Journal of the American College of Cardiology

2010 by the American College of Cardiology Foundation

Published by Elsevier Inc.

Vol. 55, No. 20, 2010

ISSN 0735-1097/$36.00
doi:10.1016/j.jacc.2010.01.039

STATE-OF-THE-ART PAPER

The Transradial Approach to

Percutaneous Coronary Intervention
Historical Perspective, Current Concepts, and Future Directions
Sunil V. Rao, MD,* Mauricio G. Cohen, MD, David E. Kandzari, MD,
Olivier F. Bertrand, MD, PHD, Ian C. Gilchrist, MD
Durham, North Carolina; Miami, Florida; La Jolla, California; Quebec City, Quebec, Canada;
and Hershey, Pennsylvania
Periprocedural bleeding complications after percutaneous coronary intervention (PCI) are associated with increased short- and long-term morbidity and mortality. Although clinical trials have primarily assessed pharmacological strategies for reducing bleeding risk, there is a mounting body of evidence suggesting that adoption of a
transradial rather than a transfemoral approach to PCI may permit greater reductions in bleeding risk than have
been achieved with pharmacological strategies alone. However, despite a long history of use, a lack of widespread uptake by physicians coupled with the technological limitations of available devices has in the past confined transradial PCI to the status of a niche procedure, and many operators lack experience in this technique.
In this review, we examine the history of the transradial approach to PCI and discuss some of the circumstances
that have hitherto limited its appeal. We then review the current state of the peer-reviewed literature supporting
its use and summarize the unresolved issues affecting broader application of this technique, including lack of
operator familiarity and an insufficient evidence base for guiding practice. Finally, we describe potential directions for future investigation in the transradial realm. (J Am Coll Cardiol 2010;55:218795) 2010 by the
American College of Cardiology Foundation

Percutaneous coronary intervention (PCI) is an integral part

of treatment for ischemic heart disease. Coupled with
evidence-based pharmacological strategies, the use of PCI
in appropriate patients reduces morbidity and mortality
across the spectrum of risk (1). Continual evolution of
antithrombotic therapy and device technology has resulted
in the application of PCI to a wider population of patients
(2). Procedural success rates are high and ischemic complications relatively rare (3); thus, attention has turned to
periprocedural bleeding complications (4). Considerable

From *The Duke Clinical Research Institute, Durham, North Carolina; University
of Miami, Miami, Florida; Scripps Clinic, La Jolla, California; Quebec HeartLung Institute, Quebec City, Quebec, Canada; and the Penn State-Hershey Medical
Center, Hershey, Pennsylvania. Dr. Rao reports receiving funding from Terumo
Medical, Portola Pharmaceuticals, Momenta Pharmaceuticals, and Cordis Corporation; is a consultant for Terumo Medical; and consults and is on the Speakers Bureaus
for The Medicines Company, Bristol-Myers Squibb, and Sanofi-Aventis. Dr. Cohen
reports receiving an honorarium for speaking at an event sponsored by Terumo
Medical. Dr. Kandzari is a consultant for Abbott Vascular, Medtronic, Cordis, and
Terumo Medical; and receives research grant funding from Medtronic, Abbott
Vascular, and Cordis. Dr. Bertrand is supported by Cordis, Bristol-Myers Squibb/
Sanofi-Aventis, and GE Healthcare. Dr. Gilchrist receives research contract support
from AstraZeneca, Eisi Medical Research, Hoffman-LaRoche, Portola Pharmaceuticals, Boston Scientific, Angel Medical, Bristol-Myers Squibb, and Osiris Therapeutics Inc.
Manuscript received October 11, 2009; revised manuscript received January 4,
2010, accepted January 5, 2010.

evidence suggests that post-PCI bleeding is associated with

an adverse prognosis (5). Clinical trials evaluating new
pharmacological strategies have focused on reducing this
risk (6,7); however, absolute reductions in bleeding risk have
been modest across most studies. A growing body of
evidence suggests that a procedural strategy using the
transradial rather than the transfemoral approach for
PCIis associated with comparatively larger reductions in
bleeding complications than those achieved with any anticoagulant strategy. In this review, we provide historical
perspective on the transradial approach, examine current
literature supporting its use, and summarize unresolved
issues and areas for future investigation.
Transradial PCI: Historical Perspective
Although the transfemoral approach to cardiac catheterization has dominated the explosive growth of invasive
cardiology in past decades, transradial access appeared
early in the development of cardiac catheterization techniques. In 1948, Radner (8) published one of the first
descriptions of transradial central arterial catheterization
and attempts at coronary artery imaging using radial
artery cut-down and 8- to 10-F catheters. Despite early
enthusiasm for the transradial approach, limitations of

