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TECHNIQUES FOR
DIAGNOSTIC ANGIOGRAPHY AND
PERCUTANEOUS INTERVENTION
Transradial Access
TECHNIQUES FOR
DIAGNOSTIC ANGIOGRAPHY AND
PERCUTANEOUS INTERVENTION
•••
Howard A. Cohen, MD, FACC, FSCAI
Temple University Health System
Philadelphia, Pennsylvania
B cardiotext.
PUBLISHING
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© 2013 Howard A. Cohen
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ISBN: 978-1-935395-41-6
Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter 7: Basic Catheter Techniques for Diagnostic Angiography and PCI. ............ 61
Tift Mann
y
vi • Contents
Chapter 10: Transradial Access for PCI in Acute Myocardial Infarction ................. 95
Sameer J. Khandhar
Oscar C. Marroquin
Suresh R. Mulukutla
Chapter 11: Transradial Approach to Peripheral Interventions ....................... 121
John T. Coppola
Cezar Staniloae
Chapter 12: Right Heart Catheterization and Transradial Access ...................... 131
Ian C. Gilchrist
Chapter 13: The Learning Curve for Transradial Access ..... . .. . ..... . ............ . . 141
Yves Louvard
Hakim Benamer
Thierry Lefevre
Chapter 14: Transradial Arterial Access: Economic Considerations .................... 155
Ronald P. Caputo
Chapter 15: Tips and Tricks for Transradial Access .. .. . .. .. . .. . .. . .. . .. . .. . .. .. . .. . 165
Tejas Patel
Sanjay C. Shah
Samir B. Pancholy
Chapter 16: Complications of Transradial Access . . .. .. .. . .. . .. . .. . .. . .. . ...... . .. . . 181
Kirk N. Garratt
Chapter 17: How to Start a Transradial Program at Your Hospital ..................... 193
Ankitkumar K. Patel
Zoltan G. Turi
vii
viii • Contributors
Jean-Pierre Dery, MD, MSc, FACC. FRCPC Tift Mann, MD, FACC
Cardiologue d'intervention, Institut Wake Heart and Vascular Associates, Raleigh,
universitaire de cardiologie et de pneumologie North Carolina
de Quebec, Universite Laval, Quebec
City, Quebec, Canada Oscar C. Marroquin, MD, FACC, FSCAI
Assistant Professor of Medicine and
Aaron M. From, MD Epidemiology; Director, UPMC Provider
Iowa Heart Center of Mercy Hospital, Analytics, Heart and Vascular Institute,
Des Moines, Iowa University of Pittsburgh Medical Center,
Pittsburgh, Pennsylvania
Kirk N. Garratt, MD, MSc
Lenox Hill Heart and Vascular Institute Suresh R. Mulukutla, MD, FACC, FSCAI
of New York; Associate Chair, Quality and Assistant Professor of Medicine and
Research; Director, Cardiac Interventions, Epidemiology; Director, Center for Quality,
Northshore/LIJ Lenox Hill Hospital, Outcomes and Clinical Research, Heart and
New York, New York Vascular Institute, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania
Ian C. Gilchrist, MD, FACC, FSCAI, FCCM
Professor of Medicine, Interventional Pierre-Louis Nadeau, MD, CSPQ FRCPC
Cardiology, Pennsylvania State University, Interniste, Resident en cardiologie; Institut
Penn State Heart and Vascular Institute, universitaire de cardiologie et de pneumologie
Hershey, Pennsylvania de Quebec, Universite Laval, Quebec
City, Quebec, Canada
Rajiv Gulati, MD, PhD, FACC, FSCAI
Associate Professor of Medicine, College Samir B. Pancholy, MD, FACP, FACC, FSCAI
of Medicine: Consultant, Division of Program Director, Cardiology Fellowship,
Cardiovascular Diseases Mayo Clinic, The Wright Center for Graduate Medical
Rochester, Minnesota Education; Associate Professor of Medicine,
Cardiovascular Diseases, The Commonwealth
Robert W. Harrison, MD Medical College, Scranton, Pennsylvania
Fellow, Department of Internal Medicine,
Division of Cardiology, Duke University Ankitkumar K. Patel, MD, MPH
Medical Center, Durham, North Carolina Cardiology Fellow, Division of Cardiology,
Cooper University Hospital, Cooper Medical
Sameer J. Khandhar, MD School of Rowan University, Camden,
Assistant Professor of Medicine, Center for New Jersey
Quality, Outcomes and Clinical Research,
Heart and Vascular Institute, University Tejas Patel, MD, DM, FCSI, FACC, FESC, FSCAI
of Pittsburgh Medical Center, Pittsburgh, Chairman and Chief Interventional
Pennsylvania Cardiologist, Apex Heart Institute,
Ahmedabad, Gujarat, India
Thierry Lefevre, MD, FESC, FSCAI
Institut Cardiovasculaire Paris Sud, Sunil V. Rao, MD, FACC, FSCAI
Massy, France Associate Professor of Medicine, Department
of Internal Medicine, Division of Cardiology,
Yves Louvard, MD, FSCAI Duke University Medical Center, The
Institut Cardiovasculaire Paris Sud, Duke Clinical Research Institute, Durham,
Massy, France North Carolina
Contributors • ix
xi
ACC American College of Cardiology PARMI Five French Arterial access with
ACS acute coronary syndromes Reopro in Myocardial Infarction
ACT activated dotting time FDA Food and Drug Administration
ACUITY Acute Catheterization and Urgent Fr French
Intervention Strategy GI gastrointestinal bleeding
AHA American Heart Association GP glycoprotein
APR-DRG All Patient Refined Diagnosis GRACE Global Registry of Acute Coronary
Related Group Events
ASB access site bleeding GU genitourinary bleeding
A-V anterior-venous GUSTO Global Use of Strategies to Open
AVF arteriovenus fistulae Occluded Coronary Arteries
BA brachial artery Hgb hemoglobin g/dL
BARC Bleeding Academic Research HORIZONS-AMI Harmonizing Outcomes
Consortium with Revascularization and Stents in Acute
BMI body mass index Myocardial Infarction
CA coronary angiography ICH intracranial hemorrhage
CABG coronary artery bypass graft lib/Ilia glycoprotein lib/Ilia inhibitor
CAD coronary artery disease IMA internal mammary artery
CARAFE Coronary Angiography Through the INR international normalized ratio
Radial or Femoral Approach IQR interquartile range
CHF congestive heart failure IUCPQ Institut Universitaire de Cardiologie
CMS Centers for Medicare and Medicaid et de Pneumologie de Quebec
Services IVUS intravascular ultrasound
COPD chronic obstructive pulmonary disease LAD left anterior descending coronary artery
CRUSADE Can Rapid Risk Stratification of LAO left anterior oblique
Unstable Angina Patients Suppress Adverse LCX left circumflex coronary artery
Outcomes with Early Implementation of the LM CA left main coronary artery
ACCIAHA Guidelines LMWH low-molecular-weight heparin
CTO chronic total occlusion LOS length of stay
C:VA cerebrovascular accident LVEF left ventricular ejection fraction
DAP dose area product MACE major adverse cardiac events
DES drug-eluting stents MI myocardial infarction
DPA deep palmar arch M.O.R.T.A.L Mortality Benefit of Reduced
D2B door-to-balloon Transfusion after Percutaneous Coronary
EASY Early Discharge Mter Transradial Intervention via the Arm or Leg
Stenting of Coronary Arteries MRA magnetic resonance angiography
ECG electrocardiogram NCDR National Cardiovascular Data Registry
ECMO extra-corporeal membrane NHLBI National Heart, Lung, and Blood
oxygenation Institute
e-GFR estimated glomerular filtration rate NPO nothing by mouth
EPIC Evaluation of c7E3 for the Prevention NR not randomized
of Ischemic Complications
xiii
xiv • Abbreviations
Lucien Campeau was the first to describe if one considers the "expert" high-volume
transradial access for diagnostic angiog- operator. This became particularly apparent in
raphy.1 Ferdinand Kiemeneij subsequently those patients with acute coronary syndromes
reported the use of transradial access requiring vigorous anticoagulation. In the
for percutaneous transluminal coronary most recently reported RIVAL trial, comparing
angioplasty (PTCA) and for stent implanta- transradial to transfemoral access, there was
tion.2·3 Early on, it became clear that one of a difference in access site complications in
the major advantages of transradial access those patients with acute coronary syndrome
was the elimination of access site complica- who required vigorous anticoagulation.
