Optimizing PCI Approach for High-Risk CABG Patients
Explore the benefits and challenges of transradial PCI in high-risk CABG patients, highlighting the efficiency and overall considerations for post-CABG coronary angiography. Review the literature on radial vs. femoral PCI outcomes and address limitations in data and study design with a focus on optimizing patient care.
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Presentation Transcript
CABG Patients are High Risk, Transradial Makes Perfect Sense and Is More Efficient Kusum Lata, MD, FACC, FSCAI Interventional Cardiology Sutter Health, CA
Disclosures None
CABG Patients are High Risk Usually have severe atherosclerosis and complex lesions Higher risk of adverse cardiovascular events Often older and have a higher prevalence of diabetes and other risk factors Concomitant peripheral artery disease could increase the risk of femoral vascular complications Making Transradial an intriguing option
Coronary angiogram challenges in post-CABG Graft angiogram / PCI is more challenging compared to native coronary (variable position of the graft ostia, suboptimal guide catheter support, and the need for adjunctive devices for preventing distal embolization). Radial procedure presents additional technical issues (steeper learning curve, catheter size, radial spasm, which limits multiple catheter exchanges).
Radial Vs Femoral PCI in CABG Literature Review JACC Cardiovasc Interv. 2013 Nov;6(11):1138-44. doi: 10.1016/j.jcin.2013.08.004. Epub 2013 Oct 16.
Limitations of this study: Only men were included in the study Decision to perform ad hoc PCI in the 2 study groups was at the discretion of the operator, and as a result, fewer TR access patients underwent ad hoc PCI. Cardiology trainees often served as first operators High crossover rates from TR to TF access may have attenuated the differences between the 2 study groups JACC Cardiovasc Interv. 2013 Nov;6(11):1138-44. doi: 10.1016/j.jcin.2013.08.004. Epub 2013 Oct 16.
Limitations of data about Radial Angio / PCI in CABG Lack of randomized controlled trials Underrepresentation of CABG patients in the majority of the studies Selection bias and the learning curve of fellows physician who often assumed the role of a primary operator. Conflicting results of various observational studies Lack of #radialfirst strategy in CABG patient (#RadialfirstinCABG)
Tips and Tricks of Radial Angio / PCI in CABG Case preparations (know anatomy, graft markers) Familiarization with left radial approach Consider ulnar access Availability of advanced radial equipment s (various guides, guide extension, wires, balloons)
Why Transfemoral is less suitable in post CABG Increased risk of femoral access complications (eg, obesity, ongoing antithrombotic therapy, severe peripheral artery disease) Patient comfort Delay discharge
Benefits of Radial Access in post CABG Angio / PCI Less vascular complications Less bleeding Early discharge Patient comfort ? Mortality benefit
Conclusion Although firm evidence from a large, adequately powered RCT is lacking, RA offers several advantages compared to FA in performing diagnostic and interventional procedures in post CABG patients. Left RA is a straightforward approach to study the LIMA. The most important factor is the level of expertise in RA.
Questions? Email: lata.drkusum@gmail.com
