Trans-Radial approach in Overweight Patients Hakim Ben Amer, MD On behalf the TROP study group.

Trans-Radial approach Trans-Radial approach in in

Overweight PatientsOverweight PatientsHakim Ben Amer, MD

On behalf the TROP study group

Predicting vascular complications in percutaneous coronary

interventions18,137 PCI pts in northern New England (1997-1999); vascular complication* 2.98%

Variables associated with increased risk in the multivariate analysis Age >or=70 OR 2.7 Female gender OR 2.4Body surface area <1.6 m OR 1.9History of congestive heart failure OR 1.4Chronic obstructive pulmonary disease OR 1.5Renal failure OR 1.9Lower extremity vascular disease OR 1.4Bleeding disorder OR 1.68Emergent priority OR 2.3Myocardial infarction OR 1.7Shock OR 1.86>or=1 type B2 lesions OR 1.32 type C lesions OR 1.7 3-vessel PCI OR 1.5Thienopyridines OR 1.4Glycoprotein IIb/IIIa inhibitors OR 1.9

Piper WD Am Heart J. 2003 Jun;145(6):1022-9Piper WD Am Heart J. 2003 Jun;145(6):1022-9

*Vascular complications: access-site injury requiring treatment or bleeding requiring transfusion*Vascular complications: access-site injury requiring treatment or bleeding requiring transfusion

Complications following diagnostic Complications following diagnostic coronary angiography: Predicting coronary angiography: Predicting

factorsfactors

Ammann CCVI 2003;59:13-18Ammann CCVI 2003;59:13-18

Factor All complications Major complications

Vascular complications

Heart failure (Killip>1)

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 (> 500)

0R 0.58; 95% CI 0.34-0.98;

p= 0.04

French: <6, =6, >6 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 20007,412 consecutive diagnostic cardiac catheterizations between 1990 and 2000

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 <0.001 death/MI: 18.1% 3.55% <0.001

HWT is a predictor of death/MI (OR = 3.49; 95% CI: 1.98-6.14)

J. Slater Am J Cardiol 2003 (suppl) 92: J. Slater Am J Cardiol 2003 (suppl) 92: 18L 18L

Clinical Significance of Bleeding Complications

From Blankenship Am Heart J 1999; 138: S287-S296From Blankenship Am Heart J 1999; 138: S287-S296

Median Length of Hospital Stay

(Day)

Extra Cost Others

Any Vascular Site Bleeding or Vascular Complication (Surgical)

+ 1Incapacitation (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 $ -

Radial / Femoral Approach meta-analysis: Entry site complications

Agostini P JACCAgostini P JACC

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

TROP CentersTROP 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)

3224

3619

1719

2761

64

2924

48

0 20 40 60 80

Riga (L)

Caen (F)

Szeged (H)

Roseraie (F)

Val de Grace (F)

Barcelona (S)

Quincy (F)

Bergamo (I )

Massy (F)

Bichat (F)

Valle Hebron (S)

Meixoeiro (S)

Brighton (E)

TROP Study Group

N = 346

Clinical DatasMean 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

Clinical Datas

TROP Study Group

64,4

11,3

24,3

8,4

0

10

20

30

40

50

60

70

ANGIO

PCI

ANGIO + PCI

EMERGENCY

%

Clinical Datas

TROP Study Group

RadialN = 249

FemoralN = 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

73,968,5

23,5

41,6 38,4

0

20

40

60

80

Clinical Datas

TROP Study Group

%

18,5

5,5

17,3

4,63,2

1,70

5

10

15

20

Clinical Datas

TROP Study Group

%

Vascular AccessTransradial 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%

TROP Study GroupIT: Intention To TreatAC: After Cross over

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

Vascular Access: Size

TROP Study Group

34

211

89

120

50

100

150

200

250

Patients

4 F

5 F

6 F

7 F

N

INDICATIONS

TROP Study Group

4,9 6,1

89

0

20

40

60

80

100

Valvulopathy

Cardiac I nsuffi .