tions. Furthermore, patient preference and Furthermore, when stratified by radial
satisfaction has clearly favored the transradial percutaneous coronary intervention (PCI)
approach. volume per center, the high-volume centers
In 1997, Kiemeneij reported the results had significantly improved outcomes. 5
of the ACCESS trial4 comparing the results Despite the apparent benefits of the
of transfemoral versus trans brachial versus transradial approach, the adoption of this
transradial access revealing the decreased technique has been slow, particularly in the
complications of the transradial approach United States. There are several reasons for
that have been replicated in virtually all this, not the least of which are the increased
subsequent trials comparing access site and technical aspects of this approach because
subsequent complication rates, especially of a smaller artery, a more difficult access
to the central circulation, and a more diffi- As the editor, I have taken the liberty to
cult engagement of the coronary arteries add [Editor's notes] in an effort to emphasize
compared to the transfemoral approach. In points or to give some additional perspective.
addition, most fellows receive good training in Chapter 2: Rationale for Transradial
the transfemoral approach with the transra- Access In this chapter, the authors describe
dial approach being taught in only a very few diagnostic angiography and percutaneous
training programs, although this appears to coronary interventions and why they play a
be changing rapidly. The "learning curve" for critical role in treating patients with ischemic
the transradial technique is steep, requiring heart disease. Over the past 2 decades,
approximately 200 cases for the operator advancements in pharmacotherapy, device
to feel completely comfortable with this therapy, and application of PCI have led to
approach for diagnostic as well as interven- significant improvements in outcomes. In
tional procedures. This will, of course, vary light of such advances in efficacy, maximizing
depending on the experience and the skill the safety of therapies and procedures has
of the individual operator. The majority of become a clinical priority. Bleeding and
operators in the United States do not perform vascular complications are a significant
200 cases per year, making it difficult for source of morbidity, mortality, and cost in the
them to attain and to maintain the necessary invasive treatment of coronary artery disease
skills to perform this technique. Conversely, and acute coronary syndromes in particular.
those operators who are performing multiple Studies indicate a significant reduction in
cases per day may find themselves "too access site bleeding and vascular complica-
busy" to master the skills necessary for this tions with the radial approach. These benefits
approach. are also associated with reduced mortality in
Any operator of reasonable talent, however, specific clinical settings and among patients
who is willing to spend the time required treated at experienced radial centers and
to learn the technique can acquire the skills by experienced operators. In addition, the
necessary to master the transradial approach. reduction in procedural complications is
The "learning curve" certainly can be flat- associated with decreased length of stay,
tened by spending time in a busy laboratory decreased hospital costs, decreased nursing
with experienced and dedicated transradial workload, and increased patient satisfaction.
operators. Wider adoption of transradial percutaneous
procedures has the potential to significantly
affect public health in a positive way.
Chapter 3: Vascular Anatomy of the Arm
• HOW TO USE THIS BOOK and Hand This chapter recognizes that
The purpose of this textbook is to provide, radial access has emerged as an important
in one place, the necessary tools for the advance in vascular medicine and, when
already experienced transfemoral operator applied appropriately, it results in improved
and for the newly minted transradial operator outcomes and patient satisfaction. To safely,
to master this technique. In addition, the effectively perform this technique, under-
textbook is meant to be a resource to learn standing the vascular anatomy of the ann
new techniques for the already experienced and hand is essential. With this knowledge,
transradial operator. We have attempted to one can alertly identify and avoid potential
make this textbook rich in still frame images procedural pitfalls that may result from the
and video callouts that can be viewed at www. presence of vascular anomalies, variances
transradial.cardiotextpublishing.com in an in vascular supply and vessel diameter, and
effort to demonstrate the technical issues encroachments of tissue integrity. This broad
involved. In this regard, the textbook is avail- understanding will foster excellent success
able digitally so that the reader can readily while maintaining complication rates at a
access the links to the teaching videos. minimal level.
chapter 1 Introduction • 3
mortality in the ACS setting. However, despite on how central venous access can actually be
these remarkable advances, these patients readily obtained using forearm veins. Whether
are among those at highest risk for bleeding needed for catheter-based hemodynamic
complications following interventional monitoring or diagnosis, for temporary pacing
procedures. Furthermore, considerable during periods of iatrogenic bradycardia from
recent evidence suggests that bleeding in interventional techniques, or for a trans-
the ACS setting increases MACE and death, venous interventional procedure, forearm
and reducing bleeding should now be made venous access can provide a reliable and safe
a priority. As such, the authors recommend entry site to complement or complete the
that the approach to care of patients with ACS transradial procedure. Venous access from the
further evolve with efforts to reduce bleeding. forearm can be accomplished efficiently and
The authors' approach to revascularization without compromise by avoiding otherwise
in the ACS setting is to consider all patients riskier anatomical approaches. Understanding
eligible for TRA and have a thoughtful process venous techniques and recognizing this
behind choosing radial access. Transradial PCI important adjunct to transradial interventions
has been shown in multiple trials to achieve completes the operator's radial skills and
equal success rates without prolonging door- further advances the potential of transradial
to-balloon times in the setting of ST-elevation interventions.
myocardial infarction. Despite trends toward Chapter 13: The Learning Curve for
lower rates of mortality by radial access Transradial Access Use of the transradial
utilization, further trials are still necessary route in interventional cardiology procedures
to precisely define the benefit. Nonetheless, may practically eradicate the occurrence
improved patient satisfaction and the poten- of arterial access complications with their
tial for decreased bleeding complications are subsequent effects on mortality, morbidity,
compelling reasons to increase utilization of disability, and health care costs. Such improve-
transradial PCI in this clinical population. ments may be achieved with a modest increase
Certainly, several studies have shown that in x-ray exposure for coronary angiography
there is a learning curve with TRA, and the (decreased with increasing experience), but
authors recommend that operators be profi- without any increase in procedural time,
cient with TRAin the elective setting prior to patient or operator irradiation for coronary
attempting in ACS patients. In addition, the angioplasty, or any differences in terms of
authors advocate for identifying patients at efficiency in almost all patients and all clinical
risk of bleeding using the predictive models and technical settings.
discussed in this chapter. This will help to However, these results can only be
identify those patients who are at highest risk achieved after completion of a long learning
for bleeding and those who may benefit the curve. Thanks to the multiple training oppor-
most from bleeding-avoidance strategies such tunities available and after appropriate patient
asTRA. selection, a good command of clinical and
Chapter 11: Transradial Approach to technical predictors of failure allows trans-
Peripheral Interventions In this chapter, radial operators to obtain rapidly acceptable
the authors explain how peripheral vascular success rates, procedural durations, and x-ray
interventions can be safely performed using exposure. This may encourage colleagues,
the radial artery as an access point. This coworkers, paramedics, patients, and hospital
approach is particularly beneficial because the managers to support widespread use of this
patients with severe peripheral arterial disease vascular approach.
are at higher risk for access site complications. Chapter 14: Transradial Arterial Access:
The main limitation to this approach is the Economic Considerations Transradial
lack of equipment that could easily access arterial access for coronary and peripheral
every vascular bed, particularly at the level of arterial procedures provides economic
superficial femoral artery and tibial vessels. advantages compared to transfemoral arterial
Chapter 12: Right Heart Catheterization access. Significant benefit is realized through
and Transradial Access This chapter focuses decreased vascular and bleeding complications
chapter 1 Introduction • 5
that are associated with added expenses Chapter 17: How to Start a Transradial
related to diagnosis, treatment, and prolonged Program at Your Hospital As the
length of stay. Decreasing vascular complica- chapter title indicates, the authors offer
tions is especially relevant in today's health advice on how to start a transradial program
care environment, given the emergence of at your hospital. Transradial catheterization is
value-related reimbursement. Early and safe increasingly being used throughout the world.
mobility following TRA also confers economic Patient satisfaction and lower complication
advantage by decreasing nursing require- rates have driven the transition for many
ments, improving patient flow efficiency, and femoral access laboratories to primarily radial
facilitating safe outpatient PCI. operations. With adequate preparation and
Chapter 15: Tips and Tricks for Transradial perseverance through the learning curve,
Access In this chapter, the authors try to the radial approach can become the primary
resolve practically all important issues related means of catheterization for all except large
to TRA. The tips and tricks discussed here sheath and some limited peripheral access
shall help both beginners and experienced procedures. As newer technologies specifically
operators. To become a "committed radialist," designed for the transradial approach come
a person needs to go through a process known to market, radialists will have an even greater
as "a new learning curve" and understand range of procedures that they can perform.
normal vascular anatomy of the region, Careful introduction of the radial technique
acquired variations, and congenital anomalies. should make the transition relatively
Chapter 16: Complications of Transradial seamless.
