J. Monségu

Hôpital Val-de-Grâce, Paris

58 ans d’expérience

Grosse artère

Accès « facile »

Une condition sine qua none: qualité de la ponction

Saignements Hématome rétropéritonéal Hématome fémoral / perforation

Faux-anévrysme Fistule artério-veineuse Dissection Infection Ischémie membre

Thrombose Embolie de cholestérol

Chandrasekar CCI 2001; 52: 289-295

worthwhile to consider data from previous studies and

the change in scenario that has since taken place.

Previous Registry and Single-Center Studies

The Collaborative Studies in Coronary Artery Surgery

(CASS) registry, which analyzed 7,553 consecutive pa-

tients undergoing coronary angiography, reported a mor-

tality rate of 0.2%, a nonfatal myocardial infarction rate

of 0.25%, and a local complication rate (brachial

femoral) of 0.7% [1]. In 1982, the Society for Cardiac

Angiography reported a complication rate of 1.77% and

a mortality rate of 0.14% for cardiac catheterization in a

study population of 53,581 patients (with wide age vari-

ation, from 1 yr to 60 yr). A nonfatal myocardial

infarction rate of 0.07% and a local complication rate of

0.57% (brachial femoral) also were noted [2]. The data

for the years 1984–1987 (222,553 patients), as found in

the Society for Cardiac Angiography and Interventions

registry, showed a complication rate of 1.74%, a mortal-

ity rate of 0.1%, a nonfatal myocardial infarction rate of

0.06%, and a local complication rate of 0.46% [3]. This

registry reported a similar incidence of complications for

diagnostic procedures in the 1990s. For 1990 and 1991,

respectively, the registry documented a complication rate

of 1.7% and 1.5%, a mortality rate of 0.11% and 0.11%,

a nonfatal myocardial infarction rate of 0.05% and

0.06%, and a local complication rate of 0.43% and 0.44%

[4,5]. More recently, an evaluation of 33,776 adult diag-

nostic cardiac catheterizations by the Joint Audit Com-

mittee of the British Cardiac Society and Royal College

of Physicians of London showed a complication rate of

Fig. 2. Complications of diagnostic and

therapeutic procedures.

TABLE I. Incidence of Cardiac Complications

Complication

Diagnostic

(n 7,953)

Therapeutic

(n 3,868)

Total

(n 11,821)

Death 34 (0.4) 42 (1.1) 76 (0.6)

Procedure-related

deatha 8 (0.1) 21 (0.5) 29 (0.2)

Q-MI 3 (0.04) 24 (0.6) 27 (0.2)

Non-Q-MI 5 (0.06) 133 (3.4) 138 (1.2)

Emergency

CABG 4 (0.05) 13 (0.3) 17 (0.1)

Acute closure 5 (0.06) 80 (2.1) 85 (0.7)

Pulmonary

edema 11 (0.1) 21 (0.5) 32 (0.3)

Q-MI, Q-wave myocardial infarction; non-Q-MI, non-Q-wave myocardial

infarction; CABG, coronary artery bypass grafting.aDescribed in the Results section.

TABLE II. Stent Failure

Complication n (%)

Failure to cross lesion with stent 18 (1.4)

Loss of stent 9 (0.7)

Emergency cardiac surgery 6 (0.5)

Deatha 3 (0.2)

aIncludes two deaths in patients in whom stents were implanted as a rescue

procedure following acute closure.

TABLE III. Incidence of Local Complications

Complication

Diagnostic

(n 7,953)

Therapeutic

(n 3,868)

Total

(n 11,821)

Hematoma 26 (0.3) 24 (0.6) 50 (0.4)

Pseudoaneurysm 61 (0.8) 27 (0.7) 88 (0.7)

A-V fistula 9 (0.1) 5 (0.1) 14 (0.1)

Transfusion 42 (0.5) 64 (1.7) 106 (0.9)

Bleedinga 9 (0.1) 11 (0.3) 20 (0.2)

A-V fistula, arterio-venous fistula.aFresh external re-bleeding after initial uncomplicated hemostasis.

292 Chandrasekar et al.

11 821 pts Prospectif mono-centrique 1996-1998

Exp Mayo-Clinic N= 17 901 1994-2005

Doyle JACC Interv 2008; 1: 202-9

Blankenship Am Heart J 1999; 138: S287-S296

Durée moyenne d’hospitalisation

(jours)

Sur-coût

Pas de saignement / pas de complication vasculaire

+ 1

Saignement mineur / complication vasculaire mineure

+ 2

+ 1327 $

Saignement majeur / complication vasculaire chirurgicale

+ 4

+ 5896 $

Smilowitz Am J Cardiol 2012; 110: 177-82

9108 procédures 71% fermetures Rétrospectif Mais aussi 1.23% d’échecs

pas de complication au point de ponction

moins de mortalité

ambulation rapide

confort du patient

hospitalisation plus courte

gain en coût

F Agostini, J Am Coll Cardiol 2004;44:349-56

Radiale 0.3% vs fémorale 2.8% p=0.0001

Eikeboom Circulation 2006: 114:774-782

12.8%

2.5%

P<0.0001

•34146 p from Oasis reg. – Oasis 2 st. – Cure st.

