TRI for STEMI/ACS: Does it
RIVAL the Trans-Femoral
Approach?
Kimberly A. Skelding MD FSCAI FACC FAHA
Associate Interventional Cardiology
Director Cardiovascular Research
Director Women’s Heart and Vascular Health Program
Geisinger Health System Pennsylvania
PCI Is Associated With Bleeding
Retrospective Analysis of 10,974 “Real World” Patients at 3 Centers
TIMI major
588 (5.4%)
Hemorrhagic strokes
15 (0.13%)
Retroperitoneal
30 (0.27%)
Gastrointestinal
63 (0.57%)
Hematoma
370 (3.37%)
TIMI minor
1,394 (12.7%)
Gastrointestinal
88
Retroperitoneal
11
Hematoma
823
Transfusion
None
Kinnaird TD et al. Am J Cardiol. 2003;92:930-935.
(5.4%)
8,992 (81.9%)
Attempts to Lower Bleeding Risk
• Continued search for lower risk drugs
–
–
–
–
Thienopyridines
Dual anti-platelet therapy
Antithrombotics
2b3a’s
• Technique changes
–
–
–
–
Smaller sheaths
Vascular closure devices
Shorter timing for antithrombotics, sheaths out quicker
Radial approach
Bivalrudin reduces STEMI access site bleeding
• Decreased major
bleeding
• Decreased
mortality
• Increased early
stent thrombosis
risk
Stone et al. N Engl J Med 2008;358:2218-30.
PCI Complications
• Acuity Trial (NSTE-ACS)
• Major bleeding
– Intracranial, intraocular, or
retroperitoneal bleeding
– Access-site hemorrhage
requiring intervention
– Hematoma ≥5cm in diameter
– Decrease in Hg of ≥4 g/dl
without or ≥3g/dl with an overt
bleeding source
– Reoperation for bleeding
– Blood product transfusion
Lansky et al. Am J Cardiol 2009;103:1196-1203
PCI: NHLBI Dynamic Registry
• Shows improving outcomes for women (in-hospital
mortality)
– 1985-1986: Adjusted OR 4.53, 95% CI 1.39-14.7
– 1997-1998: Adjusted OR 1.60, 95% CI 0.76-3.35
• Most recent analysis includes BMS and DES (2001-2004)
–
–
–
–
–
–
Attempted lesions in women had a smaller RVD
Men had more vein graft PCIs
Otherwise, similar angiographic characteristics
No sex difference in death or MI in-hospital or at one year
No sex difference in stent thrombosis rates
Women have more vascular access site complications (p<0.001)
Abbott et al. Am J Cardiol 2007;99:626-631
Effect Most Pronounced in Women
Rao et al. J Am Coll Cardiol Intv 2008;1:379-86
Highest Bleeding Risk
•
•
•
•
•
•
Elderly
Female Sex
Lower BMI
Renal Disease
Baseline Anemia
Gp 2B/3A blockade usage
Moscucci, Eur Heart J. 2003 Oct;24(20):1815-23.
Bleeding and Mortality
• Bleeding complications independently
affect adverse outcomes, including
mortality
Doyle et al. J Am Coll Cardiol 2009;53:2019-2027
Bleeding ACS patients have high
mortality risk
Manoukian et al. J Am Coll Cardiol 2007;49:1362–8)
Blood Transfusions and
Mortality
• Blood transfusions independently
associated with mortality
• Patients with access site hematoma
requiring transfusion have 9x higher risk of
in-hospital death after PCI
Yatskar et al. Cathet Cardiovasc Interv 2007;69:961-966
Complications of Femoral
Access
•
•
•
•
•
•
•
•
Groin hematoma
Small (<5cm)
Mod (5-10cm)
Neuropathy
Large (>10cm)
Groin Infection
Thrombosis/Ischemia
Arterial dissection
Pseudoaneurysm
A-V fistula
Retroperitoneal hematoma
Berry et al. Am J Cardiol 2004;94:361-363
Dx only PCI
17% 31%
6%
11%
0.5%
2%
Retroperitoneal Hematomas
• Occur in up to 1% of
patients post-PCI, but also
diagnostic cases
• Mortality rate ~4%
• Independent Predictors
– High puncture site
– Being a woman (73%)
– Smaller body surface
area (BSA <1.73m2)
Farouque et al. JACC 2005;45:363-8
• Delay in recognition
increases morbidity:
– Blood loss,
transfusions
– Prolonged
hypotension
– Further tests/
procedures
Vascular Closure Devices
• Improved patient
comfort, time to
hemostasis, and
decreased LOS
compared to manual
compression
• No improvement in
vascular
complications
Sciahbasi et al. Int J Cardiol 2008
Nikolsky et al J Am Coll Cardiol 2004;44:1200-1209
Koreny et al. JAMA 2004;291:350-357
Groin complications
• Most common peri procedural complication of
cardiac catheterization
• Retroperitoneal hematomas have a mortality
rate of 4-10%
• If patient survives they encounter prolonged hospital
stay, multiple blood transfusions
(O.R. = 9.8)
Radial access has an 80% reduction in access
site bleeding compared to transfemoral access
Tremmel, Launching a Successful Transradial Program, Journal of
Invasive Cardiology, Aug 2009 Vol 21/Suppl A pg. 3A
The most common PCI related
complication
Preventable?
