Transradial Approach for STEMI in an Octagenarian

Question: Do you do transradial percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) in octogenarians? If so, do you go left or right radial? Our doc said transradial in the elderly takes longer.

We do transradial approach as the default approach for all STEMIs, regardless of age or sex. There are, however, a few things to consider when doing transradial PCI in the elderly. The following is a complex STEMI case performed in an octagenarian.

Indications

This case involves an 82-year-old gentleman with apparently no previous cardiac history. He came in with chest discomfort, starting around 5 hours prior to arrival in the emergency department (ED). His electrocardiogram (EKG) demonstrated an acute anterior wall injury pattern (Figure 1). He was brought up to the lab immediately. En route, he went into ventricular fibrillation requiring cardioversion x 3 times, with restoration of sinus rhythm. The patient underwent cardiac catheterization. Cardiac cath was performed via the right radial approach, with right femoral access obtained as well, using a 4 French (Fr) sheath for possible intra-aortic balloon pump (IABP) placement. Intial engagement of the left main (LM) with a Q 3.5 guide (Boston Scientific) was performed, with subsequent revascularization of the culprit lesion. This was followed by completion of diagnostic angiography. The patient was found to have a 100% ostial occlusion of the left anterior descending coronary artery (LAD), a large patent ramus, and large patent dominant circumflex artery. Given his hemodynamic instability and arrhythmia, a 50cm IABP was inserted prior to revascularization of the culprit artery.

A Runthrough wire (Terumo) was passed in the circumflex artery after bivalirudin (Angiomax, The Medicines Company) was administered. A second Runthrough wire was then passed into the distal LAD. Because of the ostial LAD disease and haziness in the ramus, a third wire (Prowater wire [Abbott Vascular]) was placed into the ramus to protect it as well. We then predilated the LAD with a 3.5 x 10mm AngioSculpt balloon (AngioScore). Simultaneous kissing balloon inflations were performed in the LAD and ramus, with a 3.5 x 15mm Emerge balloon (Boston Scientific) in the LAD and a 3.0 x 15mm Emerge balloon in the ramus. Upon completion, the patient achieved TIMI-3 flow and his pain was now 1 out of 10. He was hemodynamically stable with an IABP and low-dose norepinephrine (Levophed,  Hospira, Inc.). The initial plan was to place a bare-metal stent with consideration for surgical evaluation. However, given the excellent angiographic result with plain old balloon angioplasty (POBA), no stent was placed. The patient was evaluated by the cardiothoracic surgeon and underwent bypass during this admission. The remainder of his hospital course was fairly uncomplicated. He had removal of the IABP on post op day 1 and was discharged to rehab on post op day 7. The patient has since followed up in the office and is doing well.

Discussion

This case demonstrates a number of aspects of transradial PCI: 

1) The feasibility of the transradial approach in STEMI. Studies have demonstrated similar success rates, equal procedural time, and reduced bleeding with the transradial approach.^1,2 In addition to reducing vascular complications, radial access has been associated with increased patient comfort, reduced cost, and equivalent success rates in experienced operators. Radial access has been shown to reduce major bleeding by 73%, with a trend toward reduced death, MI and stroke.³ The recently published RIVAL (Radial versus Femoral Access for Coronary Intervention) trial is the largest randomized trial comparing radial to femoral artery  access.⁴ At 30 days, the primary outcome — a composite of death, MI, stroke, or non-coronary artery bypass graft (CABG)-related major bleeding — occurred in 3.7% of patients randomized to radial access and in 4.0% of patients assigned to the femoral approach, a nonsignificant difference. Transradial access, however, did result in a 63% reduction in the risk of large vascular-access complications. A subgroup analysis of high-volume operators demonstrated a statistically significant 40% relative reduction in the risk of death, MI, stroke, or non-CABG-related major bleeding and a significant 61% relative reduction in the risk of death among STEMI patients treated via the radial artery. There was also a reported a significant reduction in the risk of the primary outcome, a 51% reduction, among PCI centers that performed the highest volume of radial procedures.