Access As with other aspects of medical We have attempted to present a compre-
practice, awareness of complication possibili- hensive approach and perspective, and I am
ties, knowledge of appropriate preventive and certain that those who are committed to and
corrective actions, and recognition of actual have an abiding interest in this technique
adverse events are the keys to a transradial will continue to learn along the way. We all
interventional practice characterized by a hope that this textbook will be a valuable
minimum of complications. resource for the transradial operator, whether
The principal benefit of radial artery access a neophyte or an expert.
for angioplasty is the added safety it offers.
This chapter describes how the complications
are less frequent than with femoral artery • REFERENCES
access, but they can still occur and can be very
1. Campeau L. Percutaneous radial artery approach
serious. Common complications include radial for coronary angiography. Cathet Cardiovasc Diagn.
artery spasm, sterile granuloma develop- 1989;16:3-7.
ment, and radial artery occlusion (transient 2. Kiemeneij F, Laarman GJ. Percutaneous transradial
or persistent), which are generally benign in artery approach for coronary stent implantation.
Cathet Cardiovasc Diagn. 1993;2:173-178.
nature; the risk of all these complications can
3. Kiemeneij F, Laarman GJ, et al. Transradial artery
be readily diminished with simple measures coronary angioplasty. Am H J . 1995;129(1):1-7.
easily incorporated into routine practice. More 4. Kiemeneij F, Laarman GJ, et al. A randomized
serious vascular complications include the comparison of percutaneous transluminal coronary
development of a forearm hematoma with angioplasty by the radial, brachial and femoral
approaches: the ACCESS study. JAm Coil of Cardiol.
compartment syndrome, which stands as
1997;29(6):1269-1275.
the most important to recognize quickly and 5. Jolly SS, Yusuf S, et al. Radial vs. femoral access for
manage correctly because it can lead quickly coronary angiography and intervention in patients
to permanent neurologic injury. Surgical with acute coronary syndromes (RIVAL): a random-
decompression of the forearm compartment ized, parallel group, multicentre trial. The Lancet.
2011;377(9775):1409-1420.
is the mainstay of therapy for this problem.
Radial artery pseudoaneurysms and arterio-
venous fistulae are rare but can cause forearm
perfusion problems and discomfort and often
require surgical intervention for repair.
chapter 2
Robert W. Harrison, MD
Sunil \1. Rao, MD
Table 2.1 Bleeding Definitions Used in Acute Coronary Syndrome Clinical Trials.
Minor Observed blood loss:~ 3 g/dl decrease in the hemoglobin concentration or~ 10% decrease
in the hematocrit
No observed blood loss:~ 4 g/dl decrease in the hemoglobin concentration or a~ 12%
decrease in the hematocrit
Minimal Any clinical overt sign of hemorrhage (including imaging) associated with a < 3 g/dl
decrease in the hemoglobin concentration or a < 9% decrease in the hematocrit
GUST()J4
Severe or Life-Threatening Intracranial hemorrhage
Bleeding that causes hemodynamic compromise and requires intervention
Moderate Bleeding that requires blood transfusion but does not result in hemodynamic compromise
Mild Bleeding that does not meet criteria for either severe or moderate bleeding
OASIS-235
Major Fatal bleeding
Intracranial hemorrhage
Bleeding requiring surgical intervention
Bleeding that requires~ 4 units of blood or plasma expanders
Bleeding judged to be disabling or requiring 2 or 3 units of blood
CURRENT-OASIS 7'.36
Severe Requiring transfusion ~ 4 units of PRBC or equivalent whole blood
Resulting in hemoglobin decrease~ 5 g/dl
Leading to hypotension requiring inotropes
Requiring surgery
Symptomatic intracranial hemorrhage
Fatal bleeding
Continued
10 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
several large regional and national quality is not without serious consequence and is
improvement registries do capture PCI-related predictive of adverse procedural outcome and
vascular complications. For example, Rao et al mortality. 13
reported on the incidence of vascular compli-
cations (defined as arterial occlusion, periph-
eral embolization, arterial dissection, arterial • NON-ACCESS SITE-RELATED
pseudoaneurysm, or arteriovenous fistula
formation) from the National Cardiovascular
BLEEDING
Data Registry (NCDR), which collects Bleeding that is unrelated to arteriotomy
outcomes in PCI procedures from more than occurs primarily due to the use of adjunctive
600 sites across the United States. In their antithrombotic and antiplatelet agents in a
analysis of 585,290 transfemoral cases, the population at risk for bleeding, such as the
combined incidence of vascular complications elderly, females, and those with ACS. Verheugt
with a transfemoral approach was 0.7%. The et al, in their analysis of the REPLACE-2,
incidence of complications was highest in ACUITY, and HORIZONS-AMI clinical trials,
the elderly(> 74 years old, 1.0%), women report that 61% of bleeding events were
(1.1%), and ST-elevation myocardial infarction not related to the access site-an overall
(STEMI) patients (0.8%). 9 The RIVAL study incidence of 3.3%.8 Approximately half of the
comparing the radial and femoral approaches non-access site bleeding could not be local-
to angiography and intervention among acute ized to a specific site. Of those events that
coronary syndrome (ACS) patients captured could be localized, genitourinary bleeding
vascular complications in detail. 10 In this trial, occurred in 18%, followed by gastrointestinal
3.7% of patients had major vascular complica- in 15%, head and neck in 10%, and pulmonary
tions-defined as a large hematoma, develop- in 1%. 8 The RIVAL trial showed a similar
ment of a pseudoaneurysm or atreriovenous proportion of access site to non-access site
fistula, or an ischemic limb requiring surgery. major bleeding. Non-CABG major bleeding
However, the majority of these complications was defined as per Table 2.1. Overall, the non-
were hematomas. Excluding these, there was a CABG major bleeding rate was 0.8%, with 70%
vascular complication rate of 0.7%-similar to of these occurring distant from the access site.
the results described in the NCDR. It should Specifically, gastrointestinal bleeds accounted
be noted, however, that a large hematoma, for 27%, followed by intracranial and pericar-
particularly one that requires transfusion, dia! bleeding. 10
chapter 2 Rationale forTransradial Access • 11
0 .95
0.9
0.85
0.8
0.75
Days to Death
Figure 2.2 Effect of bleeding severity on mortality. Kaplan-Meier estimates of 30-day survival
among patients enrolled in the GUSTO lib, PURSUIT, PARAGON A, and PARAGON B clinical trials.
Survival curves are stratified by GUSTO bleeding category. Log-rank P values are < .0001 for all
4 categories, .20 for no bleeding versus mild bleeding, < .0001 for mild versus moderate bleeding,
and < .001 for moderate versus severe bleeding. Source: Rao SV, O'Grady K, Pieper KS, et al. Impact of
bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardia/.
2005;96:1 200-1206.
chapter :Z Rationale forTransradial Access • 13
Access site and non-access site bleeding exsanguination, which is exceedingly rare
are both associated with increased mortality, after PCI, can lead to adverse outcomes simply
with the latter portending a worse prognosis. through blood loss. Similarly, bleeding in
Verheugt et al discriminated between the closed spaces such as the cranium or peri-
outcomes associated with access and non- cardia! space can lead directly to mortality
access site bleeding. As mentioned previously, through either neurological compromise or
61% of the bleeding events in this study were hemodynamic embarrassment. Other, more
not related to the access site. The adjusted common types of bleeding are associated with
mortality risk was elevated with both access worse outcomes likely through secondary
site-only bleeding (hazard ratio 1.8) and non- mechanisms. As such, they may not be
access site bleeding (hazard ratio 3.9), although directly causing the outcome. For example,
the risk attributable to non-access site evidence-based antiplatelet and antithrom-
bleeding was significantly higher. 8 Similarly, botic therapies are commonly discontinued
data from the National Heart, Lung, and in the setting of bleeding, and patients are
Blood Institute (NHLBI) Dynamic Registry less likely to leave the hospital on guideline-
supports the association between access site based antiplatelet therapy if they experienced
complications and mortalityP Mter adjusting in-hospital bleeding.15 Patients with bleeding,
for multiple variables, hematomas requiring depending on the definition used, are also
transfusion emerged as an independent more likely to receive blood transfusions.
predictor of death at 30 days (odds ratio 3.6) There is mounting evidence of the harm
and 1 year (odds ratio 1.7). Retroperitoneal associated with transfused blood, which may
hematomas resulting from transfemoral access be related to impaired nitric oxide bioactivity
have also been implicated in worsened clinical and oxygen delivery in banked blood. 16
outcomes.14
• EFFECT OF TRANSRADIAL
Nonmortal Clinical Outcomes
ACCESS ON BLEEDING AND
Aside from mortality, hemorrhagic complica-
tions are also associated with myocardial CARDIOVASCULAR OUTCOMES
infarction, stroke, and stent thrombosis.
