JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 71, NO.

10, 2018

ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

PUBLISHED BY ELSEVIER

REVIEW TOPIC OF THE WEEK

The Radial Artery for Percutaneous

Coronary Procedures or Surgery?
Mario Gaudino, MD,a Francesco Burzotta, MD, PHD,b Faisal Bakaeen, MD,c Olivier Bertrand, MD,d Filippo Crea, MD,b
Antonino Di Franco, MD,a Stephen Fremes, MD,e Ferdinand Kiemeneij, MD, PHD,f Yves Louvard, MD,g
Sunil V. Rao, MD,h Thomas A. Schwann, MD,i James Tatoulis, MD,j Robert F. Tranbaugh, MD,a
Carlo Trani, MD, PHD,b Marco Valgimigli, MD, PHD,k Pascal Vranckx, MD, PHD,l David P. Taggart, MD, PHD,m
for the Arterial Grafting International Consortium Alliance

ABSTRACT

This article summarizes the current research on the benefits of using the transradial approach for percutaneous procedures
and the radial artery as a conduit for coronary artery bypass surgery. Based on the available evidence, the authors provide
recommendations for the use of the radial artery in patients undergoing percutaneous or surgical coronary procedures.
(J Am Coll Cardiol 2018;71:1167–75) © 2018 by the American College of Cardiology Foundation.

R
Among
ecently, there has been renewed interest in
the radial artery (RA) both for cardiovascular
surgery and for percutaneous intervention.
surgeons, the publication of long-term
graft failure
benefits (7).
and mitigating long-term

To date there are no guidelines for the approach to

the RA in patients with known or possible coronary
survival

follow-up data and randomized comparative studies
has established the role of the RA as a more durable
graft than the saphenous vein (SV) for coronary artery
bypass operations (CABG) (1). Among cardiologists,
transradial access (TRA) has been shown to be a supe-
rior alternative to the classic femoral approach for
diagnostic catheterization and percutaneous inter-
ventions (2–6), and TRA procedures have become
increasingly popular. This convergence of interests,
however, has elicited concerns that, after TRA, the
RA may not be a suitable CABG conduit due to
catheter-induced trauma predisposing to premature
artery disease (8). In this paper, we provide guidance
for the use of the TRA approach for percutaneous
intervention based on the best evidence and use of
the RA as a conduit for CABG and suggest recom-
mendations for optimal use of the RA in patients with
coronary artery disease.
METHODS
WRITING PANEL. A writing panel was organized by
convening 17 physicians from the fields of clinical
cardiology (n ¼ 2), cardiothoracic surgery (n ¼ 7), and

Listen to this manuscript’s
audio summary by
JACC Editor-in-Chief
Dr. Valentin Fuster.
From the aDepartment of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York; bUniversità Cattolica Del Sacro
Cuore, Rome, Italy; cCleveland Clinic, Cleveland, Ohio; dQuebec Heart and Lung Institute, Quebec City, Quebec, Canada; eSchulich
Heart Centre, Sunnybrook Health Science, University of Toronto, Toronto, Ontario, Canada; fDepartment of Cardiology, Zuiderzee
Medical Center, Lelystad, the Netherlands; gInstitut Cardiovasculaire Paris Sud, Hopital Jacques Cartier, Massy, France; hDuke
Clinical Research Institute, Durham, North Carolina; iUniversity of Toledo Medical Center, Toledo, Ohio; jRoyal Melbourne
Hospital, Melbourne, Victoria, Australia; kSwiss Cardiovascular Center, Bern University Hospital, Bern, Switzerland; lHartcentrum
Hasselt and Faculty of Medicine and Life Sciences Hasselt University, Jessa Ziekenhuis, Hasselt, Belgium; and the mUniversity of
Oxford, Oxford, United Kingdom. Dr. Burzotta has received speakers and consultant fees from Abbott and St. Jude Medical. Dr.
Rao has served as a consultant for Medtronic and Terumo. Dr. Trani has received speaker fees from Medtronic, Abbott, Abiomed,
and Terumo; and consultant fees from Biotronik. All other authors have reported that they have no relationships relevant to the
contents of this paper to disclose. Drs. Gaudino and Burzotta contributed equally to this work and are joint first authors. Michael
Mack, MD, served as Guest Editor for this paper.

Manuscript received October 31, 2017; revised manuscript received January 4, 2018, accepted January 5, 2018.

