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Primary PCI Radial Artery Access, Drug-Eluting Stents, and Thrombus Removal Kirk N Garratt MSc MD FSCAI Society for Cardiac Angiography and Interventions Lenox Hill Heart and Vascular Institute of New York Disclosures Speaker’s bureau: DSI/Lilly Consulting: Boston Scientific DSI/Lilly Research support: Abbott Vascular Boston Scientific The Medicines Company CardiacAssist The Medicines Company Equity Infarct Reduction Technologies Guided Delivery Systems MedLogics Radial Artery Access Thrombus Removal Drug Eluting Stents Radial Artery Access Thrombus Removal Drug Eluting Stents RIVAL Trial Jolly SS, et al. Lancet 2011;DOI:10.106/S01406736(11)60404-2 RIVAL Trial NSTEMI STEMI RIFLE-STEACS Romagnoli E, JACC 2012;60:2481-9 Nine Randomized Trials Radial versus Femoral Access and Mortality Joyal D, Am J Cardiol 2012;109:813-18 NCDR CathPCI Registry Trans-radial in STEMI Baklanov D, JACC 2013;61:420-6 How Would This Work? Increased bleeding = increased mortality RIVAL found no difference in bleeding but a significant difference in mortality rates Radial artery use may have other benefits Earlier ambulation Ease of management Earlier hospital discharge ESC Recommendations If performed by an experienced radial operator, radial acess should be preferred over femoral access (IIa,B) Steg G, Eur Heart J 2012;33:2569-2619 Conclusions of The Thought Leaders “A procedural approach that has been consistently associated with reduced bleeding and vascular “…the underlying mechanisms related to the complications is trans-radial cardiac catheterization bleeding reduction… are straightforward: the radial andartery PCI… Both the randomized observational is superficial, small inand caliber, and easily data show a consistency in appear directionality of the effect compressed… patients to prefer radial of to the radial approach bleeding.” the femoral approach (and the)onreduction in vascular and bleeding complications is associated with cost savings from the hospital perspective.” Harold L. Dauerman, Sunil V. Rao, Frederic S. Resnic, and Robert J. Applegate. JACC 2001;58:1-10 Radial Artery Access Thrombus Removal Drug Eluting Stents MUSTELA Trial De Carlo M, JACC CV Intv 2012;5:1223-30 MUSTELA Trial De Carlo M, JACC CV Intv 2012;5:1223-30 ESC Guidelines Manual catheter thrombus aspiration should be considered during PCI of the culprit lesion in STEMI (IIb) Steg G, Eur Heart J 2012;33:2569-2619 AHA/ACC/SCAI Guidelines I IIa IIb III Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI. Radial Artery Access Thrombus Removal Drug Eluting Stents First Generation DES vs BMS In STEMI BMS DES Kalesan B, Eur Heart J 2012 HORIZONS AMI Three Year Mortality Stone GW, Lancet 2011;377:2193-204 DES Evidence Network Meta-Analysis Palmerini T, JACC CV Intv 2013;62:496-504 DES Evidence Network Meta-Analysis DES were associated with better overall outcomes than BMS Second-generation DES (especially CoCr-EES) performed best Palmerini T, JACC CV Intv 2013;62:496-504 ACC/AHA/SCAI Guidelines I IIaIIb III Placement of a stent (BMS or DES) is useful in primary PCI for patients with STEMI. I IIaIIb III I IIaIIb III Harm BMS* should be used in patients with high bleeding risk, inability to comply with 1 year of DAPT, or anticipated invasive or surgical procedures in the next year. DES should not be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents. *Balloon angioplasty without stent placement may be used in selected patients. Conclusions Use of radial artery access for cardiac catheterization and intervention in the setting of STEMI is associated with meaningful reductions in short-term cardiac mortality Mechanisms not understood Increased use of radial artery access in setting of primary PCI is warranted Conclusions Thrombus aspiration is probably worth the effort Utility in improving outcomes uncertain Simple to do Use aspiration catheters unless very large thrombus burden Conclusions Drug-eluting stents work in STEMI patients Reduce restenosis rates No mortality penalty Should not be used if concerns about compliance with DAPT or bleeding risks Thank You