Eikelboom et al evaluated 34,416 patients Radial Access and Bleeding
with acute coronary syndromes from the Utilizing the radial artery for PCI is associ-
OASIS registry, OASIS-2 trial, and CURE trial. ated with a marked reduction in access site
Major bleeding occurred in 2% of patients. bleeding due to its superficial location, lack
Similar to other studies, mortality was higher of adjacent vascular structures, and ease
in the group who had major bleeding both of compressibility. A significant amount of
at 30 days and at 6 months. However, they evidence has accumulated from observational
also showed an increase in the rates of stroke and randomized clinical trials to support
and myocardial infarction at 30 days (hazard a decrease in bleeding with the transradial
ratios 6.5 and 4.5, respectively).4 Manoukian approach. Rao et al analyzed the NCDRand
et al, in an analysis of the ACUITY trial, compared rates of procedural success and
demonstrated that bleeding is also associated bleeding events between 7,804 transradial and
with an approximate 5-fold increase in stent 585,290 transfemoral cases. 9 After adjusting
thrombosis in patients undergoing an invasive for NCDR risk score, gender, antithrombotic
strategy for acute coronary syndromes. 5 use, and glycoprotein IIb/IIIa use, they found
that the transradial approach was associ-
ated with a 62% reduction in the risk for
Putative Mechanisms postprocedural bleeding compared with the
The mechanism by which bleeding may transfemoral approach. Procedural success
contribute to these adverse outcomes was similar between the 2 cohorts. The
is complex and multifactorial. Frank association between the transradial approach
14 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
and decreased bleeding was more pronounced was 1.7% and 1.0% for transfemoral and
in younger (age < 75) patients, women, and transradial cases, respectively. Similarly, 1-year
patients with non-ST-elevation myocardial mortality was 3.9% and 2.8%, respectively.
infarction (NSTEMI). Interestingly, among After adjustment for potential confounders,
the 241 STEMI cases who had transradial transradial access was associated with a
catheterizations, there were no bleeding significant 17% reduction in 1-year mortality.
events or vascular complications, compared Interestingly, blood transfusion emerged as
with rates of 3% and 0.8%, respectively, in the most powerful predictor of mortality at
the transfemoral cohort. A meta-analysis 1 year. 18 After accounting for transfusion,
of 23 randomized clinical trials comparing the association between radial approach
the radial and femoral approaches to PCI and mortality was significantly attenuated,
showed similar findings with a 73% decrease suggesting that the reduction in transfu-
in bleeding among patients assigned to the sion was the mechanism that explained the
radial approachY In addition, the absolute mortality reduction. The RIVIERA (Registry
risk reduction in bleeding with transradial on IntraVenous anticoagulation In the Elective
access was highest for primary or rescue PCI and primary Real world of Angioplasty) study
for STEMI (3.1% absolute risk reduction). The evaluated patients enrolled in a multinational
rates of vascular complications in the RIVAL registry of PCI, with a focus on the effect of
trial, which randomized more than 7,000 ACS anticoagulant use on outcomes. The study
patients undergoing angiography or inter- enrolled 7,962 patients, and 11% of the
vention to transradial versus transfemoral procedures were performed via the radial
access, were significantly lower in transradial approach. Independent variables associated
patients (1.4% vs. 3. 7%)-one major vascular with a decrease in the primary endpoint of
complication was prevented for every 43 tran- in-hospital death or myocardial infarction
sradial cases performed.10 Together, these included the use of enoxaparin, PC! of the
analyses suggest that procedural success rates left anterior descending artery (LAD), use of
are similar for transradial and transfemoral nitrates, pretreatment with thienopyridines,
cases, but the radial approach is associated and radial access. Of these, radial access was
with significantly lower access site bleeds associated with the most significant reduction
and vascular complications, and this benefit with an adjusted 84% reduction in in-hospital
increases as the risk for bleeding increases. death or MI. Notably, radial access was also
the only variable independently associated
with a reduction in bleeding events. 19 The
Radial Access and Non bleeding
consistency of these analyses strongly
Clinical Outcomes suggests that, in certain populations, radial
Given the well-established association access is associated with a significant reduc-
between bleeding and adverse clinical tion in mortality, primarily driven by a reduc-
events, it is reasonable to hypothesize that tion in periprocedural bleeding. However,
the transradial approach may be associ- given the observational nature of the studies,
ated with reduction in nonbleeding clinical causality should not be inferred.
outcomes. Two large contemporary registry Prior to 2009, there were approximately
analyses have supported this hypothesis. The 23 small, randomized controlled trials investi-
M.O.R.T.A.L (Mortality benefit Of Reduced gating the benefits of transradial access, with
Transfusion after percutaneous coronary 12 of these reporting mortality, stroke, or MI
intervention via the Arm or Leg) study linked as a clinical endpoint. Jolly et al performed
a prospective PCI registry with transfusion a meta-analysis of these trials and showed
records and outcomes including 30-day a trend toward reduction in the combined
and 1-year mortality. Of the 38,872 cases endpoint of death, MI, or stroke with the
identified, 20% were performed via the radial radial approach compared with the femoral
approach. Approximately three-quarters were approach, but this did not reach statistical
urgent or emergent cases. Mortality at 30 days significanceP The overall odds ratio was
chapter :Z Rationale forTransradial Access • 15
0.71 (CI 0.49 -1.01, P = 0.058). There was relative to those found in other ACS trials.
also a trend toward improvement in mortality In a post hoc analysis using an alternative
alone, but this also did not reach statistical definition of bleeding, the study found that
significance with an odds ratio of 0.74 the rate of bleeding by the ACUITY definition
(CI 0.42- 1.30, P = 0.29). The trials included (RIVAL major bleeding, large hematomas,
in this meta-analysis were relatively small, and pseudoaneurysms requiring interven-
often performed at a single center, and tion) was significantly lower in the transradial
therefore underpowered to detect differences group (1.9%) compared to the femoral group
in major adverse cardiac events. (4.5%). This also led to a significant reduc-
The RIVAL trial was conducted to address tion in the composite of death, MI, stroke, or
these deficiencies by enrolling 7,021 ACS ACUITY bleeding (4.8% vs. 7.3%). Second, as
patients from 158 hospitals in 32 countries summarized above, two-thirds of the bleeding
with a composite of death, Ml, stroke, or events in the RIVAL trial were non-access
non-CABG-related major bleeding at 30 days site-related, and therefore would not have
as the primary endpoint. 10 Major bleeding was been significantly effected by radial access.
defined as bleeding that was fatal, resulted Third, 2 of the 6 prespecified subgroups
in transfusion of 2 or more units of blood, showed a significant benefit favoring the
caused substantial hypotension with need transradial group. Mter stratifying by
for inotropes, needed surgical intervention, radial PCI center volume, the investigators
caused severe sequelae, was intracranial or found that those patients enrolled at high-
intraocular, or led to a hemoglobin decrease volume radial centers(> 146 radial PCI per
of at least SO g/L (see Table 2.1). Prespecified operator, per year) had a benefit with regard
subgroups were designated based on age, sex, to the primary endpoint, which favored
body mass index, STEMI versus NSTEMI, transradial access (1.6% compared to 3.2%).
each operator's self-reported annual radial Furthermore, there was lower mortality
volume, and each center's self-reported radial (0.8% transradial vs. 1.5% transfemoral)
volume. Approximately 27% of the patients and there were fewer vascular complications
were enrolled for STEMI, 27% for NSTEMI, (0.4% transradial vs. 4.0% transfemoral) at
and 45% for unstable angina, and 99.8% high-volume radial centers. Patients identi-
underwent angiography with 66% receiving fied as having STEMI as their presenting
PCI. Overall, there was no significant differ- syndrome also had a significant benefit with
ence in the primary endpoint, which occurred transradial access over transfemoral access
in 3. 7% of the radial group, and 4.0% of the with regard to the primary outcome (3.7% vs.
