Marden Tabet ING.pmd - Revista Brasileira de Cardiologia Invasiva

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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
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). after the procedure. Stents were implanted in 69 (94.5%) of the patients. All exams were performed successfully through the radial access. The catheters used for the left and right coronary arteries were the extra back-up (85%) for the left and Judkins for the right artery (86%), respectively. Angiographic success took place in 70 (95.8%) of the patients. Table 3 shows the occurrence of major adverse events. There were three in-hospital deaths. One hap- TABLE 1 Basic Characteristics Basic Characteristics Total (n=73) Mean age 60.8±10.4 Male gender (%) 51 (69.8) HAS (%) 50 (68.4) Diabetes (%) 15 (20.5) Dislipidemia (%) 26 (35.6) Family History of ICO (%) 8 (10.9) Previous AMI (%) 4 (5.4) Smoking (%) 35 (47.9) Revascularization surgery (%) 0 (0) Previous Angioplasty (%) 1 (1.3) TABLE 2 Angiographic and Total Procedural Characteristics Angiographic and procedural Total (n=73) characteristics Number of vessels treated Single artery (%) 35 (47.9) Bi-artery (%) 23 (31.5) Tri-artery (%) 15 (20.5) Vessels treated DA (%) 30 (41.1) CX (%) 6 (8.2) CD (%) 37 (50.6) Angiographic Thrombus (%) 18 (24.6) Balloon time (min) 84.3±26.5 Pre TIMI Flux TIMI 0/1 pre (%) 61 (83.5) TIMI 2/3 pre (%) 12 (16.4) Tirofiban Bolus 25 µ/Kg. (%) 54 (74) Aspiration Catheter (%) 4 (5.4) Stent implant (%) 69 (94.5) Post TIMI Flux TIMI 0/1 post (%) 3 (4.1) TIMI 2/3 post (%) 70 (95.8) Angiographic Success (%) 70 (95.8) pened 12 hours after angioplasty, which was angiographically successful, due to refractory ventricular fibrillation. The second death occurred on the fourth day of hospitalization, after an unsuccessful angiography (noreflow), due to refractory cardiogenic shock. The last patient, admitted for extensive anterior AMI with a 10hour evolution, presented an angiographic thrombi, more than 15 mm in extension, without solution through thrombectomy, GPI and coronary angioplasty, with no-reflow, died on the second day due to cardiogenic shock. The late follow up was obtained in 70% of the patients. During the intermediate follow up, at seven months, four (5.4%) more deaths took place. Of these, 3 happened in the third month after the acute episode and probably due to a cardiac etiology; one patient presented acute inflammatory abdomen and died in the fourth month after the AMI. There were no other complications. There was one episode of subacute stent thrombosis, during the first week after the procedure, treated through a new coronary angioplasty, with clinical success (Table 3). No major bleeding was identified during the inhospital period. There was no need of a surgical procedure in the site of the radial punction, blood transfusion, lengthening of the hospitalization period, no hemorragic brain stroke episode or bowel bleeding. There were four cases of hematoma in the site of the punction, however, without edema or hand ischemia. There was one case of localized flebitis which responded to clinical treatment. DISCUSSION The results of this analysis prove the safety and efficacy of the transradial access in primary angioplasty, even with the use of tirofiban, in bolus regime, with increased dose. The success of the transradial approach in this sample is due to the systematic use in our service. During the same period of the analysis, we performed 327 elective angioplasties (Figure 1). The radial approach was used in 302 (92.4%) patients, and the femoral in TABLE 3 Occurrence of events Clinical Events Total (n=73) Hospital death (%) 3 (4.1) Late follow up (%) 51 (69.8) Time of follow up (months) 7.26±4.9 Late death (%) 4 (5.4) Re-infarction (%) 1 (1.3) Emergency revascularization (%) 1 (1.3) Major bleeding 0 Minor bleeding 4 (5.4) 3
Page 1: Rev Bras Cardiol Invas 2007; 15(3).
Page 5 and 6: Tebet MA, et al. Primary Angioplast

Marden Tabet ING.pmd - Revista Brasileira de Cardiologia Invasiva

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