UNIVERSITE SAINT -ESPRIT DE KASLIK
Faculte de MedecineVOlE RADIALE V/S VOlE FEMORALE :NOTRE EXPERIENCE INTRA-HOSPITALIERE
Etude prospective
These en vue d' obtention d 'un doctorat en medecine
Preparee par BIRBARAH Christian Sous la direction de Dr KHARMA Alexandre
Kaslik- Liban 2012
Soutenue le 1 Juin 2012 devant le jury compose de Dr HAMID EL BA YEH
Dr ALEXANDRE KHARMA Dr RACHW AN RACHW AN
President
Directeur de memoire
Examinateur
RESUME
Introduction: L'acces femoral pour l'angiographie coronaire a ete le site d'acces dominant pour les 2 demieres decennies. Malheureusement, l'acces radial represente moins que 10% des procedures mondiales et 1% des procedures aux Etats-Unis, ceci suggere que beaucoup de cardiologues restent non convaincus de l'utilite du changement d'acces.
Objectifs: Le but de notre etude etait de mettre l'accent sur une technique relativement nouvelle, !'approche radiale pour le catheterisme cardiaque, qui n'a pas pris beaucoup de popularite aux Etats-Unis comme en Europe; et la comparer
a
!'approche femorale standard qui a ete utilisee comme reference pour des annees.
Methodes : Une etude prospective a ete utilisee en regroupant 115 malades, selectionnes arbitrairement parmi ceux admis pour angiographie coronaire elective,
a
1 'hopital ''Notre dame des Sec ours- Lib an''.Resultats : Une difference des moyennes du temps de procedure entre la vme femorale (5.3 minutes) et la voie radiale (7 minutes) avec p =0.006
a
95% CI (- 2.87187, -0.50817). Une difference des moyennes des doses de radiation totale entre la voie femorale (29800 mGy/m2) et la voie radiale (36200 mGy/m2) avec p=O.l48a
95% CI (-15310.680, 2336.728). Un taux de sejour hospitalier moindre dans le groupe radial (64%<6 heures) compare au groupe femoral (72%> 1 jour). Une satisfaction plus elevee dans le groupe radial (67%) que dans le groupe femoral (9%). Un taux de 14.8% de difficultes
a
canuler les coronaires dans le groupe radial.Conclusion : L'approche radiale est certainement non inferieure
a
!'approche femorale et offre des avantages aussi stirs, plus pratiques et plus economiques.L' approche femorale ne doit plus etre consideree comme standard ou comme reference
a
elle seule. Le futur s' avere avec 1' acces radial.Mots
cle :
Acces radial, acces femoral, coronarographie, doses de radiationsABSTRACT
Introduction: Femoral access for coronary angiography has been the dominant access site for the last 2 decades. Unfortunately, radial access still accounts for less than 10% of procedures worldwide and 1% of procedures in the United States, suggesting that many interventional cardiologists remain unconvinced and that G,1rther data is necessary to change practice.
Objectives: The purpose of our study was to put under scope a relatively new technique, the radial approach, which has not taken as much popularity in the USA as in Europe, and to compare it to the "Golden Standard" the femoral approach which has been used for years.
Methods: A prospective study design was used among 115 patients, from those admitted for elective coronary angiography, selected randomly at the "Notre Dame des Secours University Hospital- Lebanon".
Results: A longer duration of the diagnostic procedure in the radial group (mean= 7 minutes) as compared to the femoral (mean= 5.3 minutes) with p =0.006 at 95% CI (-2.87187, -0.50817). A higher radiation dose in the radial group (mean=36200 mGy/m2) as compared to the femoral group (mean=29800 mGy/m2) withp=O.l48 at 95% Cl. A significantly lower hospitalization time in the radial group (64%<6 hours) as compared to the femoral group (72%> 1 day). A significantly higher satisfaction rate among the radial group (67%) as compared to the femoral group (9%). A 14.8% difficulty rate to cannulate the coronaries in the radial group.
Conclusion: The radial approach is certainly non inferior to the femoral. Perhaps the femoral access should not be considered "the golden standard" anymore because the radial is as safe and as effective. The future is radial and radiant.
Key words: Radial access v/s femoral access, coronary angiography, radiation dose
Table des matieres
PREMIERE PARTIE
I- Introduction ... 7
A- L 'histoire du catheterisme cardiaque ... 7
B- La cardiologie interventionnelle ... 9
C- L' approche par voie radiale ... 12
II- Le catheterisme cardiaque par voie femorale ... 14
A- L'anatomie de l'artere femorale ... 14
B- Le catheterisme par voie femorale ... 16
1- Le site de ponction ... 16
2- La ponction du site femoral ... 18
3- L'angiographie coronaire par voie femorale ... 22
C- A vantages et desavantages de la voie femorale ... 24
III- Le catheterisme cardiaque par voie radiale ... 26
A- L'anatomie de l'artere radiale ... 26
B- Les variations anatomiques de l'artere radiale ... 27
C- Le catheterisme par voie radiale ... 28
1- Preparation et site de ponction ... 29
2- L'angiographie par voie radiale ... .32
D- Comparaison entre la voie radiale et la voie femorale ... 34
DEUXIEME PARTIE
I- Hypothese ... 38
II- Methodes ... 39
A- Type de l'enquete et population source ... 39
B- Materiel utilise et parametres etudies ... .40
III- Resultats ... 43
A- Statistiques descriptives de l'echantillon ... .43
B- Comparaison des variables entre l 'acces femoral et l'acces radial ... 50
C- Comparaison des variables par rapport
a
1' acces droit et 1' acces gauche ... 61D- Comparaison des complications en prenant en compte 1e type de 1a procedure ... 68
E- Comparaison du test d' Allen inverse avant et a pres 1a procedure ... 71
IV- Discussion et conclusion ... 72
V- Annexe: 1e formulaire de l'etude ... 76
VI- Bibliographie ... 79
VI- Bibliographie
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