0% (0) 0.515
Peritoneal bleeding - 0.0% (0)
Hand ischemia 0.0% (0) -
Prolonged hospital stay due to re-bleeding 0.0% (0) 3.8% (1) 0.120
Pseudo-aneurysm 0.0% (0) 3.8% (1) 0.120
Puncture site related intervention/surgery 0.0% (0) 3.8% (1) 0.120
Transfusion 0.0% (0) 3.8% (1) 0.120
In-hospital mortality/30-day mortality 0.0% (0)/0.0% (0) 0.0% (0)/0.0% (0)
Other complications
PCI related MI
Post PCI CS
Post PCI HF
Coronary perforation
Coronary dissection
Cardiac tamponade
Cerebral infarction
Intracranial hemorrhage
Gastrointestinal bleeding
Genitourinary bleeding
Other bleedings
3.2% (2)
0.0% (0)
0.0% (0)
0.0% (0)
0.0% (0)
0.0% (0)
1.6% (1)
0.0% (0)
0.0% (0)
0.0% (0)
0.0% (0)
0.0% (0)
3.8% (1)
0.0% (0)
0.0% (0)
0.0% (0)
0.0% (0)
3.8% (1)
0.0% (0)
3.8% (1)
0.0% (0)
0.0% (0)
0.354
0.106
0.481
0.106
31. Study endpoints
In-hospital and 30-day mortality rates
Puncture site related bleeding complications
hemoglobin drop >3.0 g/dL; need for transfusion; procedural
intervention/surgery at the bleeding site to reverse/stop or
correct the bleeding; and acute anemia with a reduction in
hemoglobin > 3.0 g/dL without other obvious sources or
intraprocedural blood loss.
Puncture site hematoma (for TFA:>10cm, for TRA:>2cm)
Safety endpoint in TRA group: Procedural success rate
and RAO
Department of Cardiology
Japanese Red Cross Ashikaga 1): Mehran et. al. Circulation 2011;123:2736-2747.
32. Fluoroscopy time
/Contrast volume
TRA group
(N=62)
TFA group
(N=26)
P value
Fluoroscopy time
(min)
8.0 [3.6, 16.5] 15.5 [9.8, 27.1] 0.003
Contrast volume
(ml)
78.5 [63, 169] 132 [79.9, 132] 0.018
Department of Cardiology
Japanese Red Cross Ashikaga
TRA group PCI
% (N=24)
TFA group PCI
% (N=19)
P value
Fluoroscopy time
(min)
17.4 [14.2, 21.9] 22.5 [14.5, 33.1] 0.35
Contrast volume
(ml)
174 [139, 201] 132 [123, 229] 0.84
33. Missing baseline information
(preprocedural creatinine, sex, and
age) N=1138
eGFR>30ml/min./1.73m2 N=2138
Trans-brachial PCI N=4
Use of percutaneous cardiopulmonary
support N=2
Bidirectional approach for CTO N=8
Consecutive 3596 patients who underwent PCI
from 2009 Sep. to 2017 Dec.
TRI group
N=114 (37.3%)
TFI group
N=192 (62.7%)
34. Department of Cardiology
Japanese Red Cross Ashikaga
Bleeding
complications
and in-hospital death
Bleeding
complications
In-hospital
mortality
IPTW
analysis
OR (95% CI)
0.19
(0.06-0.62)
P=0.006
0.20
(0.04-1.98)
P=0.064
0.12
(0.03-0.59)
P=0.009
IPTW
(PS 0.1-0.9)
OR (95% CI)
0.21
(0.06-0.73)
P=0.014
0.19
(0.03-1.06)
P=0.058
0.16
(0.03-0.92)
P=0.040
35. • For the sensitivity analysis, we excluded patients with
intra-aortic balloon pump (N = 32, 10.4%). In this
population (N = 274, 89.5%), TRI had a tendency to
be a favorable predictor for a lower primary endpoint
(OR: 0.12; 95% CI: 0.01–1.01; P = 0.051).
