Cardiac Cath via Radial Access Safe, Effective for Liver Transplant Patients

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With low rates of transfusion and other complications and a high degree of success, transradial cardiac catheterization is safe and effective in candidates for liver transplantation, according to a single-center analysis published online March 3, 2014, ahead of print in the American Journal of Cardiology.

Researchers led by James D. Flaherty, MD, of Northwestern University Feinberg School of Medicine (Chicago, IL), retrospectively reviewed all cases of transradial cardiac cath at their institution from the adoption of the transradial approach (May 2008) to the time of the study (December 2008) in 1,071 consecutive patients. Most patients (90%) were non-liver transplant candidates, while the remainder (10%, n = 107) were transplant candidates.

Dr. Flaherty and colleagues explained that because of the low sensitivity and specificity of noninvasive stress imaging for detecting CAD in liver transplant candidates, cardiac cath plays a crucial role in risk stratification prior to transplantation. As such, the lower risk of bleeding—a major concern in this population—associated with the transradial approach makes it an attractive option.

Transplant patients were more commonly men (67% vs 57%; P = 0.04), and less likely to have hypertension, dyslipidemia, CAD, congestive heart failure, and peripheral vascular disease. Systolic BP, diastolic BP, and mean arterial pressure were all lower among liver transplant candidates at the time of cardiac cath. Prior to the procedure, platelet count was lower in liver transplant patients, while international normalized ratio (INR) was higher. Renal function, meanwhile, was similar between groups.

Liver transplant candidates had less exposure to fluoroscopy (8.0 vs 11.1 min; P < 0.01) and contrast dye (72 mL vs 102 mL; P < 0.01). PCI, meanwhile, was more common among non-liver transplant candidates (15% vs 4%; P < 0.01). Among transplant candidates, 96% of procedures were elective and performed for preoperative evaluation prior to liver transplantation. Among non-transplant candidates, roughly one-fifth of cases were performed for ACS.

The primary endpoint (radial approach failure) was low and similar in both groups, as were access failure, vascular failure, and adverse events (bleeding, digital ischemia, local vascular complications, contrast nephropathy, and mortality; table 1).

Table 1. Radial Access Outcomes: Liver Transplant vs Non-Transplant Candidates

 

Transplant Candidates
(n = 107)

Non-transplant Candidates
(n = 964)

P Value

Radial Approach Failure

10%

7%

0.15

Vascular Failure

4%

3%

0.58

Access Failure

7%

4%

0.16

30-day Death

2%

1%

0.51

30-day Adverse Events

1%

1%

0.99


No deaths were related to procedural complications. Periprocedural blood product transfusion was required in 3 liver transplant candidates and 1 non-liver transplant candidate; each of the 3 transfusions in liver transplant candidates were started prior to cardiac cath for bleeding prophylaxis.

Failure Rates Expected to Drop

“These findings highlight the safety and efficacy of [transradial] cardiac catheterization in the preoperative risk stratification of [liver transplant candidates],” the authors conclude. “[Transradial] cardiac catheterization was accomplished successfully in 90% of patients in the [transplant candidate] group.”

They note that previous studies have shown similar transradial failure rates, but point out that failure rates tend to be lower among highly experienced operators. “Since our institution is a teaching hospital, novice operators are frequently involved in the initial cannulation of the radial artery, which may contribute to higher rates of access failure,” they write. “As [transradial] experience grows, it would be expected that the [transradial] failure rate would fall among [liver transplant candidates] as well as [non-liver transplant candidates].” 

Radial Cath Reduces Vascular Injury

According to R. Lee Jobe, MD, of Wake Heart and Vascular (Raleigh, NC), transplant patients “are tricky for cardiac cath because patients with severe and end-stage liver disease have bleeding disorders and complications and are more likely to run into vascular problems related to bleeding with any vascular procedures including cardiac cath.”

That is what makes transradial access an attractive option in such patients, Dr. Jobe told TCTMD in a telephone interview. “The preponderance of data from just about every study has shown that the safety from radial cath has to do with reduced vascular injuries and reduced bleeding complications, and this is just another high-risk population for bleeding complications,” he said.

Dr. Jobe did note some limitations of the study, such as its lack of randomization and single-center nature. Nevertheless, the study’s message is clear, he stressed, “That radial procedures are safer and should be the access route of choice in any population of patients that are at high risk for bleeding complications including patients with end-stage liver disease and liver transplant candidates.”

 


Source:
Huded CP, Blair JE, Sweis RN, et al. Trans-radial cardiac catheterization in liver transplant candidates. Am J Cardiol. 2014;Epub ahead of print.

 

Disclosures:

  • Drs. Flaherty and Jobe report no relevant conflicts of interest.

 

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