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Schernthaner C, Hammerer M, Harb S, Heigert M, Hoellinger K, Lassnig E, Maurer E, Schuler J, Siostrzonek P, Ulmer H, Winter A, Altenberger J. Radial versus femoral access site for percutaneous coronary intervention in patients suffering acute myocardial infarction. Wien Klin Wochenschr 2017; 130:182-189. [DOI: 10.1007/s00508-017-1260-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/18/2017] [Indexed: 11/24/2022]
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Patient Versus Physician Variation in Use of Transradial Percutaneous Coronary Intervention. Am J Cardiol 2017; 119:1937-1941. [PMID: 28495430 DOI: 10.1016/j.amjcard.2017.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 03/09/2017] [Accepted: 03/09/2017] [Indexed: 11/23/2022]
Abstract
The prevalence of radial access for transradial catheterization remains low in the United States, occurring in only 28% of cases in the National Cardiovascular Data Registry (NCDR) CathPCI. It is unknown whether the low adoption rate has been influenced by patient characteristics or is more operator dependent. In a 10-center study, we compared clinical and demographic characteristics among 323 radial and 1,506 femoral access percutaneous coronary intervention (PCIs) performed by 65 interventionists capable of radial PCI. We created a hierarchical logistic regression model to identify operator and patient characteristics associated with radial PCI and the median rate ratio to quantify the variation across operators. A subset was interviewed to assess health literacy and preferences in shared medical decision making. Radial access was used in 17.7% of patients. Patient factors associated with lower rate of radial PCI were previous PCI (33.4% vs 41.4%, p = 0.008), history of coronary artery bypass graft (8.4% vs 23.0%, p <0.001), and chronic total occlusion PCI (10.2% vs 17.9%, p <0.001). Operator characteristics associated with lower rate of radial PCI are being older, being longer in practice, lower number of publications, and Southern practice location. The range of radial use across operators was 1% to 99% and the median rate ratio was 1.97. Patients with radial access had lower health literacy, as assessed by the Rapid Estimate of Adult Literacy in Medicine Revised (REALM) score (6.6 ± 2.6 vs 7.1 ± 2.0, p = 0.03) but did not differ in their preferences for shared decision making. In conclusion, our study demonstrates a high degree of variability of radial access for PCI among different operators, with few differences in patient characteristics, suggesting that improvement efforts should focus on operators.
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Shavadia J, Welsh R, Gershlick A, Zheng Y, Huber K, Halvorsen S, Steg PG, Van de Werf F, Armstrong PW. Relationship Between Arterial Access and Outcomes in ST-Elevation Myocardial Infarction With a Pharmacoinvasive Versus Primary Percutaneous Coronary Intervention Strategy: Insights From the STrategic Reperfusion Early After Myocardial Infarction (STREAM) Study. J Am Heart Assoc 2016; 5:JAHA.116.003559. [PMID: 28525886 PMCID: PMC4937283 DOI: 10.1161/jaha.116.003559] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The effectiveness of radial access (RA) in ST‐elevation myocardial infarction (STEMI) has been predominantly established in primary percutaneous coronary intervention (pPCI) with limited exploration of this issue in the early postfibrinolytic patient. The purpose of this study was to compare the effectiveness and safety of RA versus femoral (FA) access in STEMI undergoing either a pharmacoinvasive (PI) strategy or pPCI. Methods and Results Within STrategic Reperfusion Early After Myocardial Infarction (STREAM), we evaluated the relationship between arterial access site and primary outcome (30‐day composite of death, shock, congestive heart failure, or reinfarction) and major bleeding according to the treatment strategy received. A total of 1820 STEMI patients were included: 895 PI (49.2%; rescue PCI [n=379; 42.3%], scheduled PCI [n=516; 57.7%]) and 925 pPCI (50.8%). Irrespective of treatment strategy, there was comparable utilization of either access site (FA: PI 53.4% and pPCI 57.6%). FA STEMI patients were younger, had lower presenting systolic blood pressure, lesser Thrombolysis In Myocardial Infarction risk, and more ∑ST‐elevation at baseline. The primary composite endpoint occurred in 8.9% RA versus 15.7% FA patients (P<0.001). On multivariable analysis, this benefit on the primary composite outcome favoring RA persisted (adjusted odds ratio [OR], 0.59; 95% CI, 0.44–0.78; P<0.001) and was evident in both pPCI (adjusted OR, 0.63; 95% CI, 0.43–0.92) and PI cohorts (adjusted OR, 0.57 95% CI, 0.37–0.86; P interaction=0.730). There was no difference in nonintracranial major bleeding with either access group (RA vs FA, 5.2% vs 6.0%; P=0.489). Conclusions Regardless of the application of a PI or pPCI strategy, RA was associated with improved clinical outcomes, supporting current STEMI evidence in favor of RA in PCI. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00623623.
