Abstract 83: 7 C's In Preventing Stroke Complicating Coronary Angioplasty

Abstract

Introduction: Despite advances in angioplasty equipment and technique, reducing the incidence of CVA has remained an elusive target. Strokes increase mortality, cost and length of stay, residual disability. Hypothesis: 1. Monitor and benchmark CVAs, 2. Drill down for predictors, lapses in care, 3. Form a multidisciplinary group to identify failure modes, process controls. Methods: CVAs complicating coronary PCI from 2017 to present were reviewed. Results: There were 32 CVAs [5 hemorrhagic; 27 thrombotic] occurring in 6410 PCI by 18 operators [0.5%] & 9 deaths [0.28] CVA pts were high acuity: 2 [0.06] post Cardiac arrest, 11 [.34] STEMIs, 8 [.25] Non-STEMIs, 12 [.38] ACS. Age > 65 years in 22 [0.69]. Comorbidity: CVA/TIA/Carotid disease 8 [0.25], PAD 6 [0.19], CKD 4/5 in 3 [0.09], Atrial fib 4 [0.13], LVEF < 35% 12 [0.38]. Ventricular support for cardiogenic shock in 5 [0.16]. Access changed from femoral to radial with 7 CVA [0.22] associated with radial, 22 [0.69] with femoral, and 3 [0.09] with both. Anticoagulation: heparin alone 5 [0.16] and bivalirudin ± heparin in 27 [0.84]. Most interventions utilized bivalirudin. PCI with Heparin & Aspiration thrombectomy, in 5 [0.16] had a higher thrombotic CVA risk. Multidisciplinary review concerns included: 1. pt factors [bleeding/clotting history, current meds and side effects, risk factors for CVA/TIA {e.g. STEMI/non-STEMI, cardiogenic shock, atrial fibrillation, age, carotid disease}, 2. Equipment {e.g. access sheath size and length, catheter preshaped/shaped/multiple, wire [e.g. straight, curved tip, shapeable, hydrophilic, exchange], thrombectomy, angioplasty [balloon, rotoblator, stent], 3. Personnel [experience, volume, trainees], 4. Process [Anticoagulation {timing, heparin,/bivalirudin, dose, monitoring}, Cleaning hands/wires/bowl, Catheter exchanges, Case Duration. Patient monitoring, Brain attack protocol activation and response. Conclusions: The multidisciplinary group formulated a7 C’s Chain of prevention to lessen the risk of CVA: Continuous monitoring , Contributing factor identification, Consensus development of best practices, Cleanliness , Compulsive attention to detail / technique, Communication , Controversies in Care [notably DOACs].