ISSN 0735-1097/$36.00 https://doi.org/10.1016/j.jacc.2018.01.013

1168 Gaudino et al.
RA for Percutaneous Procedures or CABG?
ABBREVIATIONS interventional cardiology (n ¼ 8), highly
AND ACRONYMS experienced in the use of the RA for CABG or
TRA. The members of the panel agreed to
CABG = coronary artery bypass
operations
review the best available research and to
provide a document with recommendations.
CAD = coronary artery disease
Treatment algorithms were drafted when
PCI = percutaneous coronary
intervention general agreement among panelists was
RA = radial artery
reached.
RCT = randomized controlled SEARCH METHOD. In August 2017, a observational and randomized trials comparing TRA
trial comprehensive search to identify studies
RITA = right internal thoracic that evaluated the use of the RA for TRA and
artery
CABG was performed in the following data-
SV = saphenous vein bases from inception to present: Ovid MED-
TFA = transfemoral approach LINE, Ovid EMBASE, and the Cochrane
TRA = transradial access Library (Cochrane Database of Systematic
Reviews, Cochrane Central Register of Controlled
Trials [CENTRAL], and Cochrane Methodology Reg-
ister). Search keywords included “radial artery” in
combination with “coronary surgery,” “myocardial
revascularization,” “coronary artery bypass,” “coro-
nary angiography,” and “percutaneous coronary in-
terventions.” Relevant abstracts were reviewed, and
the related articles function was used for all included
papers. References for all selected studies were cross-
checked. The writing groups selected the most rele-
vant papers according to both methodological and
clinical considerations. Observational series were
considered only in the absence of data from ran-
domized controlled trials (RCTs). Details of the search
are given in Online Figure 1.
USE OF THE RADIAL ARTERY FOR TRANSRADIAL
PROCEDURES. Due to the superficial position and
easy compressibility of the RA, TRA has been devel-
oped as an alternative to the conventional trans-
femoral approach (TFA) to reduce the risk of
procedure-related vascular complications.
A limitation of TRA is the higher crossover rate
than that of the TFA, particularly during the learning
curve (2,3). However, the crossover rate declines
significantly with operator’s experience (3). Cross-
overs are generally due to the smaller size, the wide
range of anatomic variations, and the high suscepti-
bility to spasm of the RA (Online Table 1) (4).
The assessment of the adequacy of the ulnar
collateral circulation has been conventionally
considered necessary before TRA. However, recent
findings suggest that the patency of the palmar arches
is highly dynamic and that the vascular reserve of the
hand circulation can be recruited during and after
TRA, even in patients with poor collateral circulation
at baseline (5). The safety of using the TRA without
previous evaluation of the ulnar collateral circulation
JACC VOL. 71, NO. 10, 2018
MARCH 13, 2018:1167–75
has been recently shown in a large cohort of patients
with acute coronary syndromes (6).
BENEFITS OF USING THE TRA FOR ANGIOGRAPHY
AND PERCUTANEOUS INTERVENTIONS. Random-
ized and observational studies have shown that the
use of the TRA significantly reduces vascular access
site complications and bleeding compared to the TFA.
A meta-analysis of >600,000 patients from both
and TFA found that radial access was associated with
a 78% reduction in major bleeding and an 80%
reduction in post-procedure transfusions (9). Three
prospective randomized trials comparing TRA with
TFA in the setting of acute coronary syndromes
consistently showed that TRA reduced major
bleeding, major adverse cardiovascular events, and
mortality (6,9,10). The reduction in major vascular
complications with TRA has been similar for patients
undergoing angiography and percutaneous coronary
intervention (PCI) (10). Some data suggest that the
benefits of the TRA in terms of mortality, but not of
bleeding and vascular complications, are significantly
influenced by operator experience (6).
The TRA is also associated with benefits in patient
satisfaction, catheter laboratory throughput, and
costs. It has been shown that patients prefer TRA over
TFA (11). The enhanced recovery associated with TRA
increases catheter laboratory efficiency and same-day
discharge, leading to significant savings for the health
system. A large contemporary observational study
showed that adoption of TRA can save $3,689 per
procedure. Combining TRA and same-day discharge
has the potential to save $300 million per year in the
United States (12).
TRA IN SPECIFIC PATIENTS’ SUBSETS. The advan-
tages of the TRA have been confirmed in the elderly (6).
However, elderly patients have more complex
vascular anatomy, and the TRA may be more chal-
lenging in this population. In case of elderly patients
presenting with ST-segment elevation myocardial
infarction, the use of TRA has been shown to be asso-
ciated with a significantly reduced risk of stroke and
lower rate of vascular complications and mortality (13).
Adoption of the TRA has been shown to be asso-
ciated with clinical benefits in patients with chronic
renal disease, particularly in terms of reduction of
post-procedural acute kidney injury (14). However,
the possible need for an upper extremity arteriove-
nous fistula for dialysis is a possible argument against
the use of the TRA in this group of patients.
In patients with a previous CABG, the use of the
TRA requires dedicated skills and techniques (15). In
JACC VOL. 71, NO. 10, 2018 Gaudino et al. 1169
MARCH 13, 2018:1167–75 RA for Percutaneous Procedures or CABG?