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Affiliation(s)
- Jay Shavadia
- Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Welsh
- Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada
| | - Anthony Gershlick
- Department of Academic Cardiology, University Hospitals of Leicester, United Kingdom
| | - Yinggan Zheng
- Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada
| | - Kurt Huber
- Department of Cardiology, University of Vienna, Austria
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital HF Ullevål, Oslo, Norway
| | - Phillipe G Steg
- Sorbonne Paris-Cité, INSERM Unité 1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université Paris-Diderot, Paris, France
| | - Frans Van de Werf
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Paul W Armstrong
- Canadian VIGOUR Center, University of Alberta, Edmonton, Alberta, Canada
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Barr P, Smyth D, Harding SA, El-Jack S, Williams MJA, Devlin G, Stewart J, Flynn C, Lee M, Kerr AJ. Variation in Arterial Access for Invasive Coronary Procedures in New Zealand: A National Analysis (ANZACS-QI 5). Heart Lung Circ 2015; 25:451-8. [PMID: 26672436 DOI: 10.1016/j.hlc.2015.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/18/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Radial arterial access (RA) and femoral arterial access (FA) rates for invasive coronary angiography (ICA) vary widely internationally. The European Society of Cardiology (ESC) suggests default RA is feasible. We aim to investigate the variation in RA rates across all New Zealand public hospitals. METHODS AND RESULTS Patient characteristics, procedural details, and inpatient outcome data were collected in the All New Zealand Acute Coronary Syndrome - Quality Improvement (ANZACS-QI) registry on consecutive patients undergoing ICA over five months. Of the 5894 ICAs 81% were via RA. Hospitals averaged 25 - 176 procedures/month (46.5% - 96.4% via RA). Operators averaged 17 procedures/month. Those performing more than 20 ICAs/month had RA rates between 61% - 99%. Of the 75 operators, 69% met the ESC recommendation. After multivariable adjustment higher operator (RR 1.12, CI 1.09 - 1.30) and hospital (RR 1.21, CI 1.15 - 1.28) volume were independent predictors of RA. Those with prior CABG (RR 0.51, CI 0.45 - 0.57), STEMI <12h (RR 0.91, CI 0.87 - 0.96), and female sex (RR 0.96, CI 0.94 - 0.99) were less likely to receive RA. CONCLUSIONS New Zealand has a high RA rate for ICAs. Rates vary substantially between both operators and centres. Radial arterial was highest amongst the highest volume operators and centres.
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Affiliation(s)
- P Barr
- Cardiology Department, Middlemore Hospital, Auckland, NZ.
