番茄社区

BOSTON -- A short course of rivaroxaban (Xarelto) after transradial coronary procedures helped prevent radial artery occlusion complications, the RIVARAD trial from Tunisia showed.

The direct-acting oral anticoagulant (DOAC) reduced 30-day radial artery occlusion by half (6.9% vs 13%; OR 0.50, 95% CI 0.27-0.91), reported Rania Hammami, MD, of Hedi Chaker Hospital in Sfax, Tunisia, at the Transcatheter Cardiovascular Therapeutics (TCT) meeting hosted by the Cardiovascular Research Foundation.

Hemorrhagic complications were numerically more common with the 7-day course of rivaroxaban but not significantly so (2.70% vs 1.90% at 30 days; P=0.54), she stated. Most events were minor (2.3% BARC 1), and no bleeding events occurred among patients who received rivaroxaban without an antiplatelet agent.

Hammami noted that the population studied in Tunisia is at particularly high risk of radial artery occlusion due to a high rate of risk factors like smoking, diabetes, and dyslipidemia. However, she stated that the last randomized trial showed a prevalence of radial artery occlusion in the 8% to 10% range, similar to the control arm in theirs.

"This is a pretty important artery," noted TCT press conference panelist Roxana Mehran, MD, of Mount Sinai School of Medicine in New York City. Now that radial artery use has been given a class I indication for bypass surgery, "we need to preserve these arteries," so future procedures don't have to resort to the less durable vein grafts, she pointed out.

"With good radial artery approach, the rate of radial artery occlusion should be almost zero," she said. "But are we looking at that? ... We 'heparinize' the patients, we give all kinds of good anticoagulation during the procedure. But this idea of the periprocedural use of a direct oral anticoagulant is a good one."

Hammami noted that some 36% to 56% of operators do not assess radial artery patency before discharge, and half don't use ultrasound to do so, based on prior surveys.

Rivaroxaban was selected based on research showing it is more efficient than aspirin for preserving endothelial function, Hammami noted, but it's not clear yet if there could be a class effect across DOACs.

The relatively short regimen of rivaroxaban was probably a smart choice, as it's a convenient once a day anticoagulant, suggested TCT press conference panelist Eric A. Cohen, MD, of the Schulich Heart Program at Sunnybrook Health Sciences Centre in Toronto. He called the findings "intriguing" but said that more information on bleeding will be needed, especially as many patients go on dual antiplatelet therapy.

The trial excluded high bleeding-risk patients, Hammami noted, but more information is coming from the ongoing from Canada, which is randomizing 1,800 patients to 15-mg rivaroxaban or standard care without anticoagulation after transradial procedures.

A similar concept would be intriguing for use in trancatheter aortic valve replacement (TAVR), specifically, to tackle stroke risk, Mehran suggested. "You're always worried about bleeding when you add more, but this is low dose."

The trial included 538 patients with a mean age 60 getting transradial coronary angiography or percutaneous coronary intervention at five Tunisian medical centers from November 2021 through March 2022. They were randomized to 10 mg of rivaroxaban for 7 days post-procedure or standard of care without the anticoagulant.

Of the participants, 32% were female, a known predictor of radial artery occlusion. More than 50% had longer than 6 hours to hemostasis. A quarter had a prior transradial procedure, nearly half smoked, and nearly half had diabetes.

People getting ticagrelor (Brilinta) or prasugrel (Effient) were excluded.

Hammami noted that there was no use of closure devices, just classic manual compression reflecting real-life, real-world practice in Tunisia.

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