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RADIAL OR BUST The only choice for vascular access

RADIAL OR BUST The only choice for vascular access. Jim Nolan University Hospital of North Staffordshire United Kingdom. CONFLICTS OF INTEREST. ARTERIAL ACCESS – WHY AM I INTERESTED (Heart 1995, Am Heart J 1997). %. Major Vasacular Complications. %. %. BRACHIAL CUT DOWN COMPLICATIONS.

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RADIAL OR BUST The only choice for vascular access

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  1. RADIAL OR BUSTThe only choice for vascular access Jim Nolan University Hospital of North Staffordshire United Kingdom

  2. CONFLICTS OF INTEREST

  3. ARTERIAL ACCESS – WHY AM I INTERESTED(Heart 1995, Am Heart J 1997) % Major Vasacular Complications % %

  4. BRACHIAL CUT DOWN COMPLICATIONS

  5. NEURO-ANATOMY OF THE FEMORAL TRIANGLE

  6. FEMORAL ACCESS PRACTICE Two weeks at UHNS

  7. FEMORAL ACCESS COMPLICATIONS

  8. ACTIVE RETROPERITONEAL BLEED

  9. FEMORAL VASCULAR COMPLICATIONS IN CONTEMPORARY UK PRACTICE(Berry et-al, AJC 2004, n = 311)

  10. MAJOR VASCULAR COMPLICATIONS • 1 RPH, 3 Pseudo-aneurysms • 3 GA emergency surgery • 13 units of blood • Total of 61 extra days in hospital

  11. ANTITHROMBOTIC THERAPY AND FEMORAL COMPLICATIONS 17.5 % 5.9 2.2 1.1 DIAGNOSTIC POPULATION Berry 2004 ANGINA PCI POPULATION Moutralescot 2005 MI/REO-PRO PCI POPULATION Otavio 2004 RESCUE PCI Dauermau 2000

  12. VACD – DEVICE FAILURE RATE(Sesana et-al, JIC 2000, n = 827) FAILURE RATE (%)

  13. VCD META ANALYSIS – RANDOMISED + OBSERVATIONAL (Nikolsky et-al, JACC 2004, n = 37,066)

  14. DOES IT ALL MATTER?COMPLICATIONS OF PCI IN CONTEMPORARY PRACTICE(Heart 2005, n = 3071) %

  15. DOES IT ALL MATTER?MEDICO-LEGAL CASES ARISING FROM CARDIAC CATHETERISATION PROCEDURES(1992-2002 - MDU)

  16. NEURO-ANATOMYOF THE WRIST

  17. VASCULAR COMPLICATIONS(uhns transradial programme)Heart 2003 RADIAL FEMORAL (n=1000) (n=727) TRANSFUSION 0 (0%) 4 (0.6%) VASCULAR INTERVENTION 1 (0.1%) 6 (0.8%) INFECTION 2 (0.2%) 2 (0.3%) 3 (0.3%) 12 (1.7%)

  18. number 279 152 600 112 142 200 210 420 200 371 149 RADIAL VS FEMORAL ACCESS –RCT meta analysis(Agostoni et-al JACC 2004) Grinfield Mann ACCESS BRAFE Mann Cooper CARAFE Gorge Moriyama OCTOPLUS TEMPURA Procedural success 1999-2003 Access site complications Procedural success MACE

  19. ARE RADIAL CASES TOO HARD TO DO (Rao et al, JACCI 2008)

  20. DOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)

  21. DOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)

  22. DOES EVERYBODY BENEFIT FROM RADIAL ACCESS(Rao et-al JACCI 2008)

  23. IS PCI RELATED BLEEDING A BAD THING(MORTAL study, Heart 2008, n=38,872)

  24. DOES PREVENTION OF ACCESS SITE BLEEDING IMPROVE OUTCOME(MORTAL study, Heart 2008, n=38,872)

  25. VASCULAR COMPLICATIONS – ECONOMIC IMPACT(Nowamagbe et-al, JACC 1995, n = 1,012 CAVEAT-1) LENGTH OF STAY HOSPITAL COSTS COST ($) LOS (DAYS)

  26. TRANSRADIAL APPROACHPATIENT PREFERENCE

  27. TRANSRADIAL APPROACHNURSING PREFERENCE(Amoroso, EJCVN, 2005, n = 260) Cath lab Ward Radial Femoral Femoral Radial

  28. RADIATION EXPOSURE IS IMPORTANTSkin injury due to cardiac intervention

  29. RADIATION EXPOSURE IS IMPORTANTAccessory pathway ablation 3 weeks 5 months 6.5 months

  30. OPERATORS ALSO GET RADIATION INDUCED SKIN INJURY

  31. UHNS RADIATION EXPOSURE STUDYMean fluoroscopy time and patient and operator radiation doses(Heart 2007) P=NS P=NS P<0.05

  32. UHNS RADIATION EXPOSURE STUDYMean procedure duration (min) and time to ambulation (min)(Heart 2007) P<0.0001 P<0.005

  33. PCI OPERATIVE RADIATION EXPOSURE 2003 – 2004TLD BADGE READINGS - UHNS

  34. Mont Blanc Summit Ridge September 2007

  35. TRANSRADIAL APPROACHTHE LEARNING CURVE • Lefevre TCT 2003 • Puncture failure, spasm, different guide manipulation

  36. “…the radial approach has become increasingly popular with the potential advantage of a greater opportunity for same day discharge” “…shorter bed rest and hospital stay when the radial approach is used” “…the use of the radial approach is likely to increase”

  37. RADIAL Vs FEMORAL PCI(BCIS DATABASE)

  38. THE RADIAL ARTERY • Reduces access site bleeding • Impact on mortality • Efficient • Preferred by patients • Endorsed by BCIS • Taken up by increasing numbers of UK interventionists THE ONLY CHOICE FOR VASCULAR ACCESS

  39. THANKS TO MARK GUNNING

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