I schemic

%

Clinic Presentation

TROP Study Group

4,64,4

19,9

11,6

39,3

7,2

13

0

10

20

30

40

Atypical chest pain

ACS ST elevated

ACS ST not elevated

Silent ischemia

Stable angina

Post MI

No ischemia

%

Documented Ischemia

TROP Study Group

39,9

34,1

17,9

6,4

1,70

10

20

30

40

Patients

No test

EKG

Scintigraphy

Stress test

Other

%

Vascular AccessRadial 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

CAD extension39,9

29,7

17,9

12,5

4

0

10

20

30

40

No vessel

One vessel

Two vessels

Three vessels

Left Main

TROP Study Group

%

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

Fem vs Rad access

Radial (n=243)

Femoral (n=103)

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

Radial (n=243)

Femoral (n=103)

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

Fem vs Rad access

TROP Study Group

Fem vs Rad access

TROP Study Group

Radial (n=243)

Femoral (n=103)

P

Prior MI (%) 37 (15) 27 (26) NS

Prior CABG (%) 11 (45) 8 (8) NS

Prior PCI (%) 42 (18) 17 (16) NS

Radial (n=243) Femoral (n=103) 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

Fem vs Rad access

TROP Study Group* With transfusion §: with 8 Closing Device

Impact of Weight for in Hospital Outcome after PCI

RM, Minuella Am J cardiol 2004;93:1229-32

BMI (kg/m2)

N=95435< 18,5N=924

18,5/24,9N=25010

25/29,9N=41175

30/34,9N=19329

35/39,9N6252

>40N=2745

P

Death (%) 3,8 1,1 0,8 0,7 0,6 1,4 0,001

TransmuralMI (%)

0,5 0,3 0,3 0,4 0,3 0,3 0,227

EmergentCABG (%)

0,9 1,3 1,1 1,1 1,2 0,8 <0,001

MACE (%) 5 2,6 2,1 2,0 1,8 2,4 <0,001

VascularInjury (%)

1,4 0,6 0,5 0,5 0,5 0,9 <0,001

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

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

Bleeding Complications

F.V Aguirre et al, Circulation 1995;91:2882-90

Bleeding complications

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 2004;94:1174–1177

Distribution of patients who underwent cardiac catheterization procedures by BMI



N Cox, Am J Cardiol 2004;94:1174–1177



N Cox, Am J Cardiol 2004;94:1174–1177



N Cox, Am J Cardiol 2004;94:1174–1177

Vascular complications by BMI. The patients with the smallest BMIs experienced the highest rate of vascular complications



N Cox, Am J Cardiol 2004;94:1174–1177

Overall vascular complication rate in nonobese and obese (BMI >30.0) patient subgroups stratified by vascular access

approach



N Cox, Am J Cardiol 2004;94:1174–1177

Low-Normal or Excessive Body Mass Index: Newly Identified and Powerful Risk Factors for Death and Other ComplicationsWith Percutaneous Coronary Intervention

Stephen G. Ellis, Am J Cardiol 1996;78:642-64

Major Cardiac Outcomes and Complications

Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other Complications With Percutaneous Coronary Intervention


Peripheral Vascular Complications



Independent Correlates of Death With and Without BMI


Causes of Death


Low-Normal or ExcessiveBody Mass Index: Newly Identified and Powerful Risk Factors for Death and Other ComplicationsWith Percutaneous Coronary Intervention


Impact of Body Mass Index on Outcome AfterPercutaneous Coronary Intervention (The Obesity

Paradox)

H Gurm, P. Topol Am J Cardiol 2002; 90: 42-45


Paradox)



Paradox)



Paradox)


Impact of BMI on Short- and Long-Term FU in Patients Undergoing Coronary Revascularization: Insights From

BARI

H. Gurm J Am Coll Cardiol 2002;39:834–40

Procedural Characteristics of Study Patients According to BMI


BARIIncidence and Odds Ratios of In-Hospital Events According to BMI: PTCA

Group



BARI


Incidence and Odds Ratios of In-Hospital Events According to BMI: CABG Group


BARI


Incidence and OR of Long-Term Mortality According to BMI: PTCA Group (n=2,090)



BARIIncidence and OR of In-Hospital Events According to BMI: CABG Group

Obesity a risk for CABG surgery

N.J.O. Birkmeyer Circulation 1998;97:1689-94

Obesity a risk for CABG surgery

N.J.O. Birkmeyer Circulation 1998;97:1689-94

CVA Cerebrovascular AccidentSWI Sternal Wound infection

Trans-Radial approach in Overweight Patients Hakim Ben Amer, MD On behalf the TROP study group.

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