2188

Rao et al.
Transradial Approach for PCI

contemporary equipment resulted

in a shift to larger vessels such as
the brachial, carotid, and femoral
ACS acute coronary
systems for most catheter-based
syndrome
procedures, and the radial artery
CI confidence interval
was relegated to use as a site for
LOS length of stay
monitoring arterial pressure.
OR odds ratio
In the late 1970s, percutanePCI percutaneous
ous coronary angioplasty was incoronary intervention
troduced using predominantly
9-F guiding catheters (9). Building on reports of successful transradial angiography from
Canada in 1989 (10), Kiemeneij and Laarman (11) first
reported on the transradial approach for coronary stenting
in 1993. Given observed reductions in periprocedural bleeding and reported improvements in patient comfort with this
approach, a few enthusiastic early adopters emerged, but the
transradial approach generally remained a niche technique.
As experience with the transradial approach grew, the
lack of severe access-site complications when compared with
the transfemoral approach was repeatedly demonstrated in
small observational studies. A learning curve for developing proficiency in transradial procedures was noted (12),
cost-effectiveness was demonstrated (13,14), and small
single-center or limited multicenter randomized comparisons to femoral (with or without vascular closure devices)
and brachial approaches (15,16) showed the superiority of
transradial procedures with respect to vascular access site
complications, speed of post-procedural recovery, and patient preference. The safety of transradial PCI in patients
therapeutically anticoagulated with warfarin (17) and the potential for same-day coronary revascularization were described
(18). In addition, transradial techniques have been expanded to
peripheral arterial interventions, including carotid (19), superficial femoral (20), mesenteric (21), and renal (21,22) arteries,
as well as for pediatric percutaneous procedures (22).
As we summarize below, the future adoption of transradial PCI in the U.S. and other countries with low penetration of transradial techniques will depend on the generation
of high levels of evidence that confirm advantages seen in
smaller observational and randomized studies, the availability of training programs, commitment from operators and
professional societies, and comparative effectiveness data
that demonstrate not only better clinical outcomes compared with the transfemoral approach, but also better
economic outcomes, such as cost savings or costeffectiveness, and acceptable safety as it pertains to radiation
dose and exposure.
Abbreviations
and Acronyms

Procedural and Clinical Outcomes

After Transradial PCI
When comparing the transradial with the traditional transfemoral route for PCI, the discussion must include comparisons of procedural success, fluoroscopy times, and bleeding/
vascular complications.

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795

Procedural success and procedure time. In a systematic

overview of 12 randomized trials (n 3,224) comparing
radial and femoral approaches for diagnostic (7 studies) and
interventional (5 studies) procedures, Agostoni et al. (23)
reported significantly higher rates of procedural failure for
transradial access (odds ratio [OR]: 3.30; 95% confidence
interval [CI]: 1.63 to 6.71) . When compared with earlier
studies included in the analysis, more contemporary trials
demonstrate no differences in procedural failures between
treatment strategies, likely reflecting advances in both technique and technologies, including vasodilator pharmacology
and hydrophilic catheters. However, the composite outcome
of death, myocardial infarction, emergency repeat revascularization, or stroke did not statistically vary between
groups. Mann et al. (15) reported a single-center observational study comparing the transradial with the transfemoral
approach in which the Perclose (Abbott Vascular, Santa
Clara, California) femoral closure device was used. Procedural success, complications, post-procedural length of stay
(LOS), and percentage of patients discharged the same day
were similar across groups; however, total procedure time
was significantly longer in the femoral group (57 22 min
femoral vs. 44 22 min radial, p 0.01) because of time
needed to deploy the closure device.
The largest observational study to compare procedural
success rates between radial and femoral approaches used
data from the National Cardiovascular Data Registry
(593,094 procedures; 606 institutions) (24). Although radial
approaches represented a modest proportion (1.32%) of case
volume, risk-adjusted procedural success (defined as residual
stenosis 50% and reduction in stenosis 20% with TIMI
flow grade 2) did not differ between access methods (OR:
1.02; 95% CI: 0.92 to 1.12). In contrast, a more recent
systematic overview (23 trials; 7,000 patients) by Jolly
et al. (25) found that the radial approach was associated with
a trend toward a higher rate of inability to cross the lesion
with a wire, balloon, or stent, compared with the femoral
approach (Fig. 1).
Although overall procedural time may be similar between
methods, radial access has been associated with modest but
statistically significant increases in fluoroscopic time.
Among 420 patients undergoing diagnostic coronary angiography and percutaneous revascularization, procedural
duration and fluoroscopic time were significantly longer for
radial compared with femoral procedures, corresponding to
significantly higher radiation exposure for operators and
patients (26), although there was significant variability
among operators. In the meta-analysis by Agostoni et al.
(23), fluoroscopy time was significantly lower in the femoral
cohort (7.8 min vs. 8.9 min, p 0.001) . Similarly, in the
National Cardiovascular Data Registry, radial PCI had
longer fluoroscopy time (13.5 min vs. 11.3 min, p
0.01), but there was no significant difference in total
volume of contrast used (24). Many of these studies did
not correct for potential improvements in procedure and

Rao et al.
Transradial Approach for PCI

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795

Figure 1

2189

Association Between Vascular Access Site for PCI and Outcomes

Pooled analysis of 23 randomized trials (n 7,020) comparing the association between radial versus femoral approaches for percutaneous coronary intervention
(PCI) and procedure failure, access site crossover, death, the composite of death, stroke, or myocardial infarction (MI), and major bleeding. Adapted from Jolly et al. (25).