supply to the hand. However, sporadic cases of suc-

T A B L E 1 Clinical and Procedural Characteristics Associated With
Post-Catheterization Radial Artery Occlusion
cessful treatment of symptomatic occlusion after TRA
have been reported (20).
Early Late
Occlusion Occlusion
As intra-arterial thrombosis plays a major role in
Clinical characteristics (Online Ref. #) determining RA occlusion, the use of anticoagulation
Age (1,2) X and modified compression techniques has been
Female sex (1,2) X shown to significantly reduce its incidence after TRA,
Smaller body weight (1,3,4) X with series reporting RA occlusion rate as low as 1% to
Small radial artery size (4) X 2% (19). Distal RA access has also been proposed (21).
No statin therapy at the time of X
A list of the possible factors contributing to occlusion
catheterization (5)
Peripheral artery disease (2) X is presented in Table 1.
Diabetes (6) X The effect of the TRA on the vascular wall and
Present or former smoking habit (7,8) X function of the RA has been recently summarized in a
Procedural characteristics (Online Ref. #) review article (8). Studies using histologic and high-
Sheath-to-artery ratio $1 (2,9,10) X resolution intravascular imaging have shown that
No use of hydrophilic sheaths (2,11) X
the use of the TRA is associated with a high incidence
No use of appropriate anticoagulation X
(heparin >50 IU/kg) (12–16) of endothelial damage and a lower but not negligible
No use of patent hemostasis technique (1) X rate of medial dissection (Figure 1) (8,22). Of note, the
Prolonged post-procedure high-pressure X X vessel wall damage is higher in the distal part of the
compression (17)
RA, but it is evident even in the proximal portion of
the artery (8). The functional counterpart of the his-
tologic damage is a significant reduction of
the RADIAL-CABG (Radial Versus Femoral Access for endothelium-dependent vasodilation and a nonsig-
Coronary Artery Bypass Graft Angiography and nificant impairment of endothelium-independent
Intervention) trial, the TRA was associated with vasodilation as shown by Antonopoulos et al. (23) in
greater use of contrast, longer procedure time, a recent meta-analysis. The impairment in vaso-
greater access cross-over, and increased operator dilatory function may persist for several months after
exposure to radiation than TFA (16). However, this TRA, and to date, no clear evidence of a return to
trial was not conducted in a high-RA use center, and in baseline function with the time exists.
a meta-analysis of 9 studies in CABG patients, the use Chronic intimal thickening occurs in a high pro-
of the TRA was associated with lower risk of access-site portion of patients after TRA, with histologic studies
complications, similar procedural and fluoroscopy reporting intimal hyperplasia in 60% to 70% of cases
times, and higher rate of cross-over than TFA (17). (8). RA spasm occurs frequently during TRA. A recent
Caution should be used when using the TRA in review of the studies reported that the mean inci-
patients with severe hemodynamic compromise due dence of RA spasm after TRA is 14.7% (24). Endothe-
to the usually longer delay in initiation of coronary lial dysfunction does not predict RA spasm, whereas
intervention. On the other hand, the reduction artery sheath mismatch is a strong risk factor (25).
in access site complications associated with the Reduction of mechanical friction between the sheath
TRA can be particularly important for critically ill and catheter and the arterial wall by hydrophilic
patients. A recent multicenter study in patients coatings and use of pharmacologic vasodilation with
undergoing high-risk PCI found that the use of the nitroglycerin or verapamil or a combination of the 2
TRA was associated with a significant reduction in agents may significantly reduce RA spasm. Pressure-
adverse clinical events compared to the TFA (18). mediated dilation is a new and promising RA vaso-
Of note, due to the very high-risk clinical scenario, dilator strategy (26).
the possibility of a treatment allocation bias with
more experienced operators using the TRA cannot EVALUATION AND HARVESTING OF THE RADIAL
be excluded. ARTERY FOR CABG. There is no formal agreement on
EFFECT OF TRA ON THE RADIAL ARTERY. In a meta- the best method to pre-operatively evaluate the RA
analysis of 66 studies and >31,000 patients, the for CABG. The adequacy of ulnar collateral flow can
incidence of RA occlusion after TRA was found to be be assessed using the clinical Allen test, but many
7.7% at 1 day and 5.5% at >7 days after the procedure surgeons prefer to rely on a more objective method
(19). Of note, late RA occlusion occurring weeks or (Doppler ultrasonography, oximetry, or plethysmog-
months after TRA has also been described. RA oc- raphy) (27). Many authors also advocate ultrasonog-
clusion is usually asymptomatic due to the dual blood raphy of the artery to evaluate calcification and
1170 Gaudino et al. JACC VOL. 71, NO. 10, 2018

RA for Percutaneous Procedures or CABG? MARCH 13, 2018:1167–75

F I G U R E 1 Optical Coherence Tomography Documentation of Different Radial Artery Damages Induced by Catheterization

(A) Radial artery spasm documented at procedure’s end. (B) Radial artery intimal tear documented at procedure’s end. (C) Radial artery media
dissection documented at procedure’s end. (D) Radial artery intima thickening documented 6 months after a first transradial procedure.