femoral group. Individual components of 4.0%), death (1.3% vs. 3.2%), and vascular
the composite endpoint were also similar complications (1.3% vs. 3.5%).
at 30 days, with death occurring in 1.3% Jolly et al performed a revised meta-
and 1.5% of the radial and femoral patients, analysis of clinical trials comparing radial
respectively. Major bleeding, as defined with femoral access, which included results
above, was rare in both groups at 0.7% and of the RIVAL trial.10 This included a total of
0.9%, respectively. There were similar rates approximately 13,000 patients. Similar to
of procedure success in both arms, but there the RIVAL trial itself, transradial access was
was a higher rate of access site crossover from a reduction in major bleeding (0.5% tran-
radial to femoral compared with femoral to sradial vs.1.0% transfemoral) and vascular
radial (7.6% vs. 2.0%). complications (1.0% transradial vs. 3.1%
Although it failed to show a benefit for transfemoral), but there was no difference in
transradial access in the primary endpoint, major cardiovascular outcomes of death, MI,
the results warrant further discussion based or stroke. However, when stratifying by radial
on findings in a post hoc analysis using a expertise, there was a significant benefit in
different definition of bleeding, and in the the composite of death, MI, or stroke among
prespecified subgroups. First, the overall expert radial operators (2.3% transradial vs.
bleeding rates in the trial were quite low 3.5% transfemoral).
16 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
and numerous other factors. Although no increase in the overall hospital costs ranging
modality of cardiac catheterization has the from $14,282 in patients with no bleeding, to
potential to ameliorate all these issues, the $21,674 in patients with minor bleeding, to
transradial approach can improve many. $45,798 in patients with moderate bleeding,
Following a transradial procedure, patients to $66,564 in patients with severe bleeding.
are immediately able to sit upright and can Adjusted analysis showed that each moderate
ambulate immediately provided there are to severe bleeding event resulted in an incre-
no residual effects from procedural seda- mental cost of $3,770.
tion. Furthermore, hemostasis can often be Several studies have investigated the health
obtained with radial compression devices, care cost benefits of transradial access. The
obviating the need for manual compression CARAFE study randomized 210 patients to
and eliminating many of the bleeding and femoral, right radial, and left radial coronary
vascular complications described previously. angiography, and found that hospitalization
This can translate into greater patient satisfac- costs were reduced by approximately 20%
tion and improved quality of life. Cooper et al in the left radial and right radial groups
investigated the effect of transradial access on compared to the femoral group. 27 This was
quality of life and cost of cardiac catheteriza- balanced, however, by an increase in equip-
tion. 24 Patients were randomized to trans- ment and medication costs for the radial
femoral (99) or transradial (101) access and group, leading to statistically similar costs
underwent quality-of-life assessment at 1 day between the radial and femoral approaches.
and 1 week postprocedure. They found that Cooper et al investigated hospitalization costs
patients who had transradial procedures had in their trial randomizing 200 patients to
less back and body pain and improved walking transradial or transfemoral diagnostic cardiac
ability at 1 day. At 1 week, transradial patients catheterization. 24 Although catheterization
had improved perception of physical func- laboratory costs were the same between
tion, bodily pain, social function, and mental the 2 groups, bed and pharmacy costs were
health. The RIVAL trial also assessed patient significantly lower after transradial catheter-
preference and found that 90% of transradial ization. The median total hospital costs were
patients preferred to have a transradial $2,010 in the transradial group and $2,299 in
approach for their next procedure, compared the transfemoral group. Roussanov et al
with only 51% of transfemoral patients.10 compared hospital costs in a series of patients
Vascular access complications and bleeding undergoing coronary angiography via the
events may not only contribute to adverse radial or femoral approach. 28 A third series
clinical outcomes for the patient, but also of patients in their study received femoral
pose a significant financial burden on the closure devices. In this analysis, average total
patient and the medical system. Kugelmass hospital costs were $370 and $44 7 for the
et al performed an analysis of all Medicare transradial and transfemoral approaches,
beneficiaries who received PCI as part of a respectively. Average costs for femoral cases
hospitalization during fiscal year 2002. 25 In when a closure device was used totaled $553.
their analysis, they defined complications The savings observed in the radial group were
as in-hospital death, emergency CABG, primarily due to shortened recovery periods
postoperative stroke, acute renal failure, as the costs attributable to access equipment
and vascular complications (hemorrhage, ($93 vs. $41) and hemostasis equipment
transfusion, and/or surgical repairs). In the ($61 vs. $36) were higher in the transradial
absence of any complication, the cost of PCI group. Similar savings were found by Mann
was $13,861 ± $9,635. Vascular complica- et al in the setting of PCF9 In this study, the
tions, which included hemorrhage and blood radial approach was compared to the femoral
transfusion, added an incremental cost of approach with use of a closure device.
$9,023. Rao et al also investigated the costs Expected costs, accounting for supplies,
of bleeding during treatment for ACS.26 They complications, and delayed discharges,
found that bleeding resulted in a stepwise were $1,590 in the femoral/closure device
18 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
group and $1,314 in the radial group. Of staff. 33 Using a self-developed model of nurse
their savings, 40% was from reduced supply workload, they assessed the demands on
costs and 60% was attributable to fewer nurses in the procedural lab as well as on the
complications and subsequent discharge ward for 52 transradial and 208 transfemoral
delays. Together, these studies suggest that diagnostic and interventional procedures.
the transradial approach can lead to signifi- They found that procedural nurses committed
cant savings, primarily by reducing costly an average of 174 minutes to the care of
complications. transfemoral patients, and 86 minutes to the
Hospitalizations are prolonged by complica- care of transradial patients. Ward nurses also
tions associated with cardiac catheterization, spent less time caring for transradial patients
and these extra days spent in the hospital (386 minutes vs. 720 minutes). After adjusted
not only have a monetary cost to the patient analysis, transradial approach remained
and medical system, but they also have a a significant predictor of decreased nurse
significant opportunity cost to both parties. workload.
Patients have lost productivity, and hospitals Together these data support a conclusion
have beds that may otherwise be able to serve that the transradial approach can improve
other patients. Vascular complications, as patient satisfaction, decrease costs, shorten
captured in the Medicare database described hospitalizations, and improve nurse workflow,
above, resulted in an average length-of-stay all without sacrificing procedural efficacy.
increase of 3.4 days if a vascular complication
occurred.25 Similarly, Rao et al demonstrated
in the GUSTO lib trial that the average length
of stay for patients with NSTEMI was 5.4 days
• sUMMARY
if no bleeding occurred. This increased to 6.9, Diagnostic angiography and percutaneous
15, and 16.4 days if there was mild, moderate, coronary interventions play a critical role
or severe bleeding, respectively.26 Several small in treating patients with ischemic heart
trials have demonstrated that transradial disease. Over the past 2 decades, advance-
access is associated with shortened lengths ments in pharmacotherapy, device therapy,
of stay in ACS patients. 30 Mann et al showed and application of PCI have led to significant
that, in ACS patients randomized to either improvements in outcomes. In light of such
transradial or transfemoral PCI, postproce- advances in efficacy, maximizing the safety
dural days in the hospital were reduced from of therapies and procedures has become
2.3 days to 1.4 days in the transradial group. a clinical priority. Bleeding and vascular
Total duration of hospitalization was also complications are a significant source of
decreased in the transradial group-3.0 versus morbidity, mortality, and cost in the invasive
4.5 days. 31 Yan et al showed that, in octo- treatment of coronary artery disease and
genarian patients undergoing primary PCI acute coronary syndromes in particular.
for STEMI, total hospital length of stay was Studies indicate a significant reduction in
reduced from 10.1 to 7.2 days when the access site bleeding and vascular complica-
transradial approach was used.32 Conversely, tions with the radial approach. These benefits
duration of hospitalization was unchanged in are also associated with reduced mortality in
the RIVAL trial of patients with ACS,likely due specific clinical settings and among patients
to the lack of difference in bleeding complica- treated at experienced radial centers and
tions between the radial and femoral groups. by experienced operators. In addition, the
Nursing workload has an important effect reduction in procedural complications is
on the direct and indirect costs imposed on a associated with decreased length of stay,
hospital, and decreasing the demands placed decreased hospital costs, decreased nursing
on nursing staff in the periprocedural period workload, and increased patient satisfaction.
may lead to significant savings. Amoroso et al Wider adoption of transradial percutaneous
investigated the benefits of transradial access procedures has the potential to significantly
with regard to the demands placed on nursing affect public health in a positive way.
chapter :Z Rationale forTransradial Access • 19
24. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of 32. Yan ZX, Zhou YJ, Zhao YX, et al. Safety and feasibil-
trans radial access on quality of life and cost of car- ity of transradial approach for primary percutane-
diac catheterization: a randomized comparison. Am ous coronary intervention in elderly patients with
Heart J. Sep 1999;138(3 Pt 1):430-436. acute myocardial infarction. Chin Med J (Eng!).