fluoroscopy times that may be realized with greater

transradial experience.
In general, it seems that increasing experience with the
transradial approach is associated with decreased rates of
procedure failure. In one observational study, an annual
procedural volume 80 transradial cases correlated with
significant reductions in access failure, sheath insertion
time, and overall procedural time (Fig. 2) (27). Similarly,
other trials demonstrate an initial difference in procedural

Figure 2

Radial Volume and Outcomes

Relationship between operator volume of transradial percutaneous coronary

intervention over a 15-month period and procedure duration (min, solid diamonds), procedure failure (%, open circles), and sheath insertion time (min,
solid circles). Reprinted from Spaulding et al. (27).

time between radial and femoral cases that resolved by trial

completion as operator experience improved (12,16,23,28).
Jolly et al. (25) demonstrated that among operators who
preferred the radial route, there was no significant difference
in successful lesion crossing (adjusted OR: 1.18; 95% CI:
0.77 to 1.81; p 0.44); among less experienced operators,
there was a strong trend toward higher failure rates (adjusted OR: 3.47; 95% CI: 0.91 to 13.21; p 0.07) (25).
Bleeding and vascular outcomes. Bleeding complications
after PCI are most commonly related to vascular access site
(Figs. 3 and 4) and are associated with an increased risk of
post-PCI morbidity and mortality (4,5,29,30). A consistent
body of observational and small randomized studies supports an advantage of the transradial approach in reducing
PCI-related hemorrhagic complications compared with the
transfemoral approach (24,25). In the National Cardiovascular Data Registry, the radial approach was associated with
a significant reduction in bleeding complications that was
more pronounced in certain high-risk subgroups, such as
women and patients with acute coronary syndromes (ACS)
(24). These findings are consistent with those of other
studies evaluating the safety of a radial approach regarding
significantly reduced bleeding events, especially among
ACS patients (31), those receiving more potent antithrombotic agents (32), and elderly patients (33). Jolly et al. (25)
found that the transradial approach was associated with a
73% reduction in major bleeding compared with the transfemoral approach (Fig. 1). The radial approach may also
afford advantages in patients with peripheral arterial disease
and/or obesity, in whom the femoral artery may be difficult
to access and compress manually due to body habitus.
However, less experienced transradial operators should
probably avoid these challenging patients until they gain
more experience.

2190

Figure 3

Rao et al.
Transradial Approach for PCI

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795

Site of Bleeding Complications in an Unselected Cohort of Patients Undergoing PCI

Overall rate of Thrombolysis In Myocardial Infarction (TIMI) major (maj) bleeding 5.4%; overall rate of TIMI minor (min) bleeding 12.7%.
CVA cerebrovascular accident (ischemic stroke); GI gastrointestinal bleeding; RP retroperitoneal hemorrhage. Adapted from Kinnaird et al. (30).

When vascular complications do occur after transradial

PCI, they consist mainly of early and late radial artery
occlusion (34). Rarely, instances of radial artery eversion or
perforation (35), chronic regional pain syndrome (36), and
forearm hematoma or compartment syndrome (37) have
been described. There are no published reports of hand
ischemia occurring after transradial PCI, which may be due
to avoidance of the radial approach in patients with a
positive Allen test result or reporting bias. Post-PCI radial
artery occlusion may be reduced by using smaller diameter
catheters and anticoagulation, and by avoiding prolonged
high-pressure compression of the radial artery after arterial
sheath removal. Two clinical trials have examined the role of
patent hemostasis, or allowing antegrade flow in the radial
artery during hemostatic compression at the occurrence of
radial occlusion. In one study, compression was guided by
mean arterial pressure (the pressure applied was equal to the
mean arterial pressure) versus usual compression (38). The
incidence of radial occlusion at 24 to 72 h was 1.1% in the
mean arterial pressure guided group and 12.0% in the usual
care group (p 0.0001). In the other trial, patients were
randomized to either compression that allowed antegrade
flow in the radial artery (Table 1) or usual care (39). Again,
the incidence of radial occlusion at 24 h and 30 days was
significantly reduced (24 h: 5.0% patent hemostasis group
vs. 12.0% usual care, p 0.05; 30 days: 1.8% vs. 7%, p
0.05).
Studies have also found an association between the
reduction in bleeding events with transradial PCI and an
improvement in clinical outcomes such as death and myo-

cardial infarction. In the PRESTO ACS (Comparison of

Early Invasive and Conservative Treatment in Patients
With NonST-Elevation Acute Coronary Syndromes) vascular substudy, for example, the radial approach was associated with a significant decrease in bleeding complications
compared with the femoral approach during hospitalization
(0.7% vs. 2.4%; p 0.05), as well as a significant reduction
in 1-year death or recurrent infarction (5.5% vs. 9.9%; p
0.05) (31). Among procedural and clinical outcomes data
collected for 38,872 PCI patients (radial approach, 20.5%)
included in the British Columbia Cardiac Registry, radial
access for PCI was associated with a significantly lower rate
of post-procedural blood transfusion (1.4% vs. 2.8%, p
0.01) and a significant decrease in 30-day (OR: 0.71; 95%
CI: 0.61 to 0.82) and 1-year mortality compared with
femoral access (40). In contrast, Jolly et al. (25) found no
significant association between the radial approach and
reduced 1-year mortality (Fig. 1). An important limitation
of these data should be noted, however; most of these
studies are either observational (and subject to confounding)
or are from small randomized trials conducted at centers
with operators proficient in the radial approach. The challenges of translating the potential advantages of the radial
approach seen in these studies to the interventional community at large are discussed in the following.
Transradial Approach and Economic Outcomes
As noted previously, the most common complication in
patients undergoing PCI via transfemoral access relates to