diameter. Diffuse calcification, diameter <2.0 mm,
Raynaud phenomenon, collagen vascular diseases,
poor ulnar collateral flow, and major forearm trauma
are considered contraindications to use of RA.
Caution is recommended in patients with renal failure
due to the potential need for dialysis access. In pub-
lished CABG series, the percentage of RA judged
inadequate for use ranges from 5% to 15% (27).
Although RA harvesting from the nondominant arm
has conventionally been recommended, harvesting
from the dominant or bilateral arm is also performed
(25). The left RA is the RA of choice for most surgeons
as it can be more easily harvested simultaneously
with harvesting of the left internal thoracic artery.
Endoscopic harvest as opposed to open harvest can
also be used with similar clinical and angiographic
outcomes (28). The overall incidence of local com-
plications including wound infection or dehiscence
and permanent neurological deficits after RA har-
vesting is <1%, and reports of ischemic hand com-
plications are exceedingly rare (27).
COMPARISON BETWEEN THE RADIAL ARTERY AND
THE SAPHENOUS VEIN. Three large RCTs have
directly compared the patency of RA and SV grafts
used for CABG (Table 2). The 2 trials that extended
follow-up beyond the first postoperative year found
significantly higher patency for the RA. Six meta-
analyses summarized the results of these and other
smaller comparative RCTs. In all analyses with a
mean follow-up >1 year, the use of the RA was asso-
ciated with a significantly lower incidence of graft
failure (Table 3).
All the RCTs had primary angiographic outcomes
and were individually underpowered to detect dif-
ferences in clinical outcomes. A meta-analysis of all
JACC VOL. 71, NO. 10, 2018 Gaudino et al. 1171
MARCH 13, 2018:1167–75 RA for Percutaneous Procedures or CABG?

published RCTs found significantly lower rate of

T A B L E 2 Randomized Trials With Sample Size >100 Grafts Comparing the Patency Rate
repeat revascularization and a trend toward reduced of the Radial Artery With That of the Saphenous Vein
incidence of cardiac death and myocardial infarction
Number of Mean
in the RA group (29). Due to the small number of Trial/Year Grafts Restudied Follow-Up Main Finding
postoperative events in CABG patients in the modern RSVP/2008 134 5 yrs Better patency rate for the RA (p ¼ 0.004)
era, it is likely that even this pooled analysis was VA/2011 266 1 yr No difference in patency (p ¼ 0.98)
underpowered to detect survival differences. RAPS/2012 269 7.7 yrs Better patency rate for the RA (p ¼ 0.002)
A meta-analysis of the observational reports
RA ¼ radial artery; RAPS ¼ Radial Artery Patency Study; RSVP ¼ Radial Artery Versus Saphenous Vein Patency
comparing the RA and the SV is summarized in trial; VA ¼ Veterans Affairs trial.
Figure 2. The use of the RA was associated with
similar operative risk and a highly significant 26%
relative risk reduction in long-term mortality
In diabetics, a large propensity matched study
compared to the use of the SV.
showed similar in-hospital and long-term mortality
COMPARISON BETWEEN THE RADIAL ARTERY AND using the RA or the RITA as the second arterial graft
THE RIGHT INTERNAL THORACIC ARTERY. A large (37). Another study confirmed similar rates of survival
randomized trial showed similar patency for the RA for RITA and RA but found that the use of the RITA
and the right internal thoracic artery (RITA) (30). A was associated with increased sternal wound com-
network meta-analysis of 9 RCTs confirmed similar plications (32). A post hoc analysis of the randomized
patency for the RA and the RITA, despite a nonsig- Radial Artery Patency study showed that RA is pro-
nificant trend toward reduced functional occlusion tective against graft occlusion regardless of diabetes
for the RITA (1). (38), suggesting that RA may be the arterial graft of
Clinical outcomes between the 2 arterial grafts are choice in diabetics (due to their increased risk for
more controversial. Observational studies have yiel- sternal complications).
ded conflicting results (31,32). A recent meta-analysis RA use also improves survival in reoperations (39).
of propensity matched studies found a survival In this situation, the RA is often the best available
advantage with the RITA (33), but an RCT reported conduit due to previous use of the mammary arteries
equivalent clinical outcomes (30). and the SV. Finally, technically, the RA length is more
Of note, the recently published interim analysis of adequate than the RITA to graft distal or multiple
the ART (Arterial Revascularization Trial) showed no targets.
differences in mid-term survival and event-free sur-
USE OF RADIAL ARTERY GRAFTS FOR CABG AFTER
vival for patients receiving 1 or 2 internal thoracic
TRANSRADIAL PROCEDURES. The only 2 studies
arteries. However, in a post hoc analysis, the ART
that have compared the patency of RAs submitted to
investigators showed how the addition of the RA to
TRA to noncatheterized RAs have reported signifi-
both groups significantly reduced the rate of major
cantly lower patency for TRA-RAs. Kamiya et al. (40)
adverse cardiac events (34).
reported 23% occlusion at 30 days for TRA-RAs versus
THE RA IN SPECIFIC PATIENT SUBSETS. Due to their 2% for control RA grafts (p ¼ 0.001). The authors also
superior patency and possibly improved survival,
additional arterial grafting (using RA or RITA) to
supplement the mammary artery to the left anterior T A B L E 3 Meta-Analyses of Randomized Trials Comparing the Patency Rate of the Radial
Artery With That of the Saphenous Vein
descending artery bypass is a Class IIA recommen-
dation in the current European guidelines for patients First Author Number of Follow-Up,
(Online Ref. #), Year Patients/Grafts yrs Main Finding
with reasonable life expectancy undergoing multi-
Benedetto (1), 2010 936 mean 1.8 No difference in patency
vessel CABG (35). In the 2011 American College of
Hu (2), 2011 3,889 1–6 Better patency rate for the RA
Cardiology/American Heart Association guidelines, (RR: 0.51; 95% CI: 0.41–0.63)
multiarterial grafting receives a Class IIB recommen- Athanasiou (3), 2011 1,157 >5 Lower patency rate for the SV
dation (36); in 2016, the Society of Thoracic Surgeons (OR: 2.28; 95% CI: 1.32–3.94)
Cao (4), 2013 1,708 >4 Better patency rate for the RA
clinical practice guidelines assigned a Class IIA based (OR: 0.31; 95% CI: 0.14–0.68)
on a more recent survey of published articles (7). Zhang et al. (5), 2014 1,860 1.7–7 Better patency rate for the RA
Use of RA in contrast to use of RITA does not in- (OR: 0.52; 95% CI: 0.37–0.73)

