Trans-Radial approach in Overweight Patients

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Trans-Radial approach in Overweight Patients
Hakim Ben Amer, MD On behalf the TROP study group
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Predicting vascular complications in percutaneous
coronary interventions

• 18,137 PCI pts in northern New England
  (1997-1999) vascular complication 2.98
• Variables associated with increased risk in the
  multivariate analysis
• Age gtor70
  OR 2.7
• Female gender
  OR 2.4
• Body surface area lt1.6 m
  OR 1.9
• History of congestive heart failure
  OR 1.4
• Chronic obstructive pulmonary disease
  OR 1.5
• Renal failure
  OR 1.9
• Lower extremity vascular disease
  OR 1.4
• Bleeding disorder
  OR 1.68
• Emergent priority
  OR 2.3
• Myocardial infarction
  OR 1.7
• Shock
  OR 1.86
• gtor1 type B2 lesions
  OR 1.32
• type C lesions
  OR 1.7
• 3-vessel PCI
  OR 1.5
• Thienopyridines
  OR 1.4
• Glycoprotein IIb/IIIa inhibitors
  OR 1.9

Vascular complications access-site injury
requiring treatment or bleeding requiring
transfusion
Piper WD Am Heart J. 2003 Jun145(6)1022-9
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Complications following diagnostic coronary
angiography Predicting factors
Factor All complications Major complications Vascular complications
Heart failure (Killipgt1) 0R 2.16 95 CI 1.12-4.16 p 0.03
Left / Right catheterization 0R 2.62 95 CI 1.46-4.7 p 0.003
Senior physician (gt 500) 0R 0.58 95 CI 0.34-0.98 p 0.04
French lt6, 6, gt6 0R 2.6 95 CI 1.53-4.41 p 0.0004 0R 2.35 95 CI 1.0-5.51 p 0.05 0R 2.54 95 CI 0.93-7.02 p 0.07
Smoking 0R 2.76 95 CI 1.14-6.73 p 0.02 0R 3.93 95 CI 1.28-12.06 p 0.01
Body weight (/10 kg) 0R 1.23 95 CI 0.95-1.44 p 0.1 0R 1.4 95 CI 1.01-1.95 p 0.04
7,412 consecutive diagnostic cardiac
catheterizations between 1990 and 2000
Ammann CCVI 20035913-18
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Impact of Access Site Hematoma With Transfusion
in Patients Undergoing Percutaneous Coronary
Intervention

• 6613 PCI (98-00)(NHLBI) hematoma w transfusion
  1.8 (97 femoral)
• Predictors Older age, Lower BMI, Female, renal
  disease, HTN, AMI, 3-VD, GPIIb/IIa -,
  Postprocedure heparin
• Independent predictors Older age, female,
  thrombotic lesion, 3-VD, renal disease, emergent
  PCI, prior aspirin
• Procedural death 10.3 w HWT 1.2 w/o
  HWT p lt0.001
• death/MI 18.1
  3.55 lt0.001
• HWT is a predictor of death/MI (OR 3.49 95
  CI 1.98-6.14)

J. Slater Am J Cardiol 2003 (suppl) 92 18L
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Clinical Significance of Bleeding Complications
Median Length of Hospital Stay (Day) Extra Cost Others
Any Vascular Site Bleeding or Vascular Complication (Surgical) 1 Incapacitation (days-weeks) Return to normal activity delay
Major or Minor Vascular Site Bleeding or Vascular Complication (Surgical) 2 1327 -
Major Vascular Site Bleeding or Vascular Complication (Surgical) 4 5896 -
From Blankenship Am Heart J 1999 138 S287-S296
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Radial / Femoral Approach meta-analysis Entry
site complications
Agostini P JACC
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TransRadial ApproachIn OverWeight Patients

• Multicentric European Registry,
• Coronary angiography (CA) or angioplasty (PCI)
• Centres where there is at least one operator
• with a wide experience in the transradial
  approach
• for CA and PCI.
• We include in the registry all the overweight
• patients with BMI ? 35, undergoing CA and/or PCI
• whatever the vascular approach chosen by the
  operator.
• The primary end point is the occurrence of
  complications delaying the hospital discharge.