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795

Figure 4

Rao et al.
Transradial Approach for PCI

2191

Sites of Bleeding in PCI Trials

Rates of overall and access-site related bleeding in a sample of percutaneous coronary intervention clinical trials (REPLACE-2 [Randomized Evaluation in PCI Linking
Angiomax to Reduced Clinical Events 2] and ESPRIT [European/Australasian Stroke Prevention in Reversible Ischaemia Trial]) (A); nonST-segment elevation acute coronary syndrome trials (PARAGON [Platelet IIb/IIIa Antagonism for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network] A, PARAGON B,
GUSTO [Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries] IIb nonST-segment elevation cohort, PURSUIT [Platelet Glycoprotein IIb-IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy], and SYNERGY [Superior Yield of the New Strategy of Enoxaparin, Revascularization
and GlYcoprotein IIb/IIIa inhibitors]) (B); and ST-segment elevation myocardial infarction clinical trials (GUSTO 1, GUSTO IIb ST-segment elevation cohort, GUSTO 3,
HERO-2 [Hirulog Early Reperfusion Occlusion], ASSENT-2 [Assessment of the Safety of a New Thrombolytic]) (C). bld bleed.

2192

Rao et al.
Transradial Approach for PCI

for Post-Procedural
Patent
Hemostasis
Hemostasis Technique
Patent Technique
Table 1
for Post-Procedural Hemostasis
1. Apply hemostasis device (e.g., HemoBand, RAD-Stat, TR-Band) to wrist
2. Place pulse oximeter on ipsilateral index finger or thumb
3. Tighten hemostasis device and remove sheath
4. Occlude ipsilateral ulnar artery
5. Loosen hemostasis device until plethysmographic signal returns or bleeding
occurs
If bleeding occurs, use manual compression
If hemostasis is maintained in the presence of the plethysmographic signal,
then leave hemostasis device in place for 2 h
6. Check for maintenance of plethysmographic signal every hour
Adapted from Pancholy et al. (39).

the vascular access site. These complications are also associated with increased LOS and costs (24,41,42). Dedicated
cost analyses comparing vascular access sites have consistently shown a significant reduction in hospital costs with
transradial access. In a randomized study of patients undergoing diagnostic catheterization, Cooper et al. (14) showed
that transradial access was associated with a median cost
reduction of approximately $290/case driven by lower bed
cost, including nursing utilization, and decreased pharmacy
costs . A subsequent study comparing diagnostic catheterization via transradial versus transfemoral access with closure devices showed that, despite comparable recovery
times, total costs were still significantly lower with transradial access (transradial $369.50 $74.60 vs. transfemoral
$446.90 $60.20 vs. transfemoral with closure devices
$553.40 $81.00) (43). In a small randomized study of 142
patients undergoing PCI for ACS, post-procedural LOS
was reduced by approximately 1.5 days and total hospital
charges were decreased from $23,389 to $20,476 with
transradial access (44). A study comparing stenting via
transradial and transfemoral access with a suture closure
device showed a comparable LOS with both strategies at the
expense of higher cost and complication rates in the
transfemoral group (15).
There is also evidence that nursing workload can be
significantly reduced when the transradial approach is
systematically used. In one single-center study, the time
spent to care for patients after PCI can be reduced from
174 min with transfemoral access to 86 min with transradial access. In addition, nursing time outside the
catheterization laboratory on the medical ward was also
reduced from 720 min with transfemoral access to 386
min with transradial access (45).
We note, however, that these studies are small and
conducted in limited numbers of centers where practice
patterns may have influenced both costs and cost savings.
Whether these advantages are widely applicable needs
further study in larger multicenter randomized trials.
Unresolved Issues and Future Directions
The data summarized here illustrate several advantages of
the transradial versus the transfemoral approach to PCI.