25. Kugelmass AD, Cohen DJ, Brown PP, Simon AW, May 5 2008;121(9):782-786.
Becker ER, Culler SD. Hospital resources consumed 33. Amoroso G, Sarti M, Bellucci R, et al. Clinical and
in treating complications associated with percu- procedural predictors of nurse workload during
taneous coronary interventions. Am J Cardiol. and after invasive coronary procedures: the poten-
Feb 12006;97(3):322-327. tial benefit of a systematic radial access. Bur J
26. Rao SV, Kaul PR, Liao L, et al. Association between Cardiovasc Nurs. Sep 2005;4(3):234-241.
bleeding, blood transfusion, and costs among 34. Rao SV, O'Grady K, Pieper KS, et al. A compari-
patients with non-ST-segment elevation acute coro- son of the clinical impact of bleeding measured
nary syndromes. Am Heart J. Feb 2008;155(2): by two different classifications among patients
369-374. with acute coronary syndromes. JAm Coli Cardiol.
27. Louvard Y, Lefevre T, Allain A, Morice M. Coronary 200 6;47(4) :809-816.
angiography through the radial or the femoral 35. OASIS-2 investigators: effects of recombinant
approach: the CARAFE study. Catheter Cardiovasc hirudin {lepirudin) compared with heparin on
Interv. Feb 2001;52(2):181-187. death, myocardial infarction, refractory angina,
28. Roussanov 0, Wilson SJ, Henley K, et al. Cost- and revascularisation procedures in patients with
effectiveness of the radial versus femoral artery acute myocardial ischaemia without ST elevation: a
approach to diagnostic cardiac catheterization. randomised trial. Organization to Assess Strategies
J Invasive Cardiol. Aug 2007;19(8):349-353. for Ischemic Syndromes (OASIS-2) Investigators.
29. Mann T, Cowper PA, Peterson ED, et al. Transradial Lancet. Feb 6 1999;353(9151):429-438.
coronary stenting: comparison with femoral access 36. Steinhubl SR, Kastrati A, Berger PB. Variation in the
closed with an arterial suture device. Catheterization definitions of bleeding in clinical trials of patients
& Cardiovascular Interventions. 2000;49(2):150-156. with acute coronary syndromes and undergoing
30. Subherwal S, Rao SV. Economic benefits of the percutaneous coronary interventions and its impact
transradial approach. Cardiac Interventions Today. on the apparent safety of antithrombotic drugs. Am
Sep 2009:1-5. Heart J. Jul2007;154(1):3-11.
31. Mann T, Cubeddu G, Bowen J, et al. Stenting in
acute coronary syndromes: a comparison of radial
versus femoral access sites. JAm Coil Cardiol. Sep
1998;32 (3): 572-5 76.
chapter 3
Richard P. Abben, MD
Gary Chaisson, RTR, RCSA
21
22 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Med. anitibrach.
cutan. nerve
,.......L...U!OO!,,_ Radial nerve
llffif--:4111*- A. profunda
brachii
VoLar interosseous
b.ije1•ior ulnar
collateral
Deep ·olar
Jmm ·h
of ulnar
Volar radial carpal
Superficial olm'
~·
Figure 3.5 Anatomic course of the radial and ulnar arteries in the forearm, wrist, and hand (left panel: superficial
view; right panel: deep view). Source: Reprinted, with permission, from Gray H, Lewis W. Anatomy of the Human Body.
New York: Bartleby.com, 2000;VI,4.b.2.-3.
generally assessed clinically prior to radial Recurrent Radial Artery. The recurrent
access procedure. radial artery originates just below the origin
of the radial artery near the elbow and passes
superiorly toward the upper arm between
Radial Artery Branches the brachioradialis and brachialis muscles
Multiple tributaries originate from the (see Figure 3.3). It supplies these upper arm
radial artery as it courses from the elbow to muscles and the elbow and anastomoses
the hand, and some of these do affect the with collateral branches originating from the
retrograde course of vascular equipment as it deep brachial artery. Because of its anatomic
passes retrograde toward the central aorta. location, guidewires (particularly hydrophilic
chapter 3 Vascular Anatomy ofthe Arm and Hand • 25
types) and very small-diameter catheters may impede progress in the latter group of
passed in a retrograde manner through the vascular systems, the radial artery itself must
radial artery may be directed straight into be traversed first, and this can be challenging
this branch. If it is of sufficient size, it may due to a variety of vascular anomalies one
allow passage directly into the brachial artery may encounter. 1-6·16·22 Valsecchi and colleagues
through the collateral branches, although analyzed the effect of vascular abnormalities
significant vasospasm or perforation may on procedural success in 2,200 radial access
occur. Recognition of this anatomic deviation patients. A vascular anatomic variation was
is important because this branch is generally identified in 22.4% of the patients, and in
not of sufficient size to accommodate diag- these patients, the procedural success rate
nostic catheters, and thus recognition of this was reduced from 98% to 93%. 7 A recent
aberrant location and appropriate redirection report by Lo et al similarly highlighted this
of the guidewire to the true brachioradialis concept by assessing the procedural conse-
system is required to allow central aortic quences of vascular anomalies in radial access
access. procedures in 1,540 patients.1 Radial artery
Muscular Branches. Multiple muscular puncture was unsuccessful in 7 patients, and
branches originate from the radial artery the analysis evaluated the effects of vascular
supplying the radial aspect of the forearm anomalies in the remaining 1,533 patients.
musculature. Guidewires occasionally may Vascular anomalies were present in 13.8%
enter into their origins impeding forward of the patients, and these patients exhibited
progress. Resistance to guidewire passage a higher rate of procedural failure (14.2%)
should signal deviation from the fairly versus patients with normal anatomy (0.9%;
straight-line course to the brachial artery p = 0.0001). In addition to several rarely
and prompt fluoroscopic examination that occurring vascular abnormalities, both studies
could demonstrate branch misdirection in identified 3 major vascular anomalies as
a line perpendicular to the normal radial most common including high radial artery
artery course. [Editor's note: A small J-tipped takeoff, radial artery loop, and extreme radial
hydrophilic guidewire will usually avoid the artery tortuosity, with the latter 2 accounting
small branches (muscular and recurrent radial) for most of the procedural failures. Because
and is, therefore, very useful once the sheath these anomalies may create access difficulties,
has been inserted.] some investigators have advocated the use
Wrist and Hand Branches. Additional of preprocedure vessel analysis with ultraso-
branches originate near the wrist distal to nography.16 The present discussion describes
sites of radial artery entrance for vascular potential anatomic variations that may be
procedures including the volar carpal branch encountered in radial access procedures. It is
that supplies the wrist and carpal articulations the present authors' and others' experience
and the superficial volar branch that termi- that by effectively identifying these vascular
nates in the thumb musculature. As the radial challenges and gaining experience circum-
artery passes to the hand, additional branches venting the pitfalls associated with them, the
supply the metacarpal and finger regions with risk of procedural failure can be reduced to a
the continued vessel anastomosing with the minimal level.
terminal portion of the ulnar artery forming
the deep volar arch as described above.
High Radial Artery Takeoff
Although the brachial artery usually bifurcates
near the elbow, the most common vascular
• VASCULAR ANOMALIES anomaly involving the radial artery occurs
To achieve safe access to the central aorta, when the bifurcation is present at a higher
the guidewire and catheters must pass level, generally in the region of the middle
through the brachioradialis system and to upper humerus (Figure 3.6). An anatomic
then the axillary, subclavian, and brachia- study performed in the 1950s in 750 cadavers
cephalic vessels. Although some tortuosity identified this occurrence in 14.5% of the
26 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Figure 3.7 Complex radial artery loop with Figure 3.8 Hipped (inferior) and angle-tipped
2 recurrent radial arteries originating from the apex (superior) 0.035-in hydrophilic-coated guidewires
of the loop and extending to the upper arm. Source: (Terumo Medical Corporation, Elkton, Maryland)
Reprinted, with permission, from LoTS, Nolan J, commonly utilized in radial access procedures.