crease the risk of sternal wound complications Benedetto et al. (6), 2,780 1.7–7 Lower patency rate for the SV
2015 (OR: 2.36; 95% CI: 1.37–4.06)
including mediastinitis, an important consideration
due to increasing prevalence of diabetes and obesity CI ¼ confidence interval; OR ¼ odds ratio; RA ¼ radial artery; RR ¼ relative risk; SV ¼ saphenous vein.

in CABG patients.
1172 Gaudino et al. JACC VOL. 71, NO. 10, 2018

RA for Percutaneous Procedures or CABG? MARCH 13, 2018:1167–75

F I G U R E 2 Operative and Long-Term Mortality in Patients Receiving the Radial Artery or Saphenous Vein as the Second Conduit

A Peri-operative mortality: radial artery vs. saphenous vein

Study name Statistics for each study Odds ratio and 95% CI
Odds Lower Upper
ratio limit limit Z-Value p-Value
Anyanwu 2001 0.391 0.040 3.799 –0.809 0.418
Benedetto 2013 0.943 0.483 1.844 –0.171 0.864
Cohen 2001 1.000 0.340 2.942 0.000 1.000
Goldman 2011 1.508 0.251 9.080 0.449 0.654
Lin 2013 2.032 0.604 6.832 1.146 0.252
Locker 2013 1.161 0.362 3.724 0.251 0.802
Petrovic 2015 1.000 0.062 16.212 0.000 1.000
Santarpino 2010 0.237 0.011 4.979 –0.926 0.354
Shapira 1997 1.657 0.103 26.706 0.356 0.722
Shi 2016 0.636 0.273 1.484 –1.046 0.295
Taggart 2017 1.812 0.604 5.436 1.060 0.289
Tranbaugh 2010 0.499 0.045 5.518 –0.566 0.571
Zacharias 2004 1.101 0.465 2.606 0.219 0.826
1.021 0.733 1.422 0.123 0.902

0.01 0.1 1 10 100

RA SVG

B Long-term mortality: radial artery vs. saphenous vein grafting

Study name Statistics for each study Point (raw) and 95% CI
Point Lower Upper
(raw) limit limit Z-Value p-Value
Benedetto 2013 0.750 0.572 0.983 –2.081 0.037
Cohen 2001 0.600 0.378 0.951 –2.173 0.030
Lin 2013 0.760 0.598 0.966 –2.240 0.025
Locker 2013 0.560 0.378 0.830 –2.892 0.004
Petrovic 2015 0.720 0.562 0.923 –2.594 0.009
Shi 2016 0.790 0.706 0.884 –4.089 0.000
Taggart 2017 0.830 0.541 1.273 –0.854 0.393
Tranbaugh 2010 0.710 0.553 0.911 –2.687 0.007
Zacharias 2004 0.670 0.459 0.978 –2.076 0.038
0.748 0.692 0.809 –7.311 0.000

0.01 0.1 1 10 100

RA SVG

For details of the meta-analysis, see the Online Appendix. CI ¼ confidence interval; RA ¼ radial artery; SVG ¼ saphenous vein graft.

described a trend toward association between the
number of TRAs and the risk of graft occlusion
(p ¼ 0.07). In a similar study, Ruzieh et al. (41) re-
ported a 6- to 18-month patency of 59% in the TRA-RA
group compared to 78% in the control RA group
(p ¼ 0.03).
The current Society of Thoracic Surgeons guide-
lines suggest an interval of at least 3 months between
TRA and use of the RA for CABG, even though they
recognize that clinical data are insufficient to desig-
nate a safe wait time (7).
However, the attitude of surgeons toward the use
of RA grafts after TRA varies considerably. Even
among the panelists, some surgeons consider TRA an
absolute contraindication to use of RA use, others
consider the conduit usable at 3 to 6 months after
TRA; and others routinely use the freshly cathe-
terized RA, discarding the most distal portion of the
RA containing the puncture site. Noninvasive evalu-
ation of the endothelial function seems an attractive
option to preoperatively assess the RA after TRA, but
no data on its use have been published to date.
JACC VOL. 71, NO. 10, 2018 Gaudino et al. 1173
MARCH 13, 2018:1167–75 RA for Percutaneous Procedures or CABG?