• ACS without persistent ST segment elevation

• Patients with Major bleeding were :

Older / Often diabetics / History of stroke /

BP

serum creat / Often ST movement

- 5 x incidence of death during the first 30

days

A Chase, Heart 2008;94: 1019-25

p < 0.001

A Chase, Heart 2008;94: 1019-25

PATIENT QUALITY OF LIFE

SCIAHBASI A ET AL. INT J CARDIOL 2009;137:199-205

Thursday, September 29, 2011

Sciahbasi Int J Cardiol 2009; 137: 199-205

COURTESY OF B FAURIE ANDJ MONSEGU, MD (PARIS, 2010)

ADAPTED FROM S RAO, 2011

Thursday, September 29, 2011

Amoroso Eur J Cardiovasc Nurs 2005; 4: 234-41

courbe d’apprentissage

• sélection – préparation - spasme

• difficultés techniques

taille de la radiale

choix et support du guiding

occlusion

Left radial approach for coronary angiography: results of a prospective study

Spaulding Cathet Cardiovasc Diagn 1996;39(4):365-70

Causes des 475 échecs (7%): échec de ponction (69%), difficultés anatomiques (16%), spasme (8%), échec d’intubation (5%) ou autres (2%)

Analyse multivariée sur une large série : 6 962 radiales (94-98)

G.Barbeau AHA 1999

1533 patients

Anatomie normale

Bifurcations hautes

Boucles radiales

Tortuosités radiales

Autres anomalies

No. de patients

1321 (86%) 108 (7%) 35 (2.3%) 30 (2%) 39 (2.5%)

Femme % 28 29 49 50 33

Age 63.0±11.0 65.5±10.8 69.8±10.4

72.2±7.7 65.1±11.8

Tps Procedure

(min) 41.3±21.5 45.2±23.2

49.4±17.1

41.0±12.7 42.1±19.2

Durée rayons (min)

9.7±8.0 9.3±6.5 10.0±6.6 10.7±6.5 9.6±7.1

Echec % 0.9 4.6 37.1 23.3 12.9%

Lo, Heart 2009; 95: 410-5

4F 5F 6F 7F 8F

Diamètre de la radiale (mm)

100

80

60

40

20

0

hommes

femmes

1.6 2.0 2.4 2.8 3.2 4.4 3.6 4.0 1.2

Fre

qu

en

ce (

%)

Désilets

Saito S. CCI 1999

JR 4.0

BMW GW in RV branch

Guide wire in RCA

2.0 mm balloon inflated in RV branch

sidebranch

Main vessel

CHOIX DU CATHÉ-GUIDE – INTUBATION

GUIDE À SUPPORT– 2 GUIDES – “5 DANS LE 6"

TECHNIQUE DE L’ANCHORING

Survient dans 3-10% des cas

Facteurs prédictifs:

Learning curve

Durée de la procédure

Spasme

Ponction redux

Dose d’héparine

Ratio ratio cathé-guide/diamètre radiale

Compression

Occlusion predictive factors p

Previous radial approach 0.022

Sheath size 0.041

Sheath type 0.001

Doppler control of RAdial artery after use of TR BAND (DRABAND)

Occlusion 3.8%

Monségu TCT 2012 Pancholy J Inv Cardiol 2009; 21: 101-4

Syndrome coronaire aigu

Patients obèses

Patients âgés

Insuffisant rénal

Jolly Lancet 2011; 377: 1409-20

Jolly Lancet 2011; 377: 1409-20

Romagnoli, JACC 2012 End-point composite

Romagnoli, JACC 2012

Romagnoli, JACC 2012

La radiale est le facteur prédictif le plus fort dans la réduction du risque de complications vasculaires

Am J Card 2004;94:1174-7

0.000152.4 +/- 25.235.5 +/- 25.8Durée (min)

0.00631.9 +/- 1925.3 +/- 18.6Durée de l’angio (min)

0.00316 (10.2%)7 (1.8%)Hématome

0.00018 (5.1%)3 (0.8%)Complications vasculaires*

0.042.5 +/- 4.31.8 +/- 2.3Durée hosp après C (j)

NS4.2 +/- 4.73.6 +/- 3.9Durée Hosp (j)

0.008198 +/- 112167 +/- 97Qté contraste (ml)

PFémorale (n=157)Radiale (n=398)

Fémorale vs Radiale

* avec transfusion Benamer et al TROP Study EuroIntervention 2007; 3: 327-32

Fémorale n=185

Radiale n=192

p value

Evènement vasculaire majeur 6.5% 1.6% 0.029

Chirurgie vasculaire 0% 0.5% ns

Transfusion 1.6% 1% ns

Faux anévrysme 1.1% 0.5% ns

Chute d’hémoglobine 3.8% 0.5% 0.063

Large hématome 6.5% 1.6% 0.031

Hématome 11.4% 3.5% 0.003

Accident vasculaire cérébral 0.6% 0% ns

Louvard et al Am J Card 2004;94:1177-80

Vuurmans T, Heart 2010;96:1538-1542.

Vuurmans T, Heart 2010;96:1538-1542

Vuurmans T, Heart 2010;96:1538-1542

Les essais transformés Fémorale: taux de succès

Radiale: réduction des complications, réduction de mortalité, réduction du coût et durée d’hospitalisation

Les pénalités Fémorale: taille du désilet

Radiale: confort, ambulation précoce

Score final: 10 – 27