| | - D Smyth
- Cardiology Department, Christchurch Hospital, Christchurch, NZ
| | - S A Harding
- School of Biological Science, Victoria University, Wellington, NZ
| | - S El-Jack
- Cardiology Department, North Shore Hospital, Auckland, NZ
| | - M J A Williams
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, NZ
| | - G Devlin
- Medicine, University of Auckland, Auckland, NZ
| | - J Stewart
- Cardiology Department, Auckland City Hospital, Auckland, NZ
| | - C Flynn
- Counties Manukau District Health Board, Auckland, New Zealand
| | - M Lee
- Counties Manukau District Health Board, Auckland, New Zealand
| | - A J Kerr
- Medicine, University of Auckland, Auckland, NZ
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Kadakia MB, Rao SV, McCoy L, Choudhuri PS, Sherwood MW, Lilly S, Kobayashi T, Kolansky DM, Wilensky RL, Yeh RW, Giri J. Transradial Versus Transfemoral Access in Patients Undergoing Rescue Percutaneous Coronary Intervention After Fibrinolytic Therapy. JACC Cardiovasc Interv 2015; 8:1868-76. [DOI: 10.1016/j.jcin.2015.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 07/08/2015] [Accepted: 07/30/2015] [Indexed: 11/25/2022]
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Wimmer NJ, Cohen DJ, Wasfy JH, Rathore SS, Mauri L, Yeh RW. Delay in reperfusion with transradial percutaneous coronary intervention for ST-elevation myocardial infarction: Might some delays be acceptable? Am Heart J 2014; 168:103-9. [PMID: 24952866 DOI: 10.1016/j.ahj.2014.02.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Randomized clinical trials (RCTs) suggest benefits for the transradial approach to percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). However, transradial PCI may delay reperfusion, leading to its avoidance. We sought to quantify the delay in reperfusion from transradial PCI ("transradial delay") that would need to be introduced to offset the potential mortality benefit of transradial PCI, compared with transfemoral, observed in RCTs. METHODS We developed a decision-analytic model to compare transfemoral and transradial PCI in STEMI. Thirty-day mortality rates were estimated by pooling STEMI patients from 2 RCTs comparing transfemoral and transradial PCI. We projected the impact of transradial delay using estimates of the increase in mortality associated with door-to-balloon time delays. Sensitivity analyses were performed to understand the impact of uncertainty in assumptions. RESULTS In the base case, a transradial delay of 83.0 minutes was needed to offset the mortality benefit of transradial PCI. When the mortality benefit of transradial PCI was one-quarter that observed in RCTs, the delay associated with equivalent mortality was 20.9 minutes. In probabilistic sensitivity analyses, transradial PCI was preferred over transfemoral PCI in 97.5% of simulations when transradial delay was 30 minutes and in 79.0% of simulations when delay was 60 minutes. CONCLUSIONS A substantial transradial delay is required to eliminate even a fraction of the mortality benefit observed with transradial PCI in RCTs. Results were robust to changing multiple assumptions and have implications for operators reluctant to transition to transradial PCI in STEMI because of concern for delaying reperfusion.
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Affiliation(s)
- Neil J Wimmer
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Jason H Wasfy
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Saif S Rathore
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Laura Mauri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Robert W Yeh
- Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Bertrand OF, Carey PC, Gilchrist IC. Allen or No Allen. J Am Coll Cardiol 2014; 63:1842-4. [DOI: 10.1016/j.jacc.2014.01.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 01/28/2014] [Indexed: 10/25/2022]
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Utilization of Radial Artery Access for Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction in New York. JACC Cardiovasc Interv 2014; 7:276-83. [DOI: 10.1016/j.jcin.2013.10.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 10/04/2013] [Accepted: 10/07/2013] [Indexed: 11/19/2022]
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Bernat I, Horak D, Stasek J, Mates M, Pesek J, Ostadal P, Hrabos V, Dusek J, Koza J, Sembera Z, Brtko M, Aschermann O, Smid M, Polansky P, Al Mawiri A, Vojacek J, Bis J, Costerousse O, Bertrand OF, Rokyta R. ST-segment elevation myocardial infarction treated by radial or femoral approach in a multicenter randomized clinical trial: the STEMI-RADIAL trial. J Am Coll Cardiol 2013; 63:964-72. [PMID: 24211309 DOI: 10.1016/j.jacc.2013.08.1651] [Citation(s) in RCA: 268] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 08/01/2013] [Accepted: 08/06/2013] [Indexed: 01/30/2023]
Abstract
OBJECTIVES This study sought to compare radial and femoral approaches in patients presenting with ST-segment elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI) by high-volume operators experienced in both access sites. BACKGROUND The exact clinical benefit of the radial compared to the femoral approach remains controversial. METHODS STEMI-RADIAL (ST Elevation Myocardial Infarction treated by RADIAL or femoral approach) was a randomized, multicenter trial. A total of 707 patients referred for STEMI <12 h of symptom onset were randomized in 4 high-volume radial centers. The primary endpoint was the cumulative incidence of major bleeding and vascular access site complications at 30 days. The rate of net adverse clinical events (NACE) was defined as a composite of death, myocardial infarction, stroke, and major bleeding/vascular complications. Access site crossover, contrast volume, duration of intensive care stay, and death at 6 months were secondary endpoints. RESULTS The primary endpoint occurred in 1.4% of the radial group (n = 348) and 7.2% of the femoral group (n = 359; p = 0.0001). The NACE rate was 4.6% versus 11.0% (p = 0.0028), respectively. Crossover from radial to femoral approach was 3.7%. Intensive care stay (2.5 ± 1.7 days vs. 3.0 ± 2.9 days, p = 0.0038) as well as contrast utilization (170 ± 71 ml vs. 182 ± 60 ml, p = 0.01) were significantly reduced in the radial group. Mortality in the radial and femoral groups was 2.3% versus 3.1% (p = 0.64) at 30 days and 2.3% versus 3.6% (p = 0.31) at 6 months, respectively. CONCLUSIONS In patients with STEMI undergoing primary PCI by operators experienced in both access sites, the radial approach was associated with significantly lower incidence of major bleeding and access site complications and superior net clinical benefit. These findings support the use of the radial approach in primary PCI as first choice after proper training. (Trial Comparing Radial and Femoral Approach in Primary Percutaneous Coronary Intervention [PCI] [STEMI-RADIAL]; NCT01136187).
