Incidence, predictors, and clinical impact of bleeding after transradial coronary stenting and maximal antiplatelet therapy

Radial artery access technique evaluation trial: randomized comparison of Seldinger versus modified Seldinger technique for arterial access for transradial catheterization

BACKGROUND

Radial artery access for transradial catheterization is obtained using either Seldinger or modified Seldinger technique. There is no comparative evaluation of the safety and benefits of these two techniques.

METHODS

Four hundred twelve patients undergoing transradial catheterization were randomized to group I (n = 210) Seldinger technique, and group II (n = 202) modified Seldinger technique. Demographic and procedural data were collected at the time of the procedure. Data on hematoma and radial artery occlusion (RAO) were recorded at 24 hr and 30 days after the procedure.

RESULTS

Age, gender, weight, height, and history of diabetes mellitus were comparable between groups I and II. Access time (78.3 ± 37.7 sec vs. 134.2 ± 87.5 sec, P < 0.001), procedure time (17.1 ± 6.4 min vs. 19.3 ± 7.1 min, P < 0.01), number of attempts to get access (1.7 ± 0.8 vs. 2.2 ± 0.8, P < 0.001), were significantly different favoring group I. Access was obtained at first attempt in 53% of patients in group I compared with 16% in group II (P < 0.001). Change in technique (crossover) was required in 10.8% of group II patients, compared with no crossover in group I (P < 0.0001). Incidence of hematoma (0.5% vs. 1.5%, P > 0.2) and 30-day RAO (4.3% vs. 3.9 %, P > 0.5) was similar between groups I and II.

CONCLUSIONS

Seldinger technique is a faster and more predictable radial artery access technique compared with modified Seldinger technique with no increase in bleeding or RAO.

Managing coronary artery disease in the cancer patient

The cancer patient with coronary disease presents particular challenges that directly impact on the management of coronary disease, both stable and acute. The frequent need for surgery in the cancer patient is an important consideration in avoiding a coronary artery stent or any percutaneous coronary intervention for management of chronic stable angina, which will delay surgery or pose of risk of stent thrombosis during surgery. Cancer surgery is considered low or intermediate cardiac risk so revascularization before surgery is needed only in exceptional circumstances. Medical treatment in most patients or coronary artery bypass graft in high risk situations may be preferable if the cancer is being actively treated. The likelihood of thrombocytopenia, either primary from bone marrow disease, or secondarily during chemotherapy causes concern about the need for continuous use of platelet suppressing agents, aspirin for all patients, or double antiplatelet therapy in all patients after receiving a coronary artery stent. Drug-eluting stents pose special problems and should be avoided. Even bare metal stents may have a higher long-term risk of stent thrombosis in the cancer patient. The increase in propensity for venous clotting, either as a result of the cancer itself, or especially with selected chemotherapeutic agents may be an issue after stenting and certainly early after coronary bypass surgery. Aggressive medical treatment to reduce risk factors, especially with statins is essential to stabilize the underlying coronary disease.

Radiation exposure during cardiac catheterization: Implications for the transradial approach

Coronary angiography and intervention became an integral part of the modern cardiology. These invasive procedures beside their firmly established benefits also expose the patient to a hazard for access site complication, contrast material and radiation exposure. Transradial access significantly reduces the risk associated with the arterial puncture; however its effect regarding the radiation exposure is debated. Our aim was to review the aspects of transradial coronary intervention in the context of the radiation exposure. This review focuses on key aspects of feasibility and safety related to the access site choice and the learning curve.

Incidence, range, and clinical effect of hemoglobin changes within 24 hours after transradial coronary stenting

Anemia and major bleeding are independent predictors of outcomes after acute coronary syndromes and percutaneous coronary intervention (PCI). Although the transradial approach reduces the incidence of bleeding, the hemoglobin changes after transradial PCI have not been defined. We serially assessed the hemoglobin values before and after transradial PCI and evaluated the effect of hemoglobin changes on outcomes. In the EArly Discharge After Transradial Stenting of CoronarY Arteries (EASY) trial, 1,348 patients underwent transradial PCI. All patients received aspirin, clopidogrel, and a bolus of abciximab before PCI. The hemoglobin values were assessed immediately before and 4 to 6 hours and 12 to 24 hours after PCI. The major adverse cardiac events (death, myocardial infarction, and target vessel revascularization) were assessed < or =3 years after PCI. According to the World Health Organization classification, 206 patients (15%) had anemia before PCI and 410 (30%) developed anemia within 24 hours after PCI. A mean hemoglobin decrease of 0.6 +/- 1.0 g/dl occurred within 24 hours after PCI. At 30 days, the major adverse cardiac events were significantly increased when the hemoglobin decrease within 24 hours after PCI was >3 g/dl (p = 0.0002). Patients with anemia within 24 hours after PCI had significantly more major adverse cardiac events at 30 days, 6 months, 1 year, and 3 years than patients without anemia (log-rank p = 0.0044). After adjustment for differences in the baseline characteristics, anemia within 24 hours after PCI remained an independent predictor of major averse cardiac events at 3 years (hazard ratio 1.30, 95% confidence interval 1.01 to 1.67, p = 0.045). In conclusion, within 24 hours after transradial PCI with maximal antiplatelet therapy, only a mild hemoglobin decrease was observed. The choice of a hemoglobin decrease >3 g/dl after PCI as a cutoff value for current definitions of major bleeding in modern PCI trials appears reasonable. Measures to prevent anemia and blood loss during PCI remain to be further studied.