Fountzopoulos E, Behan M, Butler R, Hetherton SL,
Vijayalakshmi K, Rajagopal R, Fraser D, Zamen A,
Hildick-Smith D. Radial artery anomaly and its influence
on transradial coronary procedural outcome. Heart.
2009;95:41 0-415.
Figure 3.9 Crossing of a radial artery loop with a O.Q14-in hydrophilic guidewire (left panel). After larger guidewire
and catheter exchanged for smaller-diameter guidewire, the loop becomes straightened (right panel). Source:
Right panel is reproduced, with permission, from LoTS, Nolan J, Fountzopoulos E, Behan M, Butler R, Hetherton SL,
Vijayalakshmi K, Rajagopal R, Fraser D, Zamen A, Hildick-Smith D. Radial artery anomaly and its influence on transradial
coronary procedural outcome. Heart. 2009;95:41 0-415.
28 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Radial Artery Tortuosity the size of the radial artery in both cadaveric
and live subject settings, demonstrating that
Tortuosity of the radial artery may occur
although the radial artery exhibits fairly large
at any location along its course, but
variation in terms of vascular dimensions,
most commonly is encountered in the
in general the radial artery is large enough in
proximal third of the vessel similar to
most patients to accept catheters of 6-Fr size
radialloops.6•7 The reported incidence in
or less. 8•12·25 In selected patients, particularly
the literature is as high as 15.3%5 with one
larger males, some vessels are able to accept
report describing alpha (a), omega (Q), Z-,
equipment with even larger dimensions.
and S-shaped deformities of the radial artery
(Figure 3.10). An atraumatic technique
similar to the approach utilized with radial Pathologic Analysis
loops can be employed to avoid vessel injury In 1996, Shima et al reported findings from
and vasospasm while maintaining high a pathologic study of the forearm vessels
procedural success (Figure 3.11). Although taken from 52 cadaversP Mean radial artery
one report described prolongation of proce- diameter was 2.3 ± 0.5 mm, and the mean
dure times with this anomaly, in general the radial artery length was 18.1 ± 1.7 em. The
success rates have not been significantly diameter values are slightly lower than those
reduced. reported in live subjects utilizing ultrasonog-
raphy and angiography and may reflect some
constriction of the vessels in their anatomic
Additional Vascular Anomalies
preparation setting.
Another less common vascular abnormality is
hypoplasia of the radial artery itself. Although
rarely described, a report by Yokoyama et al Dimensional Analysis in Physiologic Setting
did identify this anomaly in 2 patients (1.7% Several reports have evaluated the dimen-
of their series) prior to the procedure utilizing sions of the radial artery in living subjects
ultrasonographyl-6 (Figure 3.12). A femoral with both ultrasonographic and angiographic
approach was used in both cases, and selec- techniques. A study by Yoo and associ-
tive angiography confirmed the marked ates evaluated radial artery dimensions
diminution in vessel size that would not have with this approach in 1,191 radial access
accommodated vascular catheters of sufficient patients. 2 Measurements of the radial artery
size to perform coronary angiography. Other were made 1-2 an proximal to the styloid
abnormalities that have been rarely reported process. The mean measured dimension
include sites of focal stenosis, presence of was larger than in the pathologic setting,
radial artery atherosclerosis (Figure 3.13), measuring 2.60 ± 0.4 mm in men and 2.43 ±
minor abnormalities in bifurcations, and occa- 0.38 mm in women, with a range of 1.15 to
sional unusual branch vessels. Except for focal 3.95 mm. The dimensional distribution
stenosis, a finding that can affect procedural graph presented in their report is shown
success when severe, the other abnormalities in Figure 3.14. In addition, there was good
are generally not associated with reduction in correlation between body surface area and
success rates. measured radial artery dimension (r = 0.305;
p =0.0001). The proportion of patients
with a measured diameter < 2.3 mm (outer
• vESSEL DIMENSION dimension [OD] of a 5-Fr sheath) was 17.3%,
< 2.52 mm (OD of 6-Fr sheath) was 31.7%,
CONSIDERATIONS and< 2.85 mm (OD of7-Fr sheath) was
The radial artery has been proven to be a 74.4%. The patients in the study underwent
reliable conduit for central vascular proce- either coronary angiography with 5-Fr sheaths
dures, and this has been in part related to its or coronary interventions with 6-, 7-, or
sufficient diameter to accommodate catheter 8-Fr sheaths with 5,000 to 10,000 units of
equipment.2•24 Several studies have evaluated heparin given to all patients in addition to
chapter 3 Vascular Anatomy of the Arm and Hand • 29
Figure 3.1 0 Radial artery tortuosity patterns; Panel A: a pattern; Panel B: 0 pattern; Panel C: Z pattern; Panel D:
S pattern. Source: Reproduced, with permission, from Yoo BS, Yoon J, Ko JY, Kim JY, Lee SH, Hwang SO, Choe KH.
Anatomic consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly,
and vessel tortuosity./nt J Cardiol. 2005;1 01:421-427.
Figure 3.11 Tortuosity in the proximal radial artery (left panel) that was traversed with a 0.035-in hydrophilic
guidewire with subsequent straightening of the vessel similar to the radial loop.
30 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
-(/)
c
Q)
·.;:::;
100
BS, Yoon J, Ko JY, Kim
JY, Lee SH, Hwang SO,
Choe KH. Anatomic
(lj
performing safe and successful radial access arch. The ongoing continuation of the radial
procedures. It is generally felt that this dual and ulnar arteries later joins in a deeper loca-
blood supply offers a high degree of safety in tion to form the larger deep volar or palmar
preventing ischemia of the hand in the event arch (Figure 3.15). Important branches from
of radial artery occlusion. However, there may both the superficial and deep arches supply
be anatomic variability in some patients, and the hand and the digits. There are significant
assessment of these variances is an important variations in the relative contributions of
aspect of a successful radial access program. the radial and ulnar vessels to these arches.
Considering the reported postprocedure In almost all patients, however, these arches
occlusion rates ranging from 1.8% to 19%, receive some type of dual blood supply from
most experienced operators critically assess both the radial and ulnar systems, thus
the anatomy prior to proceeding with a radial ensuring preservation of excellent blood
access case. 26- 39 supply to the hand should one of the vessels
occlude.
including 34.5% that demonstrated the classic radial artery occlusion. [Editor's note: See also
complete superficial arch with dual blood chapter on preoperative evaluation.]
supply and 43% in which the ulnar distribu-
tion reached the forefinger and thumb. A more
Diagnostic Evaluation of the
recent study analyzing data from 50 hands
demonstrated the classic superficial arch only Palmar Arches
10% of the time. In contrast, there was a Prevention of significant hand ischemia
greater reproducibility of data in the analysis in the setting of radial artery occlusion is
of the deep palmar arch with these 2 studies paramount. Simple palpation of the ulnar
demonstrating the presence of a classic deep and radial arteries has been felt to be
palmar arch in 97% and 90% of their speci- inadequate. A purportedly more accurate
mens, respectively. However, in both studies method of evaluating the integrity of the
there was great variability in the relative sizes palmar arches has been described for more
of both arches. 44 Figure 3.16 displays the than 80 years. 45•46 The modified Allen's test
anatomic variations that were identified in the is commonly utilized in this regard. The
study by Ruengsakulrach et al. In addition, Allen's test as it was originally described
these investigators could find no specimen involved compression of the radial artery and
that demonstrated the presence of incomplete then comparison of the hand color with the
superficial and deep palmar arches in the opposite hand, a difference in the degree of
same patients, thus providing reassurance rubor indicative of inadequate ulnar artery
that when an arch is incomplete, the other contribution. In the modified test, the ipsilat-
arch provides collateral support (Figure 3.17). eral fist is clenched, and then the radial and
This concept offers some reassurance and ulnar arteries are compressed simultaneously.
confirmation to the reported experience that Blanching of the palm is observed, and resolu-
radial artery access procedures are associ- tion of this blanching in less than 10 seconds
ated with a very, very low incidence of hand after release of ulnar artery compression
ischemia despite the occasional occurrence of only is felt to indicate palmar arch integrity.
chapter 3 Vascular Anatomy of the Arm and Hand • 33
Use of the modified Allen's test has been (> 10-second cutoff utilized) in 27% of the
recommended prior to arterial line placement, subjects. 52 As this number may represent an
harvesting of the radial artery for cardiac overestimation of the number of abnormal
bypass procedures, and more recently radial arches, refinements of the modified Allen's
access catheterization. 34.47•48 The intent of this test have been made, including the addi-
approach is to prevent ischemic complications tion of oximetry and plethysmography to
involving the hand, although the incidence of further analyze the pattern of ischemia in
this is quite low, even with indwelling radial the hand. In one series, the addition of these
artery catheters. 49- 51 Although intuitively the techniques demonstrated adequate collateral
preprocedure modified Allen's test makes perfusion in 80% of patients demonstrating
sense, no conducted study has confirmed its an abnormal standard modified Allen's test
effectiveness in preventing hand ischemia. at baseline. 53 Most commonly, an oximetry
However, most experienced radial access module is placed on the thumb. With bilateral
operators utilize this test routinely prior compression, a significant change in the
to each procedure, with an abnormal test pressure waveform and oxygen saturation is
resulting in an alternate access approach. observed, with improvement observed upon
With the advent of radial artery access release of the ulnar artery. It is of note that a
procedures, utilization of the modified Allen's delayed phenomenon is occasionally observed
test has increased significantly. In 1996, a with the saturation and waveform returning
time when the radial approach was gaining to baseline 15-30 seconds after release. This
acceptance, Nagin et al performed a study, probably results from recruitment of the
applying the test in 1,000 patients prior to previously described ulnar collaterals and has
catheterization, and found abnormal findings been felt to represent an acceptable result.