Radial vs. Femoral Access
• 3261 consecutive
interventional and/or
diagnostic procedures
• Major bleeding (A)
–
–
–
–
–
Women=black
Men=gray
RPH or death
Required surgical intervention
Required blood transfusions
Hg <4g/dl
Hematoma >50% of the limb, associated
with pt. discomfort and prolonged hospital
stay
• Minor bleeding (B)
– All other puncture-related hemorrhages
Pristipino et al. Am J Cardiol 2007;99:1216-1221
*p=0.0008 vs. radial; **p=0.00001 vs. radial
It is established that TRI will
reduce access site bleeding
Jolly et al. Am Heart J 2008;0:1-9.)
MORTAL Study
•
•
Association of the arterial access site at angioplasty with transfusion and mortality: the
M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion after percutaneous coronary
intervention via the Arm or Leg)
–
32,822 patients in British Columbia
–
Main outcome measures: 30-day and 1year
Results
29% Lower 30 Day Mortality
17% Lower 1 year Mortality
–
•
Results: 1134 (3.5%) patients had at least one blood transfusion. Transfused patients had a
significantly increased 30-day and 1-year mortality, adjusted odds ratio (95% CI) 4.01 (3.08 to
5.22) and 3.58
(2.94 to 4.36), respectively. By probit regression the absolute increase in risk of death at 1
year associated with receiving a transfusion was 6.78%. The number needed to treat was
14.74 (prevention of 15 transfusions required to “avoid” one death). Radial access halved the
transfusion rate. After adjustment for all variables, radial access was associated with a
significant reduction in 30-day and 1-year mortality, odds ratio = 0.71
(95% CI 0.61 to 0.82) and 0.83 (0.71 to 0.98), respectively (all P < 0.001).
Conclusion
–
In a registry of all comers to PCI, transradial access was associated
with a halving of the transfusion rate and a reduction in 30-day and
1-year mortality.
Heart. 2008;94:1019-1025 doi:10.1136/hrt.2007. 136390.
RA associated with lower mortality
NNT by the radial artery
was 1000 patients to
save 1 life
Chase et al. Heart 2008;94:1019-1025
Learning Curve Issues
Careful planning, patient selection and
training of entire team will shorten this
Louvard et al. 2004; Spaulding et al. Cathet Cardiovasc Interv 1996;39:365
Tremmel, J. A. J Invasive Cardiol 2007;21:3A-8A
Patient height predicts TRI failure
• Pt less than 5’ 5” had
a greater than 6%
failure rate
• Pts. Greater than 5’ 9”
had a less than 3%
failure rate
• Short Aorta or
Subclavian disease
likely the cause
Improving Success Rates
• Dehghani reviewed
2100 TRI case – overall
failure rate of 5%
• Height and age (>75)
were independent
predictors of failure
• 95% of cases done from
the right arm
Dehghani J Am Coll Cardiol Intv 2009;2:1057– 64
Catheter’s Course
Right Radial
2 points of
resistance
Compliments of Gilchrist.
Left Radial
Femoral
1 point of
resistance
1 point of
resistance
Reasons for failure
• Only about 10% due
to puncture failure
• About 50% due to
forearm issues
• 35% due to
subclavian and
catheter seating
troubles
Dehghani JACC Interv 2009;2 :1057-64
Influence of Single TR Operator
Cohen, M. G., Alfonso, C. J Invasive Cardiol 2007;21:11A-17A
Why do transradial for STEMI?
• Increased anticoagulants increased
bleeding risk
• Earlier ambulation
• Increased patient comfort
The largest benefit of TRI access site
bleeding reductions occur in STEMI.