Transradial percutaneous coronary intervention in acute myocardial infarction

Although transradial coronary intervention is widely applied for percutaneous procedures, its safety in the setting of ST-segment elevation myocardial infarction (STEMI) is controversial. The benefit of transradial approach in terms of reducing access site complications is well documented. However, higher rate of procedural failure and longer procedural times reported by some authors raise concerns regarding its applicability in STEMI. Our aim was to review the safety and efficacy of transradial coronary intervention versus transfemoral intervention in acute ST-elevation myocardial infarction. This review focuses on key aspects of safety and efficacy: adverse ischemic and bleeding events, reperfusion times and radiation exposure.

[Why I don't give up the femoral approach!]

Since its introduction in 1989, the safety of transradial approach compared to the femoral approach is mainly due to reducing entry site complications, allowing early ambulation, but at the price of a higher rate of procedural failure, arterial occlusion and radiation for operators and patients. Nevertheless, these advantages can be minimized with a modern femoral approach requiring a 4-French catheter for diagnostic angiography and a low dose heparin, new antithrombotic drugs and a reasonable use of glycoprotein (GB)IIb-IIIa for angioplasty. The radial approach is the best way to go in hemorrhagic high-risk patients and the femoral approach is safer in complex procedures. The operator has to hold the two accesses and to know when to switch to another approach to minimize complications, procedure time, radiation and contrast use.

Impact of final activated clotting time after transradial coronary stenting with maximal antiplatelet therapy

The optimal value of activated clotting time (ACT) during percutaneous coronary intervention (PCI) with unfractionated heparin remains controversial. No data are available on the relation between the ACT at the end of the procedure (final ACT) and the clinical outcomes after transradial PCI and maximal antiplatelet therapy. By dividing the final ACT values in tertiles, we analyzed the ischemic and bleeding events in 1,234 consecutive patients with acute coronary syndrome recruited in the EArly Discharge after Transradial Stenting of CoronarY Arteries (EASY) trial. All patients were pretreated with aspirin and clopidogrel. After radial sheath insertion, patients received 70 IU/kg unfractionated heparin. Abciximab was given before the first balloon inflation. The median final ACT value was 312 seconds (interquartile range 279 to 344). At 30 days, the rate of major adverse cardiac events, including death, myocardial infarction, and target vessel revascularization, from the lower to upper tertiles was 4%, 4%, and 2%, respectively (p = 0.16), and the rate of major bleeding was 2%, 1% and 0.7%, respectively (p = 0.20). During the 3 years of follow-up, the incidence of myocardial infarction was less in the tertile with the greatest ACT value (>330 seconds) than in the other 2 tertiles (4%, 8%, and 8%, respectively; p = 0.038). Troponin-T and creatine kinase-MB release after PCI indicated that the effect was related to periprocedural myonecrosis protection. After adjustment for baseline and procedural differences, a final ACT of >330 seconds remained associated with a 47% relative reduction in myocardial infarction (odds ratio 0.53, 95% confidence interval 0.29 to 0.93, p = 0.024). Death and target vessel revascularization remained similar in all tertiles for < or =3 years. In conclusion, with the combination of aspirin, clopidogrel pretreatment, and abciximab, a final ACT value of >330 seconds appears protective against peri-PCI myonecrosis, and this benefit was maintained for < or =3 years. With a transradial approach and maximal antiplatelet therapy, greater ACT values did not correlate with an increased risk of bleeding.

Comparison of outcomes in patients > or =70 years versus <70 years after transradial coronary stenting with maximal antiplatelet therapy for acute coronary syndrome

Elderly patients are at a higher risk for complications after percutaneous coronary intervention (PCI) when performed through the femoral approach. The impact of age on complications in patients treated using the transradial approach is not known. The bleeding and ischemic outcomes at 30 days, 6 months, 1 year, and 3 years after transradial PCI and maximal antiplatelet therapy were compared in 1,348 patients aged <70 or > or =70 years with acute coronary syndromes. All patients received aspirin and clopidogrel before catheterization, followed by abciximab at the time of PCI. Patients aged > or =70 years (n = 259 [19%]) had more hypertension, dyslipidemia, family histories, and previous coronary artery bypass grafting. Older patients had lower baseline hemoglobin, platelet, and creatinine clearance values, and they also more often had 2- or 3-vessel syndrome (p = 0.001), as well as longer procedure durations (p = 0.024). At 30 days, the rates of major adverse cardiac events and major bleeding were similar in older and younger patients. Only the incidence of gastrointestinal bleeding (p = 0.021) and mild to moderate access-site hematoma were higher in older patients (p = 0.036). The rates of major adverse cardiac events were also similar in the 2 age groups at 6 months (6% vs 9%, p = 0.08), 1 year (10% vs 13%, p = 0.22), and 3 years (19% vs 20%, p = 0.73), but mortality was significantly higher at 3 years in patients aged > or =70 years (p = 0.0031). In conclusion, age per se is not a predictor of major adverse cardiac events or major bleeding after transradial PCI with maximal antiplatelet therapy. However, older patients remain more prone to gastrointestinal bleeding and local hematoma compared to younger patients, and preventive measures need to be further investigated.