TROP Study Group
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TROP Centers

• Bergamo (Italy)
• Brighton (England)
• CHU Caen, (France)
• HEP la Roseraie, (France)
• Clinic Barcelona, (Spain)
• Hôpital Bichat, Paris (France)
• ICPS, Massy (France)
• ICPS, Quincy (France)
• Meixoeiro, (Spain)
• Riga, (Latvia)
• Szeged, (Hungary)
• Val-de-Grâce (France)
• Valle de Hebron, (Spain)

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N 346
TROP Study Group
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Clinical Datas

Mean Age 61.2 /- 10.9 years (30/83) Sexe
(Male) 52.9 Mean Weight 108 /- 15
Kg (79/155) Mean Height 1.67 /- 0.1
M (1.45/1.90) Mean BMI 38.7 /- 3.4
Kg/m2 (35/56) Renal Insuf 7.8
TROP Study Group
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Clinical Datas


TROP Study Group
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Clinical Datas

Radial N 249 Femoral N 97
Angio () 171 (49.4) 52 (14.7)
PCI () 19 (5.5) 21 (6.1)
Angio/PCI () 59 (17.1) 25 (7.2)
P .0006
TROP Study Group
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Clinical Datas

TROP Study Group
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Clinical Datas

TROP Study Group
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Vascular Access
Transradial approach IT 249/346
(71.9) Transradial approach AC 243/346
(70.2) Reasons for using Femoral access 97/346
(28.1) - Physician choice (76) 78.4 -
Dialysis (1) 1 - Need for 7F catheters (5)
5.2 - Abnormal Allen test (1) 1 - CABG
(double Mam) (4) 4.1 - No or to small radial
(4) 4.1 - Other (ring, prior rad failure)
(6) 6.2
IT Intention To Treat AC After Cross over
TROP Study Group
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Vascular Access
Cross over 17 (4.9) - Radial to femoral 9
(3.6) - Radial to radial 4 (1.6) - Femoral
to radial 3 (3.1) - Radial to Ulnar 1
(0.4)
TROP Study Group
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Vascular Access Size
N
TROP Study Group
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INDICATIONS

TROP Study Group
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Clinic Presentation

TROP Study Group
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Documented Ischemia

TROP Study Group
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Vascular Access
Radial difficulties 249 patients - Failure
10 (4) - No difficulty 210 (84.3) -
Catheterism diff. 10 (4) - Spasm 6
(2.8) - Loops 10 (4) - Others 2
(0.8) - TOTAL 29 (11.6)
TROP Study Group
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CAD extension

TROP Study Group
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PCI (N 124 pts)

• - Transradial access 78/124 (62.9)
• Femoral access 46/124 (38.1)
• - PCI success/Vessel 163/169 (96.5)
• Clinical Total Success 118 (95.2)
• QMI 4 (3.2)
• MACE 1 (3.2)
• Emergent CABG 0 (0)
• Death 0 (0)