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Affiliation(s)
- Ivo Bernat
- University Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic.
| | - David Horak
- Regional Hospital Liberec, Liberec, Czech Republic
| | - Josef Stasek
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Martin Mates
- Na Homolce Hospital Prague, Prague, Czech Republic
| | - Jan Pesek
- University Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic
| | - Petr Ostadal
- Na Homolce Hospital Prague, Prague, Czech Republic
| | - Vlado Hrabos
- Regional Hospital Liberec, Liberec, Czech Republic
| | - Jaroslav Dusek
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jiri Koza
- University Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic
| | | | - Miroslav Brtko
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | | | - Michal Smid
- University Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic
| | - Pavel Polansky
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Abdul Al Mawiri
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Josef Bis
- University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | | | | | - Richard Rokyta
- University Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic
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Effect on door-to-balloon time of immediate transradial percutaneous coronary intervention on culprit lesion in ST-elevation myocardial infarction compared to diagnostic angiography followed by primary percutaneous coronary intervention. Am J Cardiol 2013; 111:836-40. [PMID: 23313341 DOI: 10.1016/j.amjcard.2012.11.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Revised: 11/27/2012] [Accepted: 11/27/2012] [Indexed: 11/22/2022]
Abstract
Door-to-balloon (DTB) time is an important metric in primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction to optimize clinical outcomes. The aim of this study was to compare the impact of immediate PCI on culprit lesions in patients with ST-segment elevation myocardial infarctions versus diagnostic angiography followed by PCI on DTB times and procedural data at a high-volume tertiary care radial center. All patients who underwent primary PCI <12 hours after symptom onset were studied. Procedural data and all-cause mortality were assessed in all patients. The primary outcome was DTB time. From January 2006 to June 2011, 1,900 patients were included and divided into 2 groups: 562 patients (30%) underwent primary PCI followed by contralateral diagnostic angiography, and 1,338 patients (70%) underwent diagnostic angiography before primary PCI. No significant differences were observed in baseline characteristics. Left anterior descending coronary artery-related ST-segment elevation myocardial infarctions were more often found in patients who underwent PCI first (54% vs 34%, p <0.0001). Overall, there was a reduction of 8 minutes in DTB time between patients who underwent PCI first and those who underwent angiography first (32 minutes [interquartile range 24 to 52] vs 40 minutes [interquartile range 30 to 69], respectively, p <0.0001). After adjustment, immediate PCI remained an independent predictor of DTB time ≤90 minutes (odds ratio 2.42, 95% confidence interval 1.70 to 3.52, p <0.0001). There were no differences in early and late clinical outcomes. In conclusion, a strategy of transradial direct PCI of the infarct-related artery in selected patients before complete coronary angiography was associated with a benefit of 8 minutes in DTB time. Further study is required to determine whether this strategy can favorably affect clinical outcomes.
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DeMaria AN, Bax JJ, Feld GK, Greenberg BH, Hall JL, Hlatky MA, Lew WYW, Lima JAC, Mahmud E, Maisel AS, Narayan SM, Nissen SE, Sahn DJ, Tsimikas S. Highlights of the year in JACC 2012. J Am Coll Cardiol 2013; 61:357-85. [PMID: 23328613 PMCID: PMC3760511 DOI: 10.1016/j.jacc.2012.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Anthony N DeMaria
- Cardiology Division, UCSD Medical Center, San Diego, California 92122, USA.
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