• RAO among ESRD on dialysis was confirmed at both
24 hours and 30 days after the procedure in 3
patients (9.1%). All 3 patients had no symptoms of
radial artery occlusion; 7-Fr arterial sheaths were
inserted in 2 out of 3 patients and a 6-Fr arterial
sheath was inserted in 1 patient.
Good afternoon, ladies and gentleman. My name is Toshiki Kuno. It is my pleasure to talk at this AimRadial conference.
So today, I would like to present regarding “A Trans-Radial Approach of Cardiac Catheterization for Patients on Dialysis
I am currently in NY, but this study is from Japan.
This article was published this year, in Journal of invasive cardiology.
Fist I would like to present a case as an example. 83 year old, female, BMI 19, Past medical history is DM, HT, ESRD on dialysis.
CC was prologned chest pain, and EKG showed TWI in the precordial lead. On exam, fa both palpable, but very hard.
Conventionally, diagnostic catheter through FA, then, PCI if necessary with large size sheath
However, periprocedural puncture site bleeding risk is high, because of female, low bmi, elderly, and ESRD.
Periprocedural bleeding is the most common complication of PCI, and associated with an increase risk of early and late mortality.1)
Bleeding risk is high for patients on dialysis2) Bleeding avoidance strategies, such as a transradial approach (TRA), should be considered especially for patients with high bleeding risk 3) PCI operators hesitate to choose conventional TRA because of the increased risk of radial artery occlusion (RAO) and general tendency to preserve possible hemodialysis access points for the future
Previous studies demonstrated that 2-year primary and secondary patency rates of arteriovenous fistula (AVF) were 51% and 64% 1)
RAO rates were 1%-10% 2)
Preservation of possible hemodialysis access points for the future is questionable because 5-year survival rate of patients on dialysis is poor (approximately 50%) 3)
We considered that TRA would be beneficial for patients on dialysis despite the risk of RAO, because it can reduce bleeding complications and early mortality rates.
The aims of this study were to construct a TRA system and to clarify the feasibility of TRA for patients on dialysis.
This study was an ongoing, prospective, cohort study designed to collect clinical background and outcomes related to cardiac catheterization in patients on dialysis
Data of 88 consecutive patients on dialysis who underwent cardiac catheterization (diagnostic angiog- raphy [DA] or PCI) between December 2015 and December 2016 were analyzed
The institutional review board and nephrologist approved the study design
Informed consent was obtained for all patients
It mentioned the benefit of TRA, and possible risk of RAO, which will be the burden of future AVF creation.
Radial access was limited in the opposite side of AVF.
P2Y12 inhibitor was restricted to clopidogr
Patients who did not agree the consent
Patients with weak or absent radial artery pulse
Patients on peritoneal dialysis with weak or absent radial artery pulse on one side in order to preserve the other side for future access
Recent AVF failure (within 6 months)
TFA preferred by operator (eg, for 8 Fr TF PCI, which is required for large size rota bar
Nephrologist decision against TRA
This is the patient flow chart.
Glidesheath Slender® (Terumo) which shows lower rates of RAO is used for more than 6Fr1)
Radial artery diameter is measured
Bleedsafe® (Medikit) is used to hemostasis (DA 5 hours, PCI 7 hours)
Patent hemostasis2) which could decrease RAO, was attempted
Bleedsafe® was inflated for sheath removal. After removal, ulnar artery was pressed
Pulse oximetor was placed to the index finger. Plethysmographic signal returned, radial artery patency was confirmed.
If not, deflate 1cc each, with caution
If bleeding occurs, inflate again.
This is the table of baseline characteristics. Patients with TRA are older. Proportions of HT and DM are higher compared to general PCI registry
Proportions of peritoneal dialysis are higher in TRA group. In contrast, Rates of previous PCI is higher in TFA group
This table shows catheter indication, angiographic data, preprocedural medications, and radial artery diameter
Higher rates of ACS is shown in TFA group. Preprocedural medications are significantly different in both groups.
Mean RAO was 2.5mm
This table shows procedural data.
Arterial sheath sizes and PCI rates were signi cantly different be- tween the groups. Pci was performed in 49%, 43 patients out of 88.