2) The utility of transradial PCI in the elderly. Critics of the radial approach often raise concern about the difficulty in treating complex lesions or elderly patients via the radial approach, particularly since age is a predictor of transradial PCI failure.⁵ Other issues that may contribute include tortousity of the subclavian, aortic root dilation, diffuse atherosclerosis, and calcification. However, studies have demonstrated equivalent success rates  treating elderly patients and complex lesions via the transradial approach, while preserving the benefit of lower vascular complications.^6-8 This has also been demonstrated in the acute coronary syndromes (ACS) population with equivalent success and procedural time when compared to the femoral approach.^9,10

3) The ability to perform complex intervention via the transradial approach. Trifurcating coronary artery disease is a complex atherosclerotic process involving the origins of one or more of the three side branches arising from the main coronary artery vessel or main trunk (MT), with or without involvement of the MT itself. Trifurcation lesions are more difficult than bifurcation lesions for preserving the patency of the ostium of each branch. When using a 6 Fr system, consider use of a large lumen catheter (0.71’’). This will allow for kissing balloon inflation, insertion of three guide wires and performance of modified complex techniques (modified simultaneous kissing stents, T-stent, etc.). Careful manipulation of the wires should be employed to minimize entanglement.

As far as right versus left radial approach, the right subclavian is associated with more tortousity and is a predictor of a failure. However, previous randomized studies have not shown a significant reduction in procedural times or success utilizing the left radial compared to right radial access.^12-15

Orlando Marrero can be contacted at orlm8597@yahoo.com. Dr. Zaheed Tai can be contacted at zaheedtai@gmail.com.

References

1. Louvard Y, Ludwig J, Lefèvre T, Schmeisser A, Brück M, Scheinert D, et al. Transradial approach for coronary angioplasty in the setting of acute myocardial infarction: a dual-center registry.Cathet Cardiovasc Interv. 2002; 55: 206-211.
2. Mulukutla, SR, Cohen HA. Feasibility and efficacy of transradial access for coronary interventions in patients with acute myocardial infarction. Catheter Cardiovasc Interv. 2002 Oct; 57(2): 167-71.
3. 

   Post procedure EKG (click thumbnail to view larger image).

   Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: A systematic review and meta-analysis of randomized trials. Am Heart J. 2009 Jan;157(1):132-40.    
4. Jolly SS, Yusuf S, Cairns J, Niemelä K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography in patients with acute coronary syndromes (RIVAL): A randomized, parallel group, multicenter trial. Lancet. 2011 Apr 23; 377(9775): 1409-1420. 
5. Dehghani P, Mohammad A, Bajaj R, Hong T, Suen CM, Sharieff W, et al. Mechanism and predictors of failed transradial approach for percutaneous coronary interventions. JACC Cardiovasc Interv. 2009 Nov; 2(11): 1057-1064. 
6. Rathore S, Hakeem A, Pauriah M, Roberts E, Beaumont A, Morris JL. A comparison of the transradial and the transfemoral approach in chronic total occlusion percutaneous coronary intervention. Catheter Cardiovasc Interv. 2009 Jun 1; 73(7): 883-887. 
7. Watt J, Oldroyd KG. Radial versus femoral approach for high speed rotational atherectomy. Catheter Cardiovasc Interv. 2009; 74: 550-554.
8. Jaffe R, Hong T, Sharieff W, Chisholm RJ, Kutryk MJ, Charron T, Cheema AN. Comparison of radial versus femoral approach for percutaneous coronary interventions in octogenarians. Catheter Cardiovasc Interv. 2007 May 1; 69(6): 815-820.
9. Agostoni P, Biondi-Zoccai GG, deBenedictis ML, etal. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004 Jul 21;44(2):349-356.
10. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009 Jan;157(1):132-140.    
11. Kawashima O, Endoh N, Terashima M, Ito Y, Abe S, Ootomo T, et al. Effectiveness of right or left radial approach for coronary angiography. Catheter Cardiovasc Interv. 2004 Mar;61(3):333-337.
12. Sciahbasi A, Romagnoli E, Burzotta F, Trani C, Sarandrea A, Summaria F, et al. Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study. Am Heart J. 2011 Jan; 161(1): 172-179. 
13. Kanei Y, Nakra NC, Liou M, Vales LL, Gowda R, Rosero H, et al. Randomized comparison of transradial coronary angiography via right or left radial artery approaches. Am J Cardiol. 2011 Jan 15; 107(2): 195-197. 
14. Santas E, Bodí V, Sanchis J, Núñez J, Mainar L, Miñana G, et al. The left radial approach in daily practice. A randomized study comparing femoral and right and left radial approaches. Rev Esp Cardiol. 2009;62:482-490.
15. Freixa X, Trilla M, Feldman M, Jiménez M, Betriu A, Masotti M. Right versus left transradial approach for coronary catheterization in octogenarian patients. Catheter Cardiovasc Interv. 2012 Aug 1; 80(2): 267-272.