PCI & AimRadial 2018 | LEFT MAIN PCILessons from the BCIS registry - Jim Nolan

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LEFT MAIN PCI
Lessons from the BCIS registry
Jim Nolan
Professor of Cardiology
University Hospital of North
Midlands,UK

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CONFLICTS OF INTEREST

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TRA CAN NOT BE USED FOR LM-PCI
(according to TFA operators)
• Inadequate GC support
• Limitation on use of large diameter GC
• Limitation on availability of adjunctive
technology
• Can not be used in complex/acutely ill
patients
• Compromised outcomes
• Not beneficial to patients

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MA 8 observational studies,n=2858
PROCEDURAL SUCCESS RATE

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MAJOR BLEEDING,ACCESS COMPLICATIONS,MI

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IN HOSPITAL MORTALITY

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CONTRAST VOLUME,SCREENING TIME,PROCEDURE TIME

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BRITISH CARDIOVASCULAR
INTERVENTION SOCIETY
•Collects data on all PCI performed in UK via
central electronic database
•113 patient ,procedural and outcome variables
•Robust mortality data using NHS number
•Linked to NHS central register
•Legal requirement for every death in UK to be
recorded
•Examine PCI outcomes in 100,000 cases PA

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JACCi 2014
• 568 patients with STEMI due to LM
occlusion
• 57.9% shocked
• 23.3% ventilated
• 33.9% rate of TRA

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JACCI 2014 – n=5,065

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STEMI OR 0.37/0.44 NSTEMI OR 0.66/0.68
30 DAY MORTALITY
TRAvTFA

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KEELE CARDIOVASCULAR RESEARCH GROUP
JACCi 2019 ( in press)
RADIAL ARTERY ACCESS AND OUTCOMES
FOR LEFT MAIN STEM PCI: AN ANALYSIS
OF 19,482 CASES FROM THE BRITISH
CARDIOVASCULAR INTERVENTION
SOCIETY NATIONAL DATABASE

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STUDY AIM
• Build on existing BCIS LM analysis with
specific reference to access site issues
• Study temporal changes in LM access site
practice and its relationship to outcomes
in LM-PCI cases 2007-2014
• Multivariate logistic regression, propensity
scoring and Cox proportional hazard
analysis

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LENGTH OF STAY/SDD
RATES (P<0.001)
TRA
LOS (DAYS) 2.6+/-9
SDD(%) 43.0%
TFA
3.6+/-9
26.6%

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WHO STILL GETS LM PCI VIA TFA (P<0.001)
• Renal disease 2.29
• Restenosis 1.69
• CTO case 1.66
• Female gender 1.56
• Valve disease 1.47
• Hypertension 1.31
• Diabetes 1.25
• MV disease 1.14
• Increasing age 1.01
• IVUS 0.57
• OAC 0.42

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o In contemporary practice in UK, the radial artery is the
predominant access site for LMS-PCI.
o Radial access use was associated with reduced vascular
complications, major bleeding and transfusion, lower in-
hospital MACE and reduced length of stay
oConsistent with pre-existing literature on access site practice
and LM-PCI
CONCLUSIONS
o LMS-PCI cases undertaken via the radial artery were
increasing complex through the study period

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EVIDENCE BASED
MEDICINE
TRA SHOULD BE THE ACCESS
SITE OF CHOICE FOR MOST
LM-PCI

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Variable
OR for femoral
access vs. radial
access
[95% CI]
p-
value
Acute kidney injury 3.33 [1.70-6.51] <0.001
Age per year 1.03 [1.02:1.04] <0.001
Chronic renal failure 2.69 [2.10:3.44] <0.001
ACS presentation 2.05 [1.62-2.60] <0.001
Valve disease 1.74 [1.27-2.38] <0.001
No. baseline diseased vessels 1.55 [0.96-2.49] 0.073
Q wave on ECG 1.22 [0.96-1.55] 0.098
Femoral access 1.17 [0.97-1.40] 0.096
Operator LMS-PCI volume/case 0.99 [0.99-1.01) 0.028
Independent predictors of 12-month mortality following unprotected
left main stem PCI performed in England and Wales in 2012-2014

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IN HOSPITAL MORTALITY,

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o Although access site and outcomes are well defined for unselected PCI
procedures and certain sub-groups, there are few data on access site for patients
undergoing left main stem percutaneous coronary intervention (LMS-PCI)
o The aim of the present study was to address these questions by using the BCIS
National PCI Audit data for 2007 to 2014 to examine access site for LMS-PCI
o Studied temporal changes in national arterial access site practice in patients
undergoing LMS-PCI, defined in contemporary study years the predictors of
access site, and reported procedural and clinical outcomes by access site
Background

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o Data were analysed from 19,482 LMS-PCI procedures performed in England
and Wales between 2007 and 2014
o Study definitions were used as in the BCIS-NICOR database
o To investigate trends over time linear regression modelling and testing for
the slope of the regression line was performed
o Multivariate logistic regression was used to identify predictors of access site
choice and its association with outcomes. To adjust for missing data we
used multiple imputations with chained equations
Methods I

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o Individual logistic regressions were done on the imputed data set for each of
the MACE events according to the access site to quantify the independent
association between access site and outcomes
o To adjust for baseline characteristics that might influence outcomes and thus
to attempt to quantify the independent effects of access site on outcomes, we
performed a propensity score analysis with 1:1 propensity matching
o Finally, we performed a further analysis of the multi-variate predictors of 12-
month mortality using multiple imputation to generate 10 complete datasets
and running a Cox-proportional hazard model on each
Methods II