• 1.8 absolute RR in all
PCI patients
• 3.1 absolute RR for
major bleeding in
STEMI pts.
• 32 STEMI patients
treated to prevent one
major bleed
Jolly et al. Am Heart J 2008;0:1-9
What do we see from the data
• When applied to STEMI, TRI can provide an
approximately 75% reduction in access site
bleeds.
• In experienced hands, TRI success rates are
high, with femoral crossover ranging from 0 –
7%
• In experienced hands, reperfusion times are
minimally if at all increased.
Safe & Feasible Primary PCI
• Lower vascular access complications,
shorter length of stay.
• Lower bleeding both minor and major
regardless of antithrombotic or
antiplatelet agents.
• Lower one year death/MI
• Meta-analysis finds lower stroke rate
Eichhofer J et al. Am Heart J 2008;156:864-870. Cruden N et al CCI 70;670-675 (2007).Sciahbasi A et al Am J
Cardiol 2009;103:796-800. Vorobesuk A et al. Am Heart J 2009;158:814-821. Gilchrist et al 2010.
Vorobcsuk et al, Am Heart J 2009;158:814-21
Vorobcsuk et al, Am Heart J 2009;158:814-21
Vorobcsuk et al, Am Heart J 2009;158:814-21
Early Randomized studies of TRI in STEMI
Study
Patients
randomized
Crossover to
femoral
Reperfusion
times
Brasselet et al
57 TRI
57 Femoral
12%
Not reported
184 TRI
186 Femoral
1%
No difference
25 TRI
25 Femoral
4%
TRI 6 minutes
slower
Heart 2007 93: 1556-1561
Lee et al.
Chin Med J 2007;120 (7):598(7):598-600
Cantor et al
Am Heart J 2005;150:543-9
Chotor et al
Cardiology Journal 2009(16). 4,332–40
124 TRI
116 Femoral
0%
TRI 11 minutes
slower
1051 STEMI pts over a 4 year period
• Inconsistent
transradial usage
• Shock patients
excluded
Hetherington et al, Heart – online publication, July 2009
 Higher procedural failures with TRI
 Higher “crossover” to femoral for failed access
 Similar in – room procedure times
Hetherington et al, Heart – online publication, July 2009
Why doesn’t everyone do TRI for
STEMI
• Learning curve
• Concern about D2B time
• Concern for need for mechanical
support
Report Card Times
Kim et al, Yonsei Med J 2005;46(4):503-510
Procedural Characteristics
•Smaller sheaths with TRI
•Less IABP with TRI
Kim et al, Yonsei Med J 2005;46(4):503-510
Outcomes
•Lower death with TRI
•Lower TVR with TRI
•Lower bleeding with TRI
•Decreased vascular events with TRI
•Shorter length of stay
Kim et al, Yonsei Med J 2005;46(4):503-510
D2B Times
• 316 consecutive STEMIs
– Femoral n=204 (72 +14 min) vs radial n=109 (70
+17 min), p>0.27, with less access complications,
p<0.05
• 489 consecutive radial (21.4 + 11.8) vs.
femoral (22.8 + 10.3), p=0.68
• 205 consecutive STEMIs
– Femoral 86.5 min vs radial 76.4 min, p=0.008
– IH death 3.2% radial vs 9.5% femoral, p=0.08
Pancholy S et al CCI 2010, Weaver et al CCI 2010, Arzamendi D et al Am J Cardiol 2010
STEMI Numbers
4/1/2009-3/31/2011 (2 Year Span)
80
69.65
70
71.98
70.15
72.4
60
50
40
Radial
Femoral
32.56 31.79
30
20
10
0
16.62
8.29 8.49
8.33
18.19 19.14
20.66
9.67
2.52 2.53
Lab A r r ival t o
Sheat h I nser t
Sheat h I nser t
t o W i r e C r o ss
Lesi o n
Lab A r r i val t o
W i r e C r o ss
l esio n
Lab A r r i val t o
D evi ce
A ct i vat i o n
G M C A r r ival
t o W i r e C r o ss
Lesi o n
ED
Pr esent at i o n
t o W i r e C r o ss
Lesi o n
W i r e C r o ss
Lesi o n t o
D evi ce
A ct ivat io n
D o o r t o B al l o n
STEMI Numbers
4/1/2009-12/31/2009
80
76.63
74.6
69.58
67.58
70
60
50
40
29.04
30
17.6
20
10.07
10
Radial
Femoral
36.63
7.99
7.53
19.8
