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Doll JA, Beaver K, Naranjo D, Waldo SW, Maynard C, Helfrich CD, Rao SV. Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018. Circ Cardiovasc Qual Outcomes 2022; 15:e008359. [PMID: 35272504 DOI: 10.1161/circoutcomes.121.008359] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox. METHODS In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test. RESULTS Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P<0.01)) and PCI procedures (14.0%-51.8%; P<0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P=0.02) but not PCI (3.4%-2.5%, P=0.20). Femoral access patients had a higher predicted risk for bleeding. CONCLUSIONS A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.
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Affiliation(s)
- Jacob A Doll
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.).,Division of Cardiology, Department of Medicine (J.A.D.), University of Washington, Seattle.,CART Program, VHA Office of Quality and Patient Safety, Washington DC (J.A.D., S.W.W.)
| | - Kristine Beaver
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.)
| | | | - Stephen W Waldo
- CART Program, VHA Office of Quality and Patient Safety, Washington DC (J.A.D., S.W.W.).,VA Eastern Colorado Health Care System, Aurora, CO (S.W.W.).,Division of Cardiology, Department of Medicine, University of Colorado, Aurora (S.W.W.)
| | - Charles Maynard
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.)
| | - Christian D Helfrich
- Health Services Research & Development (HSR&D), Seattle-Denver Center of Innovation (COIN) for Veteran-Centered Value-Driven Care, US Department of Veterans Affairs (VA) Puget Sound Health Care System, WA (J.A.D., K.B., C.M., C.D.H.).,Department of Health Services, School of Public Health (C.D.H.), University of Washington, Seattle
| | - Sunil V Rao
- US Department of Veterans Affairs (VA) Health Care System, Durham, NC (S.V.R.)
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Malik AO, Amin A, Kennedy K, Qintar M, Shafiq A, Mehran R, Spertus JA. Patient-centered contrast thresholds to reduce acute kidney injury in high-risk patients undergoing percutaneous coronary intervention. Am Heart J 2021; 234:51-59. [PMID: 33359778 DOI: 10.1016/j.ahj.2020.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 12/19/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Contrast volume used during percutaneous coronary intervention has a direct relationship with contrast-associated acute kidney injury. While several models estimate the risk of contrast-associated acute kidney injury, only the strategy of limiting contrast volume to 3 × estimated glomerular filtration rate (eGFR) gives actionable estimates of safe contrast volume doses. However, this method does not consider other patient characteristics associated with risk, such as age, diabetes or heart failure. METHODS Using the National Cardiovascular Data Registry acute kidney injury risk model, we developed a novel strategy to define safe contrast limits by entering a contrast term into the model and using it to meet specific (eg, 10%) relative risk reductions. We then estimated acute kidney injury rates when our patient-centered model-derived thresholds were and were not exceeded using data from CathPCI version 5 between April 2018 and June 2019. We repeated the same analysis in a sub-set of patients who received ≤3 × eGFR contrast. RESULTS After excluding patients on hemodialysis, below average risk (<7%), missing data and multiple percutaneous coronary interventions, our final analytical cohort included 141,133 patients at high risk for acute kidney injury. The rate of acute kidney injury was 10.0% when the contrast thresholds derived from our patient-centered model were met and 18.2% when they were exceeded (P < .001). In patients who received contrast ≤3 × eGFR (n = 82,318), contrast-associated acute kidney injury rate was 9.8% when the contrast thresholds derived from our patient centered model were met and 14.5% when they were exceeded (P < .001). CONCLUSIONS A novel strategy for developing personalized contrast volume thresholds, provides actionable information for providers that could decrease rates of contrast-associated acute kidney injury. This strategy needs further prospective testing to assess efficacy in improving patient outcomes.
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Affiliation(s)
- Ali O Malik
- University of Missouri-Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO.
| | - Amit Amin
- Washington University School of Medicine, Barnes Jewish Hospital, St. Louis, MO
| | - Kevin Kennedy
- Saint Luke's Mid America Heart Institute, Kansas City, MO
| | - Mohammed Qintar
- University of Missouri-Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
| | | | | | - John A Spertus
- University of Missouri-Kansas City, Kansas City, MO; Saint Luke's Mid America Heart Institute, Kansas City, MO
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