Marden Tabet ING.pmd - Revista Brasileira de Cardiologia Invasiva

Tebet MA, et al. Primary Angioplasty Using the Radial Access With High Bolus Dose of Tirofiban: a Safe and Effective Technique.
Rev Bras Cardiol Invas 2007; 15(3).
can bring about a significant increase of complications,
time of stay in hospital and cost of the procedure,
especially when the angioplasty is performed under
the aggressive regime of anticoagulation and antiplatelet
therapy, especially with the use of glico-protein inhibitors
Iib/IIIa (GPI) 4 .
The use of the transradial access is based on the
reduction of hemorrhagic complications in the vascular
access site and long rest in bed. Several studies have
confirmed its applicability and potential advantages
over the femoral approach 5-9 , with equal success and
less hemorrhagic complications, even with the use of
an aggressive anti thrombotic regime, including GPI 4.
In spite of some conflicting results, studies have
established the safety and efficacy of GPIs during primary
angioplasty 10-13 . The current guidelines specifically recommend
the use of abciximab during primary PCI as
a class I 3 indication.
In patients with acute coronary syndromes, the TAR-
GET 14 study showed less efficacy of tirofiban when compared
to abciximab. It is believed that this is due to, mainly,
to an inadequate platelet inhibition in the first hours after
administering tirofiban during the procedure 14-19 . The use
of bolus with an increased dose of tirofiban have shown
platelet inhibition and similar clinical results to those
found with abciximab 20-22 . The substitution of abciximab
for tirofiban, administered with a bolus regime with increased
dose, is a promising strategy, which might show itself to
be cost effective.
The objective of this study is to assess the effectiveness
of primary angioplasty through the radius associated
to the use of bolus with an increased dose of
tirofiban.
METHOD
Between January 2006 and May 2007, 79 patients
with AMI with augmented ST segment were submitted
to primary angioplasty in our service. Seventy-three
patients made up the sample (92%). Six patients were
excluded from the sample due to the non-use of the
radial technique: three for lack of radial pulse (two for
previous use of the Sones technique and one due to
previous catheterism and angioplasty through direct
radial approach), two for cardiogenic shock and total
atria ventricular blockage with the need of a temporary
pacemaker, and another patient who evolved with
coronary embolization during an hemodynamic study
for mitral valvulopathy.
Late follow up was obtained in all the patients, either
through their case histories or through telephone calls.
The choice vessel was the right radial. The choice
of the radial technique occurred through the Allen
modified test. If the test were negative, the other vessel
used was the left radial. Short introducers (8 cmts)
were used: French 6. A solution with 5000 UI of heparin
2
sulfate and 10 mg of issosorbide mononitrate was
injected through the introducer. The procedures were
performed with the habitual techniques. Stents were
implanted with the direct or conventional technique.
The removal of the introducers was performed immediately
after the procedure; the haemeostasis was done
with a porous compressive elastic bandage (Tensoplast ® ),
for about four hours. After this period, compression was
relaxed and a small sticking plaster was used during
24 hours. There was no need of haemostatic devices.
The functional circulation of the hand was verified
after one hour.
All patients received 300 mg of aspirin in the
emergency room. Clopidogrel was administered in the
hemodynamic room, using a dose of 300 mg or 600 mg
respectively, with or without tirofiban. Non-fractioned
Heparin was used in all the patients in a total dose of
100 U/kg. Tirofiban was used at the discretion of the
operator, in the dose of 25 u/kg in 3-minute bolus and
in the maintenance dose of 1.5 u/kg/min for 12 – 18
hours. A catheter for the aspiration of coronary thrombi
was also used at the operator’s discretion (Pronto ® ).
The outcomes used were: angiographic success
(percentual of the diameter of the stenosis of the target
vessel < 20% and coronary flux in the target vessel
TIMI 3), general in-hospital death, complications in
the arterial access – such as major bleeding (determiners
of a long hospital stay, surgical intervention, blood
transfusion or hemorrhagic stroke), arterio-venous fistulae,
ischemia of the limb with the need of vascular
surgery and failure of the procedure, defined as the
need of a second vessel entry or failure of the procedure
due to the impossibility of canalization of the radial
artery or conclusion of the coronary angioplasty or
due to a major complication in the site of the arterial
punction.
The continuous variables were expressed in medians
and standard deviation and, the categorical variables,
in absolute numbers and their percentual.
RESULTS
The majority (73.8%) of the patients were male.
There was a low incidence of patients with a previous
history of myocardial infarction, coronary angioplasty
and myocardial revascularization surgery. The demographic
data is in Table 1. Most of the patients were
unilateral and there was a higher striking of the right
coronary artery (Table 2). Angiographically visible
thrombi occurred in 18 (24.6%) of the patients but
thrombectomy was performed in only 22% of that
population, beginning in October 2006). The bolus
regime, with increased dose of tirofiban, was used in
74% of the patients. In our sample, seven (9.5%) of the
patients were 75 years old or more and out of these,
four (5.4%) used tirofiban without any bleeding episodes,
neither major nor minor. Heparin was not used