16.28
18.31
8.28
2.2 2.18
0
Lab A r r ival t o
Sheat h I nser t
Sheat h I nser t
t o W i r e C r o ss
Lesi o n
Lab A r r i val t o
W i r e C r o ss
l esio n
Lab A r r i val t o
D evi ce
A ct i vat i o n
G M C A r r ival
t o W i r e C r o ss
Lesi o n
ED
Pr esent at i o n
t o W i r e C r o ss
Lesi o n
W i r e C r o ss
Lesi o n t o
D evi ce
A ct ivat io n
D o o r t o B al l o n
STEMI Numbers
1/1/2010-12/31/2010
80
71.12
72.57
73.55
75.17
70
60
50
40
Radial
Femoral
34.75
30.61
30
23.08
20.1
20
10
0
15.48
7.32
8.87
18.11
11.17
8.16
2.62 2.98
Lab A r r ival t o
Sheat h I nser t
Sheat h I nser t
t o W i r e C r o ss
Lesi o n
Lab A r r i val t o
W i r e C r o ss
l esio n
Lab A r r i val t o
D evi ce
A ct i vat i o n
G M C A r r ival
t o W i r e C r o ss
Lesi o n
ED
Pr esent at i o n
t o W i r e C r o ss
Lesi o n
W i r e C r o ss
Lesi o n t o
D evi ce
A ct ivat io n
D o o r t o B al l o n
STEMI Numbers
1/1/2011-3/31/2011
80
72.08
70.44
70
60
57.89
55.47
50
40
Radial
Femoral
34.58
30
30
22.58
20
20
10
9.68
9.08
17.88
19.76
10.32
8.8
2.58
0
Lab A r r ival t o
Sheat h I nser t
Sheat h I nser t
t o W i r e C r o ss
Lesi o n
Lab A r r i val t o
W i r e C r o ss
l esio n
Lab A r r i val t o
D evi ce
A ct i vat i o n
G M C A r r ival
t o W i r e C r o ss
Lesi o n
ED
Pr esent at i o n
t o W i r e C r o ss
Lesi o n
1.88
W i r e C r o ss
Lesi o n t o
D evi ce
A ct ivat io n
D o o r t o B al l o n
A randomized comparison of
RadIal Vs. femorAL access for
coronary intervention in ACS
(RIVAL)
SS Jolly, S Yusuf, J Cairns, K Niemela, D Xavier, P
Widimsky, A Budaj, M Niemela, V Valentin, BS Lewis,
A Avezum, PG Steg, SV Rao, P Gao, R Afzal, CD
Joyner, S Chrolavicius, SR Mehta on behalf of the
RIVAL Steering committee
Bleeding is associated with
Death and Ischemic Events
HR 5.37 (3.97-7.26)
14.0%
HR 4.44 (3.16-6.24)
12.0%
10.0%
8.0%
No Major Bleed
Major Bleed
6.0%
4.0%
HR 6.46 (3.54-11.79)
2.0%
0.0%
Death
MI
Eikelboom JW et al. Circulation 2006;114(8):774-82.
Stroke
Prior Meta-analysis of 23 RCTs
of Radial vs. Femoral (N=7030)
Major bleeding
0.27 (0.16-0.45)
Death
0.74 (0.42-1.30)
Death, MI or stroke
0.71 (0.49-1.01)
PCI Procedure Failure
1.31 (0.87-1.96)
Radial better
Jolly SS, et al. Am Heart J 2009;157:132-40.
1.0
Femoral better
RIVAL Study Objective
• To determine if Radial vs. Femoral access for
coronary angiography/PCI can reduce the
composite of death, MI, stroke or non-CABG
major bleeding in ACS patients
RIVAL Study Design
NSTE-ACS and STEMI
(n=7021)
Key Inclusion:
•Intact dual circulation of hand required
•Interventionalist experienced with both (minimum 50 radial
procedures in last year)
Randomization
Radial Access
(n=3507)
Femoral Access
(n=3514)
Primary Outcome: Death, MI, stroke
or non-CABG-related Major Bleeding at 30 days
Jolly SS et al. Am Heart J. 2011;161:254-60.
Study Outcome Definitions
Major Bleeding
(CURRENT/
OASIS 7)
• Fatal
• > 2 units of Blood transfusion
• Hypotension requiring inotropes
• Requiring surgical intervention
• ICH or Intraocular bleeding leading to significant vision loss
Major Vascular
Access Site
Complications
• Large hematoma
• Pseudoaneurysm requiring closure
• AV fistula
• Other vascular surgery related to the access site
Final Recruitment
RIVAL sub-study during
OASIS 7/CURRENT
N= 3831
+
RIVAL Stand-Alone
After CURRENT
N= 3190
RIVAL
Total
N=7,021
Follow-up complete in 99.9%
CURRENT-OASIS 7. N Engl J Med. 2010;363:930-42.