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795

Although these data strongly support use of the transradial

approach as the default method for coronary intervention, it
is also important to review several limitations of this
technique and the data supporting it (Table 2). These
limitations relate broadly to practical issues (training and
experience of operators and catheterization laboratory staff),
patient issues (previous coronary artery bypass grafting,
challenging forearm and chest arterial anatomy), technical
issues (e.g., limitation in the size of the guide catheter that
can be used, potentially increased procedure times and
radiation exposure), and gaps in evidence (lack of large
multicenter randomized data on efficacy and safety). Importantly, changing practice from the transfemoral to the
transradial approach will, in most cases, result in increased
contrast use and radiation exposure to operator and patient
early in the learning curve. Table 3 lists selected transradial
procedural challenges and outlines strategies for addressing
them.
There is scant discussion of the transradial approach in
current published training guidelines. Although there is a
minimum number of diagnostic and interventional cases
recommended for fellows undergoing interventional training, no minimum number of transradial cases is specified
(notably, no minimum of femoral or brachial cases is
specified either) (46). The obvious result is the continuous
production of cardiovascular specialists without training or
even exposure to transradial PCI during fellowship. Currently, there are no transradial training programs supported
by the major cardiovascular professional societies; there are,
however, a limited number of courses supported by industry.
This lack of systematic training leads to the transradial PCI
being viewed as a niche procedure, a fact underscored by
data from large registries showing that the radial approach
accounts only for 1.3% of all PCI procedures in the U.S.
(24). This ultimately affects both the quality of care provided to the majority of PCI patients as well as the quality
of studies examining the relative merits of transradial PCI
(see the following text).
of Transradial
Advantages
and
Approach
Disadvantages
to PCI
Advantages
and
Disadvantages
Table 2
of Transradial Approach to PCI
Advantages
Reduced bleeding risk
Reduced length of stay and costs
Early ambulation
Improved patient comfort
Obviates discontinuation of oral anticoagulant therapy
Same-day discharge possible
Disadvantages
Learning curve
Not routinely taught in fellowship programs
Limits guide catheter size
Possible greater radiation exposure to operator*
Long-term consequences to radial artery (e.g., for re-access or for use as
bypass graft) unknown
*May be a function of operator experience.

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795

and Strategies
Selected
Transradial
to Overcome
Challenges
ThemChallenges
Selected
Transradial
Table 3
and Strategies to Overcome Them
Patient setup
Prep wrist with patients arm at his or her side (radial artery parallel to
femoral artery)
Prep femoral artery simultaneously in case of crossover
Use either a rectangular platform or 2 banjo arm boards underneath
patients arm to create a working space distal to patients hand
Place towels on working space to elevate working space to level of wrist
For left radial cases, elevated left arm using pillows to bring left radial above
left groin or have patient bring left arm across body after obtaining left
radial artery access
Radial artery access
Small-caliber artery
Inject subcutaneous nitroglycerin
Check contralateral radial artery
Spasm
Intra-arterial nitroglycerin, calcium channel blockers
Patient sedation
Use smaller French size catheters
Repeat access
Check patency of artery (ultrasonography or reverse Allen test*); obtain
access more proximally
Traversing the radiobrachial region
Radiobrachial angiogram for any resistance to advancing the wire or catheter
Radial loop: use 0.014-inch hydrophilic wires to traverse and straighten loop
Consider femoral access bailout if unable to traverse radial loop or if there is
significant patient discomfort
Traversing the chest arteries
Have patient take a deep breath to straighten subclavian/innominate arteries
and subclavian/innominate-aortic junction to direct catheter to ascending
aorta
For extreme z-curves, use hydrophilic 0.035-inch wires to direct catheters into
ascending aorta
Engaging the coronary arteries
Judkins curves: use longer JR curve (e.g., JR5), shorter JL curve (e.g., JL3.5)
Specialized curves (e.g., Kimny, Tiger, Jacky, Ikari, Amplatz)
Previous CABG: use left wrist with JR4/JL4 catheters, multipurpose catheter,
or specialized curves
*For reverse Allen test, occlude both radial and ulnar arteries, then release radial artery to
determine presence of antegrade flow.
CABG coronary artery bypass grafting.

A related issue is patient-specific factors that remain

challenging in the transradial context. These include difficulties in accessing the radial artery, traversing the radial/
brachial/subclavian arterial anatomy, achieving adequate
guiding catheter support, and performing transradial catheterization and PCI using the left radial artery in patients
who have undergone previous coronary artery bypass grafting (47). All of these challenges can increase procedure time
and radiation exposure to both operator and patient, but can
be addressed with adequate operator experience (12). These
limitations are offset by the advantages offered to patients
(Table 2). Operator experience can be positively influenced
through formal training programs and a commitment to
transradial PCI in daily practice. Other technical limitations
are being addressed through the evolution of radial equipment, such as sheathless 7.5-F guiding catheters that allow
greater support and accommodate dual-stent techniques and