TROP Study Group
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Fem vs Rad access
Radial (n243) Femoral (n103) P
Mean age (y) 61.2 /- 11.3 60.5 /- 10.1 NS
Male () 138 (56.7) 56 (54.4) NS
BMI (Kg/m2) 39 /- 14 38 /- 5 0.04
TROP Study Group
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Fem vs Rad access
Radial (n243) Femoral (n103) P
Hypertension () 180 (70) 76 (70) NS
Hypercholesterolemia () 165 (68) 72 (70) NS
Family History () 41 (17) 40 (39) 0,001
Smokers () No Current Past 137 (56) 30 (12) 60 (25) 60 (58) 17 (16) 26 (25) NS
Diabetes () No ID NID 137 (56) 24 (10) 82 (34) 65 (63) 9 (9) 29 (28) NS
TROP Study Group
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Fem vs Rad access
Radial (n243) Femoral (n103) P
Prior MI () 37 (15) 27 (26) NS
Prior CABG () 11 (45) 8 (8) NS
Prior PCI () 42 (18) 17 (16) NS
TROP Study Group
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Fem vs Rad access
Radial (n243) Femoral (n103) P
Nb Cath used Angio (n) 1.9 /- 0.8 2.3 /- 0.7 0,0005
Contrast Total (ml) 159 /- 95 189 /- 102 0.01
Contrast Angio (ml) 117 /- 64 122 /- 70 NS
Total Duration (min) 35.3 /- 25.4 55.6 /- 23.3 0.0001
Angio Duration (min) 26.1 /- 19.0 31.3 /- 17.7 0.03
Hosp stay (d) 3.7 /- 4.1 4.4 /- 4.6 NS
Hosp stay after C (d) 1.7 /- 2.2 2.7 /- 4.3 0.02
Vascular complication () 3 (1.2) 3 (2.9) NS
Hematoma () 4 (1.6) 9 (8.7) 0.001
TROP Study Group
With transfusion
with 8 Closing Device
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Impact of Weight for in Hospital Outcome after PCI
BMI (kg/m2) N95435 lt 18,5 N924 18,5/24,9 N25010 25/29,9 N41175 30/34,9 N19329 35/39,9 N6252 gt40 N2745 P
Death () 3,8 1,1 0,8 0,7 0,6 1,4 0,001
Transmural MI () 0,5 0,3 0,3 0,4 0,3 0,3 0,227
Emergent CABG () 0,9 1,3 1,1 1,1 1,2 0,8 lt0,001
MACE () 5 2,6 2,1 2,0 1,8 2,4 lt0,001
Vascular Injury () 1,4 0,6 0,5 0,5 0,5 0,9 lt0,001
RM, Minuella Am J cardiol 2004931229-32
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Conclusion 1

• Obesity is a risk factor for CAD (Hypertension,
  Dyslipidemia, Diabetes)
• Obesity is more frequent in female gender
• Obesity is a factor of complication in diagnostic
  angiography and coronary intervention

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Conclusion 2

• Preliminary analysis of this study
• Radial approach in obese patients reduces the
  rate of vascular complications
• Subgroup analysis (pending) is necessary to
  better define patients at higher risk, interest
  of closure devices for femoral procedures
• Potential other advantage of radial approach
  prevention of infectious complication