Mehta SR, et al. Lancet. 2010; 376:1233-43.
International Study
North America
1614
Europe 3564
Middle
East/Israel 239
Asia
1117
South America 423
Australia and New
Zealand 64
Baseline Characteristics
Radial
(n =3507)
Femoral
(n =3514)
62
62
Male (%)
74.1
72.9
Diabetes (%)
22.3
20.5
UA (%)
44.3
45.7
NSTEMI (%)
28.5
25.8
STEMI (%)
27.2
28.5
Mean Age (years)
Diagnosis at presentation
Therapies - Initial Hospitalization
Radial
Femoral
(n=3507)
%
(n=3514)
%
ASA
99.2
99.3
Clopidogrel
96.0
95.6
LMWH
51.5
51.8
UFH
33.3
31.6
Fondaparinux
10.9
10.8
Bivalirudin
2.2
3.1
GP IIb IIIa inhibitors
25.3
24.0
PCI
65.9
66.8
CABG
8.8
8.3
Operator Volume
Procedure Characteristics
Radial
(n=3507)
Femoral
(n=3514)
300
(190, 400)
300
(190,400)
40
(25,70)
40
(25, 70)
95.4
95.2
HR (95% CI)
P
value
1.01 (0.95-1.07)
0.83
Operator Annual
Volume
PCI/year
(median, IQR)
Percent Radial PCI
(median, IQR)
PCI Success
• Vascular closure devices used in 26% of Femoral group
Primary and Secondary Outcomes
Radial Femoral
HR
95% CI
P
4.0
0.92
0.72-1.17
0.50
3.2
3.2
0.98
0.77-1.28
0.90
0.7
0.9
0.73
0.43-1.23
0.23
(n=3507)
(n=3514)
%
%
3.7
Primary Outcome
Death, MI, Stroke,
Non-CABG Major
Bleed
Secondary Outcomes
Death, MI, Stroke
Non-CABG Major
Bleeding
Other Outcomes
Radial Femoral
Major Vascular
Access Site
Complications
TIMI Non-CABG
Major Bleeding
ACUITY Non-CABG
Major Bleeding*
* Post Hoc analysis
HR
95% CI
P
(n=3507)
(n=3514)
%
%
1.4
3.7
0.37 0.27-0.52 <0.0001
0.5
0.5
1.00 0.53-1.89
1.9
4.5
0.43 0.32-0.57 <0.0001
1.00
Other Outcomes
Radial Femoral
HR
95% CI
P
1.5
0.86
0.58-1.29
0.47
1.7
1.9
0.92
0.65-1.31
0.65
Stroke
0.6
0.4
1.43
0.72-2.83
0.30
Stent Thrombosis
0.7
1.2
0.63
0.34-1.17
0.14
(n=3507)
(n=3514)
%
%
Death
1.3
MI
Other Outcomes
Radial
Femoral
(n=3507)
(n=3514)
Access site Cross-over (%)
7.6
2.0
<0.0001
PCI Procedure duration (min)
35
34
0.62
Fluoroscopy time (min)
9.3
8.0
<0.0001
2.6
3.1
0.22
90
49
<0.0001
Persistent pain at access site
>2 weeks (%)
Patient prefers assigned
access site for next
procedure (%)
P
Access Site Major Bleeds
HR 0.50 (95% CI 0.19-1.33)
12
6*
Allocated to
Radial
Allocated to
Femoral
*All access site major bleeds actually occurred at femoral arterial
site (in radial group due to cross-over or IABP)
RIVAL
Subgroups: Primary Outcome
Death, MI, Stroke or non-CABG major Bleed
Overall
Age
<75
≥75
Gender
Female
Male
BMI
<25
25-35
>35
Radial PCI Volume/year by Operator
≤70
70-142.5
>142.5
Radial PCI Volume by Centre
Lowest Tertile
Middle Tertile
Highest Tertile
Clinical Diagnosis
NSTE-ACS
STEMI
0.25
Radial better 1.00 Femoral better4.00
Hazard Ratio(95% CI)
p-value
Interaction
0.79
0.36
0.83
0.54
0.021
0.025
RIVAL
Results stratified by High*, Medium* and Low* Volume radial Centres
*High (>146 radial PCI/year/ median operator at centre),
Medium (61-146), Low (≤60)
HR (95% CI)
Tertiles of Radial PCI Centre Volume/yr
Primary Outcome
High
Medium
Low
Death, MI or stroke
High
Medium
Low
Non CABG Major Bleed
High
Medium
Low
Major Vascular Complications
High
Medium
Low
Access site Cross-over
High
Medium
Low
1.00
No significant interaction by Femoral 0.25
Radial better
PCI center volume
Hazard Ratio(95% CI)
p-value
Interaction
0.021
0.013
0.538
0.019
0.003
4.00
Femoral better
16.00
RIVAL
Outcomes stratified by STEMI vs. NSTEACS