Rao et al.
Transradial Approach for PCI

2193

larger devices, but which create arteriotomies that are

smaller than 6-F sheaths (48).
The compartmentalization of transradial PCI to a few
centers or operators has also limited the quality of data
supporting its use. Most of the studies reviewed in this
article are retrospective and observational and therefore
subject to significant selection bias. Even when randomized
trials are performed, they are either single-center studies or
include only a few centers with high concentrations of
experienced radialists. The practice of PCI has evolved to
include pharmacotherapy that reduces bleeding risk with the
transfemoral approach (7) and very-low-profile coronary
devices that substantially improve the odds of procedural
success. In this context, unresolved issues related to transradial PCI in the modern era include the true incidence of
radial artery occlusion and its clinical sequelae, re-access
of the radial artery for repeat procedures, the durability of
previously accessed radial arteries as conduits for coronary
artery bypass grafting, the utility of the Allen test in
preventing complications related to vascular compromise
after transradial PCI, the true learning curve for transradial
PCI including the rate of crossover to the transfemoral
approach, the effect of the transradial approach on bleeding
and hard clinical outcomes such as death or postprocedural stroke, the influence of transradial PCI on costs,
the safety of same-day discharge after transradial PCI, and
the advantages and disadvantages of the transradial approach for primary PCI for ST-segment elevation myocardial infarction.
Although many of these topics have been addressed in
previous studies, none have been the focus of recent studies
that take into account modern pharmacotherapy, patent
hemostasis for post-procedural radial artery compression, or
the current attention on door-to-balloon times for primary
PCI. Upcoming investigations capable of illuminating some
of these important issues are summarized in Table 4.
Another important contribution possible with wider application of transradial PCI is the study and potential
application of higher doses of antithrombotics. Antithrombotic doses studied in phase 3 trials are often determined by
examining complications that occur across a range of doses
explored during phase 2 trials. The upper limit of dosing for
anticoagulants and parenteral antiplatelet agents commonly
used in PCI is determined by bleeding complications, many
of which occur at the vascular access site. Figure 4 displays
the overall bleeding rates and proportion of bleeding related
to access site across a sampling of PCI, nonST-segment
elevation ACS, and ST-segment elevation myocardial infarction trials. The substantial reduction in access-site
bleeding afforded by the transradial approach may allow
higher doses to be carried forward into phase 3 trials and
ultimately into clinical practice.
For example, current guidelines for dosing of unfractionated heparin during PCI are based on data demonstrating
an association between higher activated clotting times and
increased bleeding events (49). However, some studies have

2194

Rao et al.
Transradial Approach for PCI

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795

Ongoing
Evaluating
Transradial
Table 4Trials
Ongoing
Trialsthe
Evaluating
theApproach
Transradial Approach
ClinicalTrials.gov Identifier

Comparisons

Planned Sample Size, n

Outcomes

NCT01014273

Radial vs. femoral approach to PCI in UA, NSTEMI, STEMI

7,000

30-day death, MI, stroke, or major bleeding

NCT00815997

4- vs. 6-F guide catheter for transradial PCI

160

Radial artery patency 2 days post-procedure

NCT00329979

Radial vs. femoral diagnostic catheterization in severe

aortic stenosis

152

Acute brain injury assessed by diffusionweighted brain MRI

NCT00597324

Transradial catheterization in patients with normal and

abnormal Allen test results

180

30-day levels of capillary lactate in the

thumb of instrumented hand

NCT00821106

Right radial vs. left radial approach for diagnostic and

interventional procedures

NCT00638586

Radial vs. femoral access for PCI

1,500
160

Fluoroscopy time and patient radiation dose

Post-procedure anxiety, pain, satisfaction

MI myocardial infarction; MRI magnetic resonance imaging; NSTEMI nonST-segment elevation myocardial infarction; PCI percutaneous coronary intervention; STEMI ST-segment elevation
myocardial infarction; UA unstable angina.

also demonstrated an association between higher heparin

doses and reduced ischemic events (50). The transradial approach may allow a wider therapeutic index for anticoagulants
such as unfractionated heparinpreserving ischemic reduction
with higher doses while minimizing the penalty of increased
bleeding.

2.

3.

Conclusions
4.

The evolution of PCI practice has led to an emphasis on

minimizing post-procedural vascular and bleeding complications while maintaining procedural success. A growing
body of literature supports the use of the radial artery over
the femoral artery to achieve these goals, and data demonstrate an association between the transradial approach and
reduced costs and post-procedural LOS. Despite these
advantages, there are some limitations to this approach,
such as the potential impact on radial artery patency and
greater radiation exposure during the learning curvea
factor that has limited adoption of this technique.
Greater penetration of the transradial approach will
depend on the availability of educational programs for
interventionalists and fellows-in-training, commitment
from professional societies to support transradial PCI,
and the generation of high-quality evidence to determine
its comparative effectiveness against the traditional femoral approach. Systematic use of the transradial approach
may also affect drug development by allowing higher (and
potentially more efficacious) doses of anticoagulants to be
studied in phase 3 trials and implemented in clinical
practice.
Reprint requests and correspondence: Dr. Sunil V. Rao, The
Duke Clinical Research Institute, 508 Fulton Street (111A),
Durham, North Carolina 27705. E-mail: sunil.rao@duke.edu.

5.

6.
7.

8.
9.
10.
11.
12.
13.
14.
15.

REFERENCES

16.
1. Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA.
ACCF/SCAI/STS/AATS/AHA/ASNC 2009 appropriateness criteria for coronary revascularization: a report by the American College of
Cardiology Foundation Appropriateness Criteria Task Force, Society
for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American

17.

Heart Association, and the American Society of Nuclear Cardiology.

