Download Primary PCI - Society for Cardiovascular Angiography and

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