%
%
2N Radial Femoral
Primary Outcome
NSTE/ACS
5063 3.8
3.5
STEMI
1958 3.1
5.2
Death, MI or stroke
NSTE/ACS
5063 3.4
STEMI
1958 2.7
Death
NSTE/ACS
5063 1.2
STEMI
1958 1.3
Non CABG Major Bleed
NSTE/ACS
5063 0.6
STEMI
1958 0.8
Interaction
p-value
0.025
2.7
4.6
0.011
0.8
3.2
0.001
1.0
0.9
0.56
Major Vascular Complications
NSTE/ACS
5063 1.4
3.8
STEMI
1958 1.3
3.5
0.89
0.25
1.00
Radial better
Hazard Ratio(95% CI)
4.00
Femoral better
Updated Meta-analysis of RCTs
Radial(%) Femoral(%)
Non-CABG Major Bleeds
Pre-RIVAL
0.2
RIVAL
0.7
Combined
0.5
1.2
0.9
1.0
P-value
Heterogeneity
p-value
0.40
0.002
Major Vascular Access Complication
Pre-RIVAL
0.6
2.5
RIVAL
1.4
3.7
Combined
1.0
3.1
0.41
<0.0001
Death,MI or Stroke
Pre-RIVAL
RIVAL
Combined
0.72
0.17
0.67
0.005
2.3
3.2
2.8
3.3
3.2
3.3
Death, MI or Stroke (Radial Experts)
Pre-RIVAL*
RIVAL **
Combined
2.8
1.3
2.3
4.1
2.7
3.5
*Radial Expert Centres defined as centres default approach radial
or known expert radial centre
** High volume radial centres (highest tertile)
0.25
1.00
4.00
Radial better
Femoral better
Odds Ratio(95% CI)
Conclusion
• No significant difference between radial and
femoral access in primary outcome of death, MI,
stroke or non-CABG major bleeding
• With radial access compared to femoral, rates of
primary outcome appeared to be lower in high
volume radial centres and STEMI
• Radial had fewer major vascular complications but
similar PCI success
Implications
• Both radial and femoral approaches are safe and
effective
• Increasing experience may improve outcomes
with radial access
• Clinicians and patients may choose radial
because of its similar efficacy and reduced
vascular complications
Using TRI for all cases
• Start with cases you likely will be successful with, but become nonselective
– Radial first, radial default
• Selective Operators aka “dabblers”
– Slower to achieve technical excellence
– Never fully realize transradial potential
– Never get to the groups with the most to gain
• Higher risk STEMI/NSTEMI
• Elderly
• Women
Beginnings
• Start with catheters you know and work
on technique
– Decrease the number of new variables
• Once confident, consider specialty
catheters
• You don’t need any special equipment
besides a hydrophilic sheath
• Transradial first, femoral as bailout
– The groin is always there if you need it
• Improvement in outcomes particularly
bleeding (and particularly in women)
• STEMI & high risk patients
– Rotablator, bifurcations, unprotected left
main, old & small women
Positioning the
morbidly obese
patient
Radial vs. Femoral
• “Where else in medicine do we have two equally efficacious therapies, yet
we routinely use the one that poses more risk and discomfort to our
patients?” - Jennifer Tremmel MD, Transradial Debate 2009
Conclusions
• TRI offers an opportunity to perform
rapid and successful PCI of STEMI
• TRI offers an opportunity to
substantially impact major bleeding in
STEMI patients, and now decreased
death, MI, stroke
Unanswered Questions
• Will applying TRI to a large number of
STEMI patients improve survival ?
• Are there subsets of patients who will
derive greater benefit from TRI in
STEMI?
• Are there ways to further improve
success rates and decrease D2B in
STEMI ?
• WE NEED MORE STUDIES BUT THE
DATA IS BUILDING