J Am Coll Cardiol 2009;53:530 53.
Batchelor WB, Anstrom KJ, Muhlbaier LH, et al. Contemporary
outcome trends in the elderly undergoing percutaneous coronary
interventions: results in 7,472 octogenarians. National Cardiovascular
Network Collaboration. J Am Coll Cardiol 2000;36:72330.
Singh M, Rihal CS, Gersh BJ, et al. Twenty-five-year trends in
in-hospital and long-term outcome after percutaneous coronary
intervention: a single-institution experience. Circulation 2007;115:
2835 41.
Doyle BJ, Rihal CS, Gastineau DA, Holmes DR, Jr. Bleeding, blood
transfusion, and increased mortality after percutaneous coronary intervention: implications for contemporary practice. J Am Coll Cardiol
2009;53:2019 27.
Rao SV, Eikelboom JA, Granger CB, Harrington RA, Califf RM,
Bassand JP. Bleeding and blood transfusion issues in patients with
non-ST-segment elevation acute coronary syndromes. Eur Heart J
2007;28:1193204.
Montalescot G, White HD, Gallo R, et al. Enoxaparin versus
unfractionated heparin in elective percutaneous coronary intervention.
N Engl J Med 2006;355:1006 17.
Lincoff AM, Bittl JA, Harrington RA, et al. Bivalirudin and
provisional glycoprotein IIb/IIIa blockade compared with heparin
and planned glycoprotein IIb/IIIa blockade during percutaneous
coronary intervention: REPLACE-2 randomized trial. JAMA
2003;289:853 63.
Radner S. Thoracal aortography by catheterization from the radial
artery; preliminary report of a new technique. Acta Radiol 1948;29:
178 80.
Gruntzig A. Transluminal dilatation of coronary-artery stenosis. Lancet 1978;1:263.
Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:37.
Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach
for coronary stent implantation. Cathet Cardiovasc Diagn 1993;30:
173 8.
Louvard Y, Lefevre T, Morice MC. Radial approach: what about the
learning curve? Cathet Cardiovasc Diagn 1997;42:467 8.
Mann T, Cubeddu G, Bowen J, et al. Stenting in acute coronary
syndromes: a comparison of radial versus femoral access sites. J Am
Coll Cardiol 1998;32:572 6.
Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access
on quality of life and cost of cardiac catheterization: a randomized
comparison. Am Heart J 1999;138:430 6.
Mann T, Cowper PA, Peterson ED, et al. Transradial coronary
stenting: comparison with femoral access closed with an arterial suture
device. Catheter Cardiovasc Interv 2000;49:150 6.
Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der
Wieken R. A randomized comparison of percutaneous transluminal
coronary angioplasty by the radial, brachial and femoral approaches:
the access study. J Am Coll Cardiol 1997;29:1269 75.
Hildick-Smith DJ, Walsh JT, Lowe MD, Petch MC. Coronary
angiography in the fully anticoagulated patient: the transradial route is
successful and safe. Catheter Cardiovasc Interv 2003;58:8 10.

Rao et al.
Transradial Approach for PCI

JACC Vol. 55, No. 20, 2010

May 18, 2010:218795
18. Bertrand OF, De Larochelliere R, Rodes-Cabau J, et al. A
randomized study comparing same-day home discharge and abciximab
bolus only to overnight hospitalization and abciximab bolus and infusion
after transradial coronary stent implantation. Circulation 2006;114:
2636 43.
19. Folmar J, Sachar R, Mann T. Transradial approach for carotid
artery stenting: a feasibility study. Catheter Cardiovasc Interv
2007;69:355 61.
20. Casserly IP. Trans-radial treatment of in-stent restenosis of the
superficial femoral arterythe importance of case selection. Catheter
Cardiovasc Interv 2009;74:499.
21. Raghu C, Louvard Y. Transradial approach for percutaneous transluminal angioplasty and stenting in the treatment of chronic mesenteric
ischemia. Catheter Cardiovasc Interv 2004;61:450 4.
22. Davenport JJ, Lam L, Whalen-Glass R, et al. The successful use of
alternative routes of vascular access for performing pediatric interventional cardiac catheterization. Catheter Cardiovasc Interv 2008;72:
392 8.
23. Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus
femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol 2004;44:349 56.
24. Rao SV, Ou FS, Wang TY, et al. Trends in the prevalence and
outcomes of radial and femoral approaches to percutaneous coronary
intervention: a report from the National Cardiovascular Data Registry.
JACC Cardiovasc Interv 2008;1:379 86.
25. Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus
femoral access for coronary angiography or intervention and the
impact on major bleeding and ischemic events: a systematic review
and meta-analysis of randomized trials. Am Heart J 2009;157:
132 40.
26. Brasselet C, Blanpain T, Tassan-Mangina S, et al. Comparison of
operator radiation exposure with optimized radiation protection
devices during coronary angiograms and ad hoc percutaneous
coronary interventions by radial and femoral routes. Eur Heart J
2008;29:6370.
27. Spaulding C, Lefevre T, Funck F, et al. Left radial approach for
coronary angiography: results of a prospective study. Cathet Cardiovasc Diagn 1996;39:36570.
28. Goldberg SL, Renslo R, Sinow R, French WJ. Learning curve in the
use of the radial artery as vascular access in the performance of
percutaneous transluminal coronary angioplasty. Cathet Cardiovasc
Diagn 1998;44:14752.
29. Kugelmass AD, Cohen DJ, Brown PP, Simon AW, Becker ER,
Culler SD. Hospital resources consumed in treating complications
associated with percutaneous coronary interventions. Am J Cardiol
2006;97:3227.
30. Kinnaird TD, Stabile E, Mintz GS, et al. Incidence, predictors, and
prognostic implications of bleeding and blood transfusion following
percutaneous coronary interventions. Am J Cardiol 2003;92:930 5.
31. Sciahbasi A, Pristipino C, Ambrosio G, et al. Arterial access-siterelated outcomes of patients undergoing invasive coronary procedures
for acute coronary syndromes (from the ComPaRison of Early Invasive
and Conservative Treatment in Patients With Non-ST-ElevatiOn
Acute Coronary Syndromes [PRESTO-ACS] Vascular Substudy).
Am J Cardiol 2009;103:796 800.
32. Choussat R, Black A, Bossi I, Fajadet J, Marco J. Vascular complications and clinical outcome after coronary angioplasty with platelet
IIb/IIIa receptor blockade. Comparison of transradial vs transfemoral
arterial access. Eur Heart J 2000;21:6627.
33. Achenbach S, Ropers D, Kallert L, et al. Transradial versus
transfemoral approach for coronary angiography and intervention in
patients above 75 years of age. Catheter Cardiovasc Interv 2008;
72:629 35.
34. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van
der Wieken R. Incidence and outcome of radial artery occlusion

