Rates of Silent Stroke Similar for Radial, Femoral Cath in Aortic Disease Patients

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In patients with severe aortic stenosis undergoing cardiac catheterization, the postprocedural rate of silent cerebral infarct is high but does not differ between radial and femoral access, according to a small study published online June 15, 2012, ahead of print in the American Heart Journal.

For the prospective, multicenter study, Martial Hamon, MD, of University Hospital of Caen (Caen, France), and colleagues randomized 160 patients with severe aortic stenosis scheduled for cardiac catheterization before surgery to either the radial (n = 83) or femoral (n = 77) approach. Diffusion-weighted MRI to observe the occurrence of new cerebral infarct was performed within 24 hours before and 48 hours after cath. Patient and cath characteristics, including procedure duration, were similar in both groups. However, 3 patients crossed over from the radial to femoral group due to radial access failure.

Postprocedural cerebral infarct occurred in 24 patients (15 radial and 9 femoral). Among them, 22 patients remained asymptomatic (91.6%), with no difference between the incidence of cerebral infarct observed in those receiving radial or femoral access (12.5% vs. 17.5%; P = 0.51 for per-protocol comparison).

A subanalysis assessed acute cognitive impairment by comparing mental state before and after catheterization in patients with (n = 13) or without silent cerebral infarct (n = 56); no difference was detected between the 2 groups (P = 0.88).

The researchers also used transcranial Doppler in a subset of 21 patients to look at the number of high-intensity transient signals (HITS) per procedure, a measurement that helps characterize microemboli. Similar HITS were found for procedures done either by radial or femoral access (56.2 ± 36.4 vs. 52.7 ± 21.7; P = 0.87) as well as between patients with and without cerebral infarct after catheterization (61.3 ± 20.6 vs. 52.4 ± 26.8; P = 0.59).

On multivariate analysis that considered various clinical and procedural parameters, only higher patient height (OR 8.24; 95% CI 2.71-25.02; P < 0.0001) and lower transvalvular gradient (OR 0.96; 95% CI 0.93-0.99; P = 0.027) were associated with an increased risk of periprocedural cerebral thromboembolism as detected by MRI.

Larger Studies Needed

“Among the issues raised by our results, we can mention the need to inform patients and the cardiac surgeon,” Dr. Hamon and colleagues write. “Indeed especially in the elderly further heart catheterization can be required and if cardiac surgery requiring anticoagulation is performed, recent [silent cerebral infarct] might increase the risk of symptomatic stroke or hemorrhagic transformation. Postponing cardiac surgery and allowing recent [silent cerebral infarcts] to heal should be considered and requires further attention in future studies.”

Cerebral MRI results might act as a “surrogate marker,” they suggest, encouraging adjustments to medical therapy or technical aspects of catheterization that would reduce ischemic complications.

The investigators called for larger studies to establish not only the clinical impact of asymptomatic cerebral ischemic lesions, but also “the rate of embolization to other peripheral organs, like kidneys and bowels and their respective impact on patients' outcomes.

“Further studies are required to analyze this phenomenon and the relative impact of more effective antithrombotic agents or new filters able to reduce silent cerebral embolism during left heart catheterization and percutaneous cardiovascular interventions,” they conclude.

Study Details

Intravenous use of unfractionated heparin (50 IU/kg) was recommended to all patients at the beginning of catheterization.

 

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Source:
Hamon M, Lipiecki J, Carrié D, et al. Silent cerebral infarcts after cardiac catheterization: A randomized comparison of radial and femoral approaches. Am Heart J. 2012;Epub ahead of print.

 

 

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