经桡动脉冠状动脉介入治疗的术者学习曲线：对当代美国实践中开展经桡动脉入路项目的启示

Operator learning curve for transradial percutaneous coronary interventions: implications for the initiation of a transradial access program in contemporary US practice.

作者信息

Barbash Israel M, Minha Sa'ar, Gallino Robert, Lager Robert, Badr Salem, Loh Joshua P, Kitabata Hironori, Pendyala Lakshmana K, Torguson Rebecca, Satler Lowell F, Pichard Augusto D, Waksman Ron

机构信息

Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC.

出版信息

Cardiovasc Revasc Med. 2014 Jun;15(4):195-9. doi: 10.1016/j.carrev.2014.03.001. Epub 2014 Mar 13.

DOI:10.1016/j.carrev.2014.03.001

PMID:24746598

Abstract

OBJECTIVES

Our study aimed to assess the characteristics and outcomes of transfemoral approach (TFA) versus the initial steps of a transradial approach (TRA) program and to assess the learning curve of TRA in contemporary, US practice.

BACKGROUND

When compared to TFA, TRA has been shown to lower bleeding and vascular complications during percutaneous coronary intervention (PCI). However, use of TRA is still low. There are limited data regarding the characteristics of TRA learning curve, especially in an era with designated TRA equipment.

METHODS

Consecutive patients undergoing PCI in a single US center were divided into two cohorts according to vascular access approach: the last 250 TFA patients prior to the establishment of a TRA program and the initial 239 TRA patients following the establishment of a TRA program. Subgroup analysis of the TRA group, which was divided into five sequential case groups of 50 cases per group, was performed in order to assess TRA learning curve.

RESULTS

Overall, the baseline characteristics of TFA vs. TRA groups were comparable. Fluoroscopy time was significantly longer during TRA procedures (18±11 vs. 15±8min, respectively, p=0.002); however, contrast use was lower during TRA procedures (161±72 vs. 180±63ml, respectively, p=0.002). In-hospital outcomes were similar between the two groups, with low frequencies of mortality, myocardial infarction, and stent thrombosis. Subanalysis of TRA group for learning curve assessment showed no major differences in patient demographics among the five subgroups. In the initial cases, more PCI was performed among non-acute cases (62% in patients 1-50 vs. 8-27% in patients 51-239, p<0.001). Despite these differences, characteristics of the treated vessels were similar between groups. There was no significant change in fluoroscopy time or in the amount of iodinated contrast volume delivered. Similarly, no differences in procedural, in-hospital, and long-term outcomes were documented.

CONCLUSIONS

Adopting TRA as a default is feasible for high-volume operators without significant learning curve effects.

摘要

目的

我们的研究旨在评估经股动脉入路（TFA）与经桡动脉入路（TRA）项目初始阶段的特点及结果，并评估美国当代实践中TRA的学习曲线。

背景

与TFA相比，TRA已被证明在经皮冠状动脉介入治疗（PCI）期间可降低出血和血管并发症。然而，TRA的使用仍然较少。关于TRA学习曲线特点的数据有限，尤其是在有指定TRA设备的时代。

方法

在美国一个单一中心接受PCI的连续患者根据血管入路方式分为两个队列：TRA项目建立前的最后250例TFA患者和TRA项目建立后的最初239例TRA患者。对TRA组进行亚组分析，该组分为五个连续的病例组，每组50例，以评估TRA的学习曲线。

结果

总体而言，TFA组与TRA组的基线特征具有可比性。TRA手术期间透视时间明显更长（分别为18±11分钟和15±8分钟，p = 0.002）；然而，TRA手术期间造影剂使用量更低（分别为161±72毫升和180±63毫升，p = 0.002）。两组的院内结局相似，死亡率、心肌梗死和支架血栓形成的发生率较低。TRA组学习曲线评估的亚分析显示五个亚组之间患者人口统计学无重大差异。在最初的病例中，非急性病例中进行PCI的比例更高（1 - 50例患者中为62%，而51 - 239例患者中为8 - 27%，p < 0.001）。尽管存在这些差异，但两组治疗血管的特征相似。透视时间或碘造影剂用量均无显著变化。同样，手术、院内和长期结局均无差异记录。