34 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
the access site or perforations of the brachial groupings including the thenar compartment,
or radial arteries and their side branches hypothenar compartment, adductor compart-
along the course to the thorax.60•61 A less ment, interosseous compartment, and carpal
common complication associated with these canal.
procedures is vessel occlusion with resulting
ischemia and inflammation. The incidence of
compartment syndrome associated with radial Compartment Syndrome
access procedures reported in the literature In 1881, Volkmann63 first described the
ranges from 0.4% to a most recently reported clinical findings of myonecrosis and contrac-
value of 0.004%. 10•63 In general, the compart- ture due to prolonged muscle ischemia. He
ments of the forearm have the greatest hypothesized that splints led to diminished
potential to be affected by these complica- arterial inflow, which in turn caused muscle
tions. Understanding the pathoanatomic and nerve damage. Jepson, 54 45 years later,
relationships of the compartments enables demonstrated that constricting bandages
the practitioner to recognize and prevent the could lead to Volkmann's ischemic contrac-
associated compartment syndromes with their ture, but if the limbs were surgically explored
attendant potential to severely compromise and drained, the animals would avoid perma-
upper extremity function. When compartment nent muscle damage. Compartment syndrome
syndrome develops, neuromuscular function is is a condition that occurs when interstitial
compromised. There are 3 patterns of clinical tissue pressures rise in an enclosed facial
findings affecting the arm and the hand space, preventing adequate tissue oxygenation
depending on which compartment is involved. and ultimately causing cellular necrosis of the
compartment contents.
Background. Compartment syndrome
Compartment Anatomy results from either intracompartmental
Anatomy. The brachium, or upper arm, swelling or external compression, and both
comprises 3 anatomic compartments: processes can lead to elevated tissue pressures.
anterior, posterior, and deltoid. The anterior As interstitial pressure increases, local blood
compartment is bounded by the humerus flow decreases. Transmural pressure, the
posteriorly, an intermuscular septum both difference between intramural and extralu-
laterally and medially, and the brachial minal pressure, is the determining factor
fascia anteriorly. The deltoid muscle has a in local blood flow within a compartment.
thick membrane that can be described as a As elevated intracompartmental pressures
compartment within a compartment. The rise, local blood flow is diminished due to a
deltoid muscle epimysium is not as inelastic decrease in transmural pressure, vessel radius,
as the fascia but is inelastic enough to increase and arteriovenous gradient. The cells are then
interstitial pressure.58 subjected to a hypoxic environment, resulting
Forearm. The antebrachium, or forearm, in cell death and subsequent tissue necrosis.
is the most common site of compartment Both muscular and neural functions may be
syndrome as a result of radial access proce- severely affected as a result of this cascade
dures.58 The mobile wad, volar compartment, of events. Although cooling the affected
and dorsal compartment make up the region may slow this process by reducing the
3 general fascial enclosures of the antebra- metabolic demands, in general, reversal of
chium. Anatomic interconnections between severely affected limbs can only be achieved
these compartments exist, and because of by surgical decompression with a fasciotomy
these interconnections, a single fasciotomy procedure.58,59,66
can oftentimes be performed to decompress Recognition and Management of
the entire forearm. Compartment Syndromes. Although the
Hand. The muscular compartments of specific hand and arm regions affected
the hand can be characterized into 5 general are determined by the compartment
36 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
8. Saito S, Iker H, Hosokarwa G, Tanaka S. Influence arteries in patients with chronic heart failure.
of the ratio between radial artery inner diameter Circulation. 1998;97:363-368.
and sheath diameter on radial artery flow after tran- 25. Saito S, Ikei H, Hosokawa G, Tanaka S. Influence
sradial coronary intervention. Catheter Cardiovasc of the ratio between radial artery inner diameter
Interv. 1999;46:173-178. and sheath outer diameter on radial artery flow
9. Wallach S. Cannulation injury of the radial artery: after transradial coronary intervention. Catheter
diagnosis and treatment algorithm. Am J Crit Care. Cardiovasc Interv. 1999;46: 173-178.
2004;13:315-319. 26. Nagai S, Abe S, Sate T, Hozawa K. Yuki K,
10. Tizon-Marco H, Barbeau GR. Incidence of com- Hanashima K, Tomoike H. Ultrasonic assessment
partment syndrome of the arm in a large series of vascular complications in coronary angiography
of transradial approach for coronary procedures. and angioplasty after transradial approach. Am
J Intervent Cardiol. 2008;21:380-384. J Cardiol. 1999;83:180-186.
11. Gray H, Lewis W.Anatomy of the Human Body. New 27. Wu S, Galani R, Bahro A, Moore JA, Burket MW,
York: Bartleby.com, 2000;VI,4.b.2.-3. Cooper CJ. 8 French trans radial coronary interven-
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13. McCormick TJ, Caudwell EV, Anson BJ. 28. Hall J, Arnold A, Valentine R, McCready R, Mick
Brachial and antecubital arterial patterns: a M. Ultrasound imaging of the radial artery follow-
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1953;96:44-54. 199 6; 77:108-109.
14. Rodriguez-Niedenfuhr M, Vazquez T, Nearn L, et al. 29. Saito S, Miyake S, Hosokawa G, et al. Transradial
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with a review of the literature. J Anat. 2001;199 30. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D,
(Pt 5):547-566. Slagboom T, vander Wieken R. Incidence and out-
15. Rodriguez-Niedenfuhr M, Sanudo JR, Vazquez T, come of radial artery occlusion following transradial
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connecting the deep, or normal, brachial artery with Diagn. 1997;40:156-158.
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2000;196(Pt 1):115-119. of vascular complications in coronary angiography
16. Yokoyama N, Takeshita S, Ochiai M, Koyama Y, and angioplasty after transradial approach. Am
Hoshino S, Isshiki T, et al. Anatomic variations of J Cardiol. 1999;83:180-186.
the radial artery in patients undergoing transradial 32. Dahm JB, Vogelgesang D, Hurn mel A, Staudt A,
coronary intervention. Catheter Cardiovasc Intervent. Volzke H, Felix SB. A randomized trial of 5 vs.
2000;49:357-362. 6 French transradial percutaneous coronary inter-
17. Drizenco A, Maynou C, Mestdagh H, Mauroy B, ventions. Catheter Cardiovasc Interv. 2002;57:
Bailleul JP. Variations in the radial artery in man. 172-176.
Surg Ro.diol Arch. 2000;22:299-303. 33. Lee KL, Miller JG, Laitung G. Hand ischaemia fol-
18. Louvard Y, Lefevre T. Loops and transradial lowing radial artery cannulation. J Hand Surg. [Br]
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19. Fujii T, Masuda N, Tamiya S, Shima M, Toda E, Ito D, Klinke P, Mildenberger R, Williams MB, Hilton
G, Nakazawa T, Matsukage N, Morino N, Tanabe Y, D. Vascular communications of the hand in
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Successful transradial percutaneous coronary inter- 36. Pancholy SB. Comparison of the effect of intra-
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2010;60:593-595. occlusion after trans radial catheterization. Am
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23. Gonzalez-Compta X. Origin of the radial artery J Thorac Cardiovasc Surg. 1998;115:1136- 1141.
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lar anomalies. J Hand Surg. [Br] 1991;16A:293-296. approach for coronary angiography: results of
24. Horning