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(No Transcript)
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Bleeding Complications
F.V Aguirre et al, Circulation 1995912882-90
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Bleeding complications
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Comparison of the Risk of Vascular Complications
Associated With Femoral and Radial Access
Coronary Catheterization Procedures in Obese
Versus Nonobese Patients
Distribution of patients who underwent cardiac
catheterization procedures by BMI
N Cox, Am J Cardiol 20049411741177
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Comparison of the Risk of Vascular Complications
Associated With Femoral and Radial Access
Coronary Catheterization Procedures in Obese
Versus Nonobese Patients
N Cox, Am J Cardiol 20049411741177
36
Comparison of the Risk of Vascular Complications
Associated With Femoral and Radial Access
Coronary Catheterization Procedures in Obese
Versus Nonobese Patients
N Cox, Am J Cardiol 20049411741177
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Comparison of the Risk of Vascular Complications
Associated With Femoral and Radial Access
Coronary Catheterization Procedures in Obese
Versus Nonobese Patients
Vascular complications by BMI. The patients with
the smallest BMIs experienced the highest rate of
vascular complications
N Cox, Am J Cardiol 20049411741177
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Comparison of the Risk of Vascular Complications
Associated With Femoral and Radial Access
Coronary Catheterization Procedures in Obese
Versus Nonobese Patients
Overall vascular complication rate in nonobese
and obese (BMI gt30.0) patient subgroups
stratified by vascular access approach
N Cox, Am J Cardiol 20049411741177
39
Comparison of the Risk of Vascular Complications
Associated With Femoral and Radial Access
Coronary Catheterization Procedures in Obese
Versus Nonobese Patients
N Cox, Am J Cardiol 20049411741177
40
Low-Normal or Excessive Body Mass Index Newly
Identified and Powerful Risk Factors for Death
and Other ComplicationsWith Percutaneous Coronary
Intervention
Major Cardiac Outcomes and Complications
Stephen G. Ellis, Am J Cardiol 199678642-64
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Low-Normal or ExcessiveBody Mass Index Newly
Identified and Powerful Risk Factors for Death
and Other Complications With Percutaneous
Coronary Intervention
Peripheral Vascular Complications
Stephen G. Ellis, Am J Cardiol 199678642-64
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Low-Normal or ExcessiveBody Mass Index Newly
Identified and Powerful Risk Factors for Death
and Other Complications With Percutaneous
Coronary Intervention
Independent Correlates of Death With and Without
BMI
Stephen G. Ellis, Am J Cardiol 199678642-64
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Low-Normal or ExcessiveBody Mass Index Newly
Identified and Powerful Risk Factors for Death
and Other Complications With Percutaneous
Coronary Intervention
Causes of Death
Stephen G. Ellis, Am J Cardiol 199678642-64
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Low-Normal or ExcessiveBody Mass Index Newly
Identified and Powerful Risk Factors for Death
and Other ComplicationsWith Percutaneous Coronary
Intervention
Stephen G. Ellis, Am J Cardiol 199678642-64
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Impact of Body Mass Index on Outcome
AfterPercutaneous Coronary Intervention (The
Obesity Paradox)
H Gurm, P. Topol Am J Cardiol 2002 90 42-45
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Impact of Body Mass Index on Outcome
AfterPercutaneous Coronary Intervention (The
Obesity Paradox)
H Gurm, P. Topol Am J Cardiol 2002 90 42-45
47
Impact of Body Mass Index on Outcome
AfterPercutaneous Coronary Intervention (The
Obesity Paradox)
H Gurm, P. Topol Am J Cardiol 2002 90 42-45
48
Impact of Body Mass Index on Outcome
AfterPercutaneous Coronary Intervention (The
Obesity Paradox)
H Gurm, P. Topol Am J Cardiol 2002 90 42-45
49
Impact of BMI on Short- and Long-Term FU in
Patients Undergoing Coronary Revascularization
Insights From BARI
Procedural Characteristics of Study Patients
According to BMI
H. Gurm J Am Coll Cardiol 20023983440
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Impact of BMI on Short- and Long-Term FU in
Patients Undergoing Coronary Revascularization
Insights From BARI
Incidence and Odds Ratios of In-Hospital Events
According to BMI PTCA Group
H. Gurm J Am Coll Cardiol 20023983440
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Impact of BMI on Short- and Long-Term FU in
Patients Undergoing Coronary Revascularization
Insights From BARI
Incidence and Odds Ratios of In-Hospital Events
According to BMI CABG Group
H. Gurm J Am Coll Cardiol 20023983440
52
Impact of BMI on Short- and Long-Term FU in
Patients Undergoing Coronary Revascularization
Insights From BARI
Incidence and OR of Long-Term Mortality According
to BMI PTCA Group (n2,090)
H. Gurm J Am Coll Cardiol 20023983440
53
Impact of BMI on Short- and Long-Term FU in
Patients Undergoing Coronary Revascularization
Insights From BARI
Incidence and OR of In-Hospital Events According
to BMI CABG Group
H. Gurm J Am Coll Cardiol 20023983440
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Obesity a risk for CABG surgery
N.J.O. Birkmeyer Circulation 1998971689-94
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Obesity a risk for CABG surgery
CVA Cerebrovascular Accident SWI Sternal Wound
infection
N.J.O. Birkmeyer Circulation 1998971689-94