John Coppola, MD FACC

1
John Coppola, MDFACC
Chief Cardiac Catherization Lab Saint Vincents
Medical Center, NY, USA

• Transradial Angioplasty
• in the United States

2
Birth of TRI

• Dr Kiemeneij in 1992 first interventions
• Need for high level anticoagulation INR3 or
  greater
• Radial offered lower incidence puncture site
  complications
• Increased patient comfort post procedure

3
TRI subsets

• Saito Catheter Cardiovasc Interv 4637-41 1999
  TRI in Japanese patients
• Caputo et al Cath Cardiovasc Interv 51287-290
  2000 TRI in elderly
• Gilchrist Catheter Cardiovasc Interv 5610-13
  2002 Same day TRI stenting with glycoprotein
  IIb/IIIa agents

4
TRI in Dwarfs
5
Why TRI

• access complications exceedingly rare shorter
  hospital stay Grossman Cardiac Catherization
  Angiography and Interventions seventh Edition
  2006
• less than 10 all coronary procedures in the
  United States

6
Why radial artery

• No important nerve or vein near by
• Easy to compress
• Early ambulation early discharge
• Complications from access site less

7
Access Study

• Dr Kiemeneij JACC 29 1269-75 1997
• Success of coronary cannulation radial 93
  brachial 95.7 femoral 99.7
• Radial failure inability to puncture vessel 14
  cases failure to advance sheath 2 cases failure
  to enter ascending aorta 5 cases for total of 21
  failures
• Entry site complications radial 0 brachial 2.3
  femoral 2

8
TRI

• Lack of acceptance in United States
• Brinker from Johns Hopkins Catheter Cardiovasc
  Interv 51291 2000 most reports suggest that
  radial artery catherization is an acceptable
  alternative to femoral catherization when the
  later procedure is absolutely or relatively
  contraindicated

9
Reason

• Lack of programs
• Femoral easy to access
• Large enough to accommodate large cather systems

10
Radial

• Technically more difficult
• Spasm
• Subclavian-aorta curves
• Difficult to cannulate coronary arteries

11
Truth about TRI

• Hildick-Smith TRI in patients with
  Contraindications to femoral approach
• 500 patients average age 66
• Contraindications femoral PVD 61 Anticoagulation
  16 muscular skeletal 12 morbid obesity 6
• 2 operators did 355 of 500 procedures

12
Hildick-Smith

• Major operators 335 /355 success 94.4
• 16 other operators 128/145 success 88
• Radial failure due to failed access 9 spasm 13
  failure to enter ascending aorta 9
• Profound vagal reaction 2 failure to cannulate
  coronary 4

13
Operator Learning curve
Case Procedure success duration Fluro time
0-20 18/20 90 48 mins 8.7
20-100 75/80 94.7 48min 6.5
gt100 162/168 96.4 38 mins 5.9
14
TRI Learning Curve

• Fernandez Rev Esp Cardiol 2003 56(2) 152-9
• TRI in 526 patients overall success 93.7
• First 200 cases 91 success
• Next 326 cases 95.4
• Duration from 23 to 19 minutes
• Fluro time 6.4 to 5 minutes

15
TRI learning curve

• 100 to lose fear
• 200 to 300 to be comfortable
• Great comfort less spasm
• greater success
• Recognize benefit of less vascular complications

16
Medical care system

• Hospitals have open labs in United States
• Large profit for hospitals in cardiovascular
  procedure
• Many operators doing 50 or less cases
• Learning curve will take 4 to 5 years
• No economic pressure to learn yet
• Same day discharge for intervention with
  financial reward maybe greatest friend to TRI in
  United States

17
Starting Program

• Best with second person
• Begin with younger patients
• Males with bigger radial arteries
• Avoid elderly with longstanding
• hypertension in the beginning

18
Beginning

• Allen test
• Perfect patients
• Do stick
• Place cather in Ascending aorta
• Advance fellows to cather movement finally to
  stick

19
TRI

• 0 in NOV 2003
• 30 2005
• Graduating fellows 2004 2005 doing 50 of work
  via TRI