C ENTR AL I LL U STRA T I O N Flowchart for Transradial Approach for Percutaneous Procedures

Acute Coronary Syndrome Stable presentation

PCI Angiography

– High clinical suspicion of

severe CAD
– Lack of conduits for CABG
– Surgeons use RA for CABG

No Yes

Consider TRA through the site

TRA
with worst ulnar compensation
(possibly through right RA)
or alternative approaches

Gaudino, M. et al. J Am Coll Cardiol. 2018;71(10):1167–75.

CABG ¼ coronary artery bypass grafting; CAD ¼ coronary artery disease; PCI ¼ percutaneous coronary intervention; RA ¼ radial artery;
TRA ¼ transradial access.

RECOMMENDATIONS FOR THE USE OF THE RA IN hydrophilic sheaths, intravenous anticoagulation

PATIENTS UNDERGOING PERCUTANEOUS
SURGICAL CORONARY PROCEDURES. As described
above, the use of the RA either as vascular access for
percutaneous coronary procedures or as conduit for
CABG is associated with significant clinical benefits.
However, catheterization is associated with RA
damage that may ultimately preclude the use of this
artery as a conduit for CABG. Hence, every effort
should be made to preserve short and long-term RA
patency after TRA. Because many patients with cor-
onary artery disease will undergo repeat catheteri-
zation and/or PCI over the years, post-TRA RA
occlusion has major clinical implications. Beyond the
short-term benefit of offering repeat access by the
previously used artery, cardiologists should ideally
also be concerned about preserving, if possible, an
“untouched” RA as a potential conduit if patients
require CABG.
Although not yet universally practiced, the use of a
combination of smaller catheters, better profiled
OR during TRA procedures, and patent hemostasis with
shorter compression time after procedure completion
are key to preserve the RA for future use. For cardi-
ologists, it is time to consider the potential additional
benefit of the RA not only as preferred access to the
coronary circulation but also as a better conduit for
CABG, which might impact long-term quality of life as
well as survival.
The decision to use the RA at the time of percuta-
neous procedures or surgery must be individualized
and based on the characteristics of the single patient,
including the current clinical status, and likely future
scenarios.
Based on the current evidence, this panel has
elaborated the following recommendations:
1. The TRA should be preferred over the TFA for
diagnostic angiography and PCI. This is particu-
larly important in acute coronary syndromes and
when intervention is required.
1174 Gaudino et al. JACC VOL. 71, NO. 10, 2018

RA for Percutaneous Procedures or CABG? MARCH 13, 2018:1167–75

2. When appropriate, the RA should be used in pref-
erence to the SV to achieve multiarterial CABG
because of its superior patency and potential for
improved patient longevity. In particular, the RA
may be the preferred second arterial conduit in
patients who are at high risk for sternal wound
complications.
3. Ideally, an effort should be made to reserve one RA
for TRA and the other for potential use as a conduit
for CABG. Generally, the use of both RAs for TRA
or for CABG is not advisable, unless there are
clinical indications or conduits shortage.
4. The laterality of the RA for use is at the discretion
of the TRA operator. As most catheter laboratories
are set up to use the right RA for TRA and most
surgeons prefer to harvest the left RA, it seems
reasonable to recommend that, whenever possible,
TRA interventions should be performed through
the right forearm, and the left arm should be
reserved for possible use at surgery.
5. Recommendation 4 may result in a small percent-
age of cases where the left RA is unusable at sur-
gery due to lack of ulnar
Consequently, in stable patients undergoing angi-
ography, where there is a high likelihood of severe
coronary artery disease and limited available con-
duits for bypass in institutions where the RA is
used for CABG, one may consider discussion with
the patient regarding alternatives to radial access
or TRA on the side with the
compensation.
6. Every effort should be made to adopt strategies to
minimize RA damage during TRA, including the
use of the most distal RA access point, use of
miniaturized equipment, optimal intravenous
antithrombotic treatment, and patent hemostasis
techniques.
7. In patients previously submitted to TRA, the non-
punctured artery should be used for CABG. In sit-
uations where the punctured RA is the only
available conduit, consideration should be given to
the risk of delaying surgery, although the specific
time interval required to optimize graft patency is
unknown at present.
CONCLUSIONS
Future studies are urgently needed in order to, first,
identify additional strategies to minimize the risk of
radial artery damage during TRA, and second, corre-
late the extent of RA endothelial damage assessed
noninvasively with the patency of RA grafts used for
CABG to establish an eventual optimal waiting inter-
compensation. val for the use of catheterized RA for CABG.
A flowchart that summarizes, in part, the current
recommendations is presented in the Central
Illustration.
ADDRESS FOR CORRESPONDENCE: Dr. Mario Gau-
dino, Department of Cardiothoracic Surgery, Weill
worst ulnar Cornell Medicine, 525 East 68th Street, New York,
New York 10065. E-mail: mfg9004@med.cornell.edu.