Rotablator was performed in 30% among all patients who underwent PCI, and 47% in TFA group.
Patent hemostasis was achieved in 62.3% of patients. One radial artery spasm occurred in TRA group, which required crossover to TFA. Procedure success rates in TRA group was 98.4%
RAO occurred in 4 patients (6.5%). Of these, 2 patients underwent PCI with 7 Fr Glidesheath Slender and radial artery diameters were 2.1 mm and 3.3 mm. In the other 2 patients, 6 Fr Glidesheath Slender was inserted for DA and radial artery diameters were 1.5 mm and 2.2 mm. Patent hemostasis was achieved in 3 of these patients. None of the 4 patients had symptoms of RAO.
In-hospital and 30-day mortality rates were both 0.0%. Puncture-site bleeding occurred in 1 patient (3.8%) from the TFA group and coil embolization was required for pseudoaneurysm closure. On the other hand, no puncture-site bleeding occurred in the TRA group (P=.12). In the TRA group, 1 patient (1.6%) had puncture-site hematoma, but no surgical procedure or transfusion was necessary. No other puncture-site related complications (such as AVF, neurological injury, collagen-plug embolization, or puncture-site infection) were observed in either group.
It is well known that patients on dialysis have high bleeding risk for PCI 1)
The advantages of TRA are patients’ comfort, decrease bleeding risk, and improve patients’ outcomes2,3)
The current American Heart Association statement includes a class III recommendation for the routine use of vascular closure devices to reduce the incidence of vascular complications 4)
And our previous study did not reveal decrease of bleeding events5)
In our study, we did not reveal major endpoints such as puncture site bleeding due to limited number of patients
This is my article published in AsiaIntervention, VCD means vascular closure device. Bleeding events are similar after PS matching.
In our study, the rate of RAO was 6.5%, which was relatively high, but within the range of previous studies. Arterial intimal thickening in patients on dialysis may be suspected because RAO can be caused by arterial tears. There is a paucity of data in terms of RAO in patients on dialysis. Thus, showing the rate of RAO in these patients has great value.
Patent hemostasis was not effective because 3 out of 4 patients with RAO had patent hemostasis. Downsizing sheath size is considered to be effective according to the vessel size But we did not perform PCI with 5 Fr sheaths. Because patients on dialysis have more complicated lesions, at least 6 Fr sheaths were usually used for PCI. Sheathless guiding with 6.5 Fr devices. And The higher rate of rotational atherectomy use (30.2%) in patients on dialysis compared to other populations required larger sheath sizes
The long compression time could be one of the reasons behind RAO in the current study. However we could not change conventional compression time due to the lack of experience with short-term compression and concern over compartment syndrome due to the high bleeding risk profile of these patients.
Ulnar compression to recanalize RAO after band removal could be effective, we should have tried that method
Multiventer RCT is necessary to prove the efficacy of TRA
I have never distal puncture, but if it is attempted to patients on dialysis, this could be a good study.
Discuss the benefit and the risk of TRA with Patients
Angiography showed LAD #6 99% with Calcification
PCI performed with 7Fr Glidesheath® (Rotablator and stenting)
No complications such as bleeding and RAO
Which do you prefer, TRA or TFA,
for patients on dialysis?
透析患者さんへのTRAの可能性につき検証した。
本研究はN数の問題もあり、Puncture site bleeding 等のEndpointに有意な差は生じなかった。
今回のRAO率は6.5%と今までの研究結果とそこまで変わらない。
RAOの問題はあるが、今回の研究をもとに透析患者の心臓カテーテル検査を施行する上で選択肢の一つとしてのTRAを広めていきたい。
A pulse-oximeter sensor was placed over the index finger. Radial and ulnar arteries were compressed; subsequently, the radial artery was released.
When plethysmographic signal returned, radial artery patency was confirmed.
This test was performed on the next day after the procedure. If RAO was suspected, ultrasonography with duplex Doppler was performed to observe the absence of blood flow, after which RAO was confirmed.
These patients were examined at 30 days post procedure because RAO rates at 30 days were reportedly lower than those detected at 24 hours 1)