35.
36.

37.
38.
39.

40.

41.
42.

43.
44.

45.
46.

47.

48.
49.

50.

2195

following transradial artery coronary angioplasty. Cathet Cardiovasc

Diagn 1997;40:156 8.
Calvio-Santos RA, Vazquez-Rodrguez JM, Salgado-Fernandez J,
et al. Management of iatrogenic radial artery perforation. Catheter
Cardiovasc Interv 2004;61:74 8.
Papadimos TJ, Hofmann JP. Radial artery thrombosis, palmar arch
systolic blood velocities, and chronic regional pain syndrome 1 following transradial cardiac catheterization. Catheter Cardiovasc Interv
2002;57:537 40.
Tizon-Marcos H, Barbeau GR. Incidence of compartment syndrome
of the arm in a large series of transradial approach for coronary
procedures. J Interv Cardiol 2008;21:380 4.
Cubero JM, Lombardo J, Pedrosa C, et al. Radial compression guided
by mean artery pressure versus standard compression with a pneumatic
device (RACOMAP). Catheter Cardiovasc Interv 2009;73:46772.
Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial
artery occlusion-patent hemostasis evaluation trial (PROPHET
study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization. Catheter Cardiovasc Interv 2008;72:335 40.
Chase AJ, Fretz EB, Warburton WP, et al. Association of the
arterial access site at angioplasty with transfusion and mortality: the
M.O.R.T.A.L study (Mortality benefit Of Reduced Transfusion
after percutaneous coronary intervention via the Arm or Leg).
Heart 2008;94:1019 25.
Rao SV, Kaul PR, Liao L, et al. Association between bleeding, blood
transfusion, and costs among patients with non-ST-segment elevation
acute coronary syndromes. Am Heart J 2008;155:369 74.
Cohen DJ, Lincoff AM, Lavelle TA, et al. Economic evaluation of
bivalirudin with provisional glycoprotein IIB/IIIA inhibition versus
heparin with routine glycoprotein IIB/IIIA inhibition for percutaneous coronary intervention: results from the REPLACE-2 trial. J Am
Coll Cardiol 2004;44:1792 800.
Roussanov O, Wilson SJ, Henley K, et al. Cost-effectiveness of the
radial versus femoral artery approach to diagnostic cardiac catheterization. J Invasive Cardiol 2007;19:349 53.
Investigators TPT. Inhibition of platelet glycoprotein IIb/IIIa with
eptifibatide in patients with acute coronary syndromes: platelet glycoprotein IIb/IIIa in unstable angina: receptor suppression using integrilin therapy. N Engl J Med 1998;339:436 43.
Amoroso G, Laarman GJ, Kiemeneij F. Overview of the transradial
approach in percutaneous coronary intervention. J Cardiovasc Med
(Hagerstown) 2007;8:230 7.
Beller GA, Bonow RO, Fuster V. ACC revised recommendations for
training in adult cardiovascular medicine. Core Cardiology Training II
(COCATS 2). (Revision of the 1995 COCATS training statement).
J Am Coll Cardiol 2002;39:1242 6.
Burzotta F, Trani C, Hamon M, Amoroso G, Kiemeneij F. Transradial approach for coronary angiography and interventions in patients
with coronary bypass grafts: tips and tricks. Catheter Cardiovasc Interv
2008;72:26372.
Mamas MA, Fath-Ordoubadi F, Fraser DG. Atraumatic complex
transradial intervention using large bore sheathless guide catheter.
Catheter Cardiovasc Interv 2008;72:357 64.
Brener SJ, Moliterno DJ, Lincoff AM, Steinhubl SR, Wolski KE, Topol
EJ. Relationship between activated clotting time and ischemic or hemorrhagic complications: analysis of 4 recent randomized clinical trials of
percutaneous coronary intervention. Circulation 2004;110:994 8.
Montalescot G, Cohen M, Salette G, et al. Impact of anticoagulation
levels on outcomes in patients undergoing elective percutaneous
coronary intervention: insights from the STEEPLE trial. Eur Heart J
2008;29:46271.

Key Words: acute coronary syndromes y percutaneous coronary

intervention y review y transradial.