REFERENCES

1. Benedetto U, Raja SG, Albanese A, Amrani M,
Biondi-Zoccai G, Frati G. Searching for the second
best graft for coronary artery bypass surgery: a
network meta-analysis of randomized controlled
trials. Eur J Cardiothorac Surg 2015;47:59–65;
discussion 65.
2. Jolly SS, Amlani S, Hamon M, Yusuf S,
Mehta SR. Radial versus femoral access for coro-
nary angiography or intervention and the impact
on major bleeding and ischemic events: a sys-
tematic review and meta-analysis of randomized
trials. Am Heart J 2009;157:132–40.
3. Hess CN, Peterson ED, Neely ML, et al. The
learning curve for transradial percutaneous coro-
nary intervention among operators in the United
States: a study from the National Cardiovascular
Data Registry. Circulation 2014;129:2277–86.
4. Burzotta F, Brancati MF, Trani C, et al. Impact of
radial-to-aorta vascular anatomical variants on
risk of failure in trans-radial coronary procedures.
Catheter Cardiovasc Interv 2012;80:298–303.
5. Valgimigli M, Campo G, Penzo C, et al. Trans-
radial coronary catheterization and intervention
across the whole spectrum of Allen test results.
J Am Coll Cardiol 2014;63:1833–41.
6. Valgimigli M, Gagnor A, Calabró P, et al. Radial
versus femoral access in patients with acute cor-
onary syndromes undergoing invasive manage-
ment: a randomised multicentre trial. Lancet 2015;
385:2465–76.
7. Aldea GS, Bakaeen FG, Pal J, et al. The Society
of Thoracic Surgeons clinical practice guidelines on
arterial conduits for coronary artery bypass
grafting. Ann Thorac Surg 2016;101:801–9.
8. Mounsey CA, Mawhinney JA, Werner RS,
Taggart DP. Does previous transradial catheteri-
zation preclude use of the radial artery as a
conduit in coronary artery bypass surgery? Circu-
lation 2016;134:681–8.
9. Bertrand OF, Bélisle P, Joyal D, et al. Compar-
ison of transradial and femoral approaches for
percutaneous coronary interventions: a systematic
review and hierarchical Bayesian meta-analysis.
Am Heart J 2012;163:632–48.
10. Jolly SS, Yusuf S, Cairns J, et al. Radial versus
femoral access for coronary angiography and
intervention in patients with acute coronary syn-
dromes (RIVAL): a randomised, parallel group,
multicentre trial. Lancet 2011;377:1409–20.
11. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Ef-
fect of transradial access on quality of life and cost
of cardiac catheterization: a randomized compari-
son. Am Heart J 1999;138:430–6.
12. Amin AP, Patterson M, House JA, et al. Costs
associated with access site and same-day
discharge among medicare beneficiaries undergo-
ing percutaneous coronary intervention: an eval-
uation of the current percutaneous coronary
intervention care pathways in the united states.
J Am Col Cardiol Intv 2017;10:342–51.
13. Alnasser SM, Bagai A, Jolly SS, et al.
Transradial approach for coronary angiography
and intervention in the elderly: a meta-analysis
of 777,841 patients. Int J Cardiol 2017;228:
45–51.
14. Andò G, Cortese B, Russo F, et al. Acute kidney
injury after radial or femoral access for invasive
acute coronary syndrome management: AKI-MA-
TRIX. J Am Coll Cardiol 2017;69:2592–603.
JACC VOL. 71, NO. 10, 2018
MARCH 13, 2018:1167–75
15. 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;72:263–72.
16. Michael TT, Alomar M, Papayannis A, et al.
A randomized comparison of the transradial and
transfemoral approaches for coronary artery
bypass graft angiography and intervention: the
RADIAL-CABG Trial (RADIAL Versus Femoral Ac-
cess for Coronary Artery Bypass Graft Angiography
and Intervention). J Am Col Cardiol Intv 2013;6:
1138–44.
17. Rigattieri S, Sciahbasi A, Brilakis ES, et al.
Meta-analysis of radial versus femoral artery
approach for coronary procedures in patients with
previous coronary artery bypass grafting. Am J
Cardiol 2016;117:1248–55.
18. Romagnoli E, De Vita M, Burzotta F, et al.
Radial versus femoral approach comparison in
percutaneous coronary intervention with intra-
aortic balloon pump support: the RADIAL PUMP
UP registry. Am Heart J 2013;166:1019–26.
19. Rashid M, Kwok CS, Pancholy S, et al. Radial
artery occlusion after transradial interventions: a
systematic review and meta-analysis. J Am Heart
Assoc 2016;5:e002686.
20. Pasha AK, Elder MD, Malik UE, Khalid AM,
Noor Z, Movahed MR. Symptomatic radial artery
thrombosis successfully treated with endovascular
approach via femoral access route. Cardiovasc
Revasc Med 2014;15:357–9.
21. Kiemeneij F. Left distal transradial access in the
anatomical snuffbox for coronary angiography
(ldTRA) and interventions (ldTRI). Euro-
Intervention 2017;13:851–7.
22. Ul Haq MA, Rashid M, Kwok CS, Wong CW,
Nolan J, Mamas MA. Hand dysfunction after
transradial artery catheterization for coronary
procedures. World J Cardiol 2017;9:609–19.
23. Antonopoulos AS, Latsios G, Oikonomou E,
et al. Long-term endothelial dysfunction after
trans-radial catheterization: a meta-analytic
approach. J Card Surg 2017;32:464–73.
24. Kristic I, Lukenda J. Radial artery spasm during
transradial coronary procedures. J Invasive Cardiol
2011;23:527–31.
25. van der Heijden D, van Leeuwen MAH,
Janssens GN, et al. Endothelial dysfunction and
the occurrence of radial artery spasm during
transradial coronary procedures: the ACRA-spasm
study. EuroIntervention 2016;12:1263–70.
26. Collet C, Corral JM, Cavalcante R, et al. Pres-
sure-mediated versus pharmacologic treatment of
radial artery spasm during cardiac catheterisation:
a randomised pilot study. EuroIntervention 2017;
12:e2212–8.
27. Gaudino M, Crea F, Cammertoni F, Mazza A,
Toesca A, Massetti M. Technical issues in the use
of the radial artery as a coronary artery bypass
conduit. Ann Thorac Surg 2014;98:2247–54.
28. Rahouma M, Kamel M, Benedetto U, et al.
Endoscopic versus open radial artery harvesting: a
meta-analysis of randomized controlled and pro-
pensity matched studies. J Card Surg 2017;32:
334–41.
29. Zhang H, Wang ZW, Wu HB, Hu XP, Zhou Z,
Xu P. Radial artery graft vs. saphenous vein graft
for coronary artery bypass surgery: which conduit
offers better efficacy? Herz 2014;39:458–65.
30. Hayward PA, Buxton BF. Mid-term results of
the Radial Artery Patency and Clinical Outcomes
randomized trial. Ann Cardiothorac Surg 2013;2:
458–66.
31. Caputo M, Reeves B, Marchetto G, Mahesh B,
Lim K, Angelini GD. Radial versus right internal
thoracic artery as a second arterial conduit for
coronary surgery: early and midterm outcomes.
J Thorac Cardiovasc Surg 2003;126:39–47.
32. Hoffman DM, Dimitrova KR, Lucido DJ, et al.
Optimal conduit for diabetic patients: propensity
analysis of radial and right internal thoracic ar-
teries. Ann Thorac Surg 2014;98:30–7; discussion
36–7.
33. Benedetto U, Gaudino M, Caputo M, et al.
Right internal thoracic artery versus radial artery
as the second best arterial conduit: Insights from a
meta-analysis of propensity-matched data on
long-term survival. J Thorac Cardiovasc Surg
2016;152:1083–91.
34. Taggart DP, Altman DG, Flather M, et al. As-
sociations between adding a radial artery graft to
single and bilateral internal thoracic artery grafts
and outcomes: insights from the arterial revascu-
larization trial. Circulation 2017;136:454–63.
35. Authors/Task Force members, Windecker S,
Kolh P, et al. 2014 ESC/EACTS guidelines on
myocardial revascularization: the Task Force on
Myocardial Revascularization of the European So-
ciety of Cardiology (ESC) and the European
Gaudino et al. 1175
RA for Percutaneous Procedures or CABG?
Association for Cardio-Thoracic Surgery (EACTS)
developed with the special contribution of the
European Association of Percutaneous Cardiovas-
cular Interventions (EAPCI). Eur Heart J 2014;35:
2541–619.
36. Hillis LD, Smith PK, Anderson JL, et al. 2011
ACCF/AHA guideline for coronary artery bypass
graft surgery. A report of the American College of
Cardiology Foundation/American Heart Associa-
tion Task Force on Practice Guidelines. Developed
in collaboration with the American Association for
Thoracic Surgery, Society of Cardiovascular Anes-
thesiologists, and Society of Thoracic Surgeons.
J Am Coll Cardiol 2011;58:e123–210.
37. Raza S, Blackstone EH, Houghtaling PL, et al.
Similar outcomes in diabetes patients after coro-
nary artery bypass grafting with single internal
thoracic artery plus radial artery grafting and
bilateral internal thoracic artery grafting. Ann
Thorac Surg 2017;104:1923–32.
38. Deb S, Singh SK, Moussa F, et al. The long-
term impact of diabetes on graft patency after
coronary artery bypass grafting surgery: a sub-
study of the multicenter Radial Artery Patency
study. J Thorac Cardiovasc Surg 2014;148:
1246–53; discussion 1253.
39. Zacharias A, Schwann TA, Riordan CJ, et al.
Late outcomes after radial artery versus saphe-
nous vein grafting during reoperative coronary
artery bypass surgery. J Thorac Cardiovasc Surg
2010;139:1511–8.e4.
40. Kamiya H, Ushijima T, Kanamori T, et al. Use of
the radial artery graft after transradial catheteri-
zation: is it suitable as a bypass conduit? Ann
Thorac Surg 2003;76:1505–9.
41. Ruzieh M, Moza A, Siddegowda Bangalore B,
Schwann T, Tinkel JL. Effect of transradial cathe-
terisation on patency rates of radial arteries used
as a conduit for coronary bypass. Heart Lung Circ
2017;26:296–300.
KEY WORDS coronary artery bypass,
percutaneous procedures, radial artery
A PP END IX For details of the meta-analysis
reported in Figure 2 and supplemental
references as well as a supplemental table and
figure, please see the online version of this
paper.