Sunil V. Rao MD

The Duke Clinical Research Institute

The Durham VA Medical Center

Duke University Medical Center

Transradial PCI in Octogenarians: Caveats,

Tips, and Tricks

Disclosures

Consultant, Honoraria Sanofi-Aventis/BMS, The Medicines

Company, Terumo Corporation, Astra Zeneca, Eli Lilly/Daiichi-Sankyo, Terumo

Research funding Cordis Corporation, Momenta

Pharmaceuticals, Portola Pharmaceuticals Off-label uses

May be discussed in this presentation

Transradial PCI in elderly patientsIssues

Comorbidities Higher risk – ischemia, bleeding Complex CAD Calcification Tortuous vasculature

These issues are not specific to transradial!!

PCI-related outcomes N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI

Klein LW, et. al. JACC 2002

PCI-related outcomes – Multivariable model N=8828 octogenarians undergoing PCI in ACC-NCDR CathPCI

Klein LW, et. al. JACC 2002

Independent predictors of major bleeding in marker- positive acute coronary syndromes

Independent predictors of major bleeding in marker- positive acute coronary syndromes

Moscucci, GRACE Registry, Eur Heart J. 2003 Oct;24(20):1815-23.

Predictors of Major Bleeding in ACS

► Older Age► Female Gender► Renal Failure► History of Bleeding► Right Heart Catheterization► GPIIb-IIIa Antagonists

► Older Age► Female Gender► Renal Failure► History of Bleeding► Right Heart Catheterization► GPIIb-IIIa Antagonists

Risk Factors for Bleeding- Adjusted Analysis

Variable OR 95% CI Square

Female 1.74 1.64-1.85

319.3

Age (per 10 yrs) 1.36 1.31-1.42

223.6

GFR (per 10 ml/min decrease)

1.11 1.10-1.13

210.2

Prior PCI 0.69 0.64-0.73

128.9

Cardiogenic Shock 1.87 1.66-2.10

104.7

Emergent/Salvage PCIUrgent PCI

2.221.46

1.98-2.491.34-1.57

81.7

COPD 1.31 1.23-1.39

70.6

All p values <0.001 Mehta SR. Circulation: CI 2009

Access sites bleeding in “real-world” PCI patients

TIMI Maj TIMI Min0

10

20

30

40

50

60

70

80

90

100

73.459

5.9

0.8

12.5

6.3

2.9

CVAGIRPHematoma

%

Kinnaird et al Am J Cardio 2003

5.4% 12.7%

Transradial PCI in Patients ≥ 75 years oldN=307 pts randomized to radial vs. femoral

RadialN=152

FemoralN=155

P-value

Duration of Dx angio

18.1 15.0 0.009

Fluoro time (min) 5.6 4.7 0.47

Crossover to other access

9% 0.6%

Major adverse events*

0 3.2% < 0.001

*Defined as death, MI, CVA, vascular complications requiring surgery, redcell transfusion, Hgb decrease > 3 g/dl

Achenbach S, et. al. CCI 2008

Transradial PCI – Outcomes by AgeN=593,094 pts in ACC-NCDR CathPCI Registry

< 75 yrs ≥ 75 yrs < 75 yrs ≥ 75 yrs0

0.5

1

1.5

2

2.5

3

3.5

0.47

2.05

0.13

0.44

1.42

2.99

0.62

1.00

r-PCIf-PCI%

Bleeding Complications

Vascular Complications

Rao SV, et. al. JACC:CI 2008

Transradial PCI – Outcomes by AgeN=593,094 pts in ACC-NCDR CathPCI Registry

Rao SV, et. al. JACC:CI 2008

While there is a trend toward less bleeding in the pts ≥ 75 years oldWith the radial approach, it does not reach statistical significance.This underscores the importance of non-access site bleeding

Bleeding and Outcomes

26,452 patients from PURSUIT, PARAGON A, PARAGON B, GUSTO IIb NST

Adjusted hazard ratios for 30d DeathStratified by Procedure and Non-procedure related bleeds

Bleeding severity

Procedure Related

Non-procedure Related

Mild 1.2 2.1*

Moderate 3.7* 2.5*

Severe 16.5* 10.9*

*p<0.0001

Rao SV, et. al. AJC 2005

Excessive Dosing of Antithrombotics by Age

LMW Heparin UF Heparin GP IIb/IIIa0

10

20

30

40

50

60

70

12.5

28.7

8.512.5

3733.1

16.5

38.5

64.5

< 65 yrs 65-75 yrs >75 yrs

% E

xc

es

siv

e D

os

e

Alexander KP, et. al. JAMA 2005

<55 55-64 65-740

2

4

6

8

10

12

14

6.57.1

9.0

11.0

7.0

8.6 8.6

12.2

Heparin(s) + GP IIb/IIIa Bivalirudin

ACUITY PCI: Ischemic outcomes by age

Patient age (years)

P=.75

≥75

P=.30 P=.77

P=.57

(n=1,346) (n=1,483) (n=1,454) (n=897)

Per

cen

tag

e (%

)

Lopes RD, et. al. JACC 2009

<55 55-64 65-740

2

4

6

8

10

12

14

4.3

5.7

6.7

12.3

1.7

3.0

4.2

6.1

Heparin(s) + GP IIb/IIIa Bivalirudin

≥75

ACUITY PCI: Non-CABG bleeding by age

Patient age (years)

(n=897)(n=1,454)(n=1,483)(n=1,346)

P=.007

P=.01P=.03

P=.001

Per

cen

tag

e (%

)

Lopes RD, et. al. JACC 2009

Issues specific to transradial in elderly patients

Tortuosity of arm and chest vessels Low threshold for angiography Deep breath to direct wire Get experience with other catheter curves

Complex PCI – few limitations with currently available 6Fr guiding catheters used via the transradial approach

Transradial PCI in the elderlyConclusions (1)

PCI-related ischemic outcomes have improved in older patients High rates of procedure success Low rates of peri-PCI ischemic events

Reducing bleeding risk is the priority Transradial is associated with reduced bleeding

risk, but… Crossover to femoral may be higher Non-access site related bleeding is important in

older patients

Strategies for reducing bleeding risk in older pateints include: Transradial Pharmacological therapies – appropriate dosing,

alternative antithrombin strategies Transradial tips/tricks

Low threshold for forearm/chest angiography Deep breath to direct equipment Use of other guide catheter curves New technology coming

Transradial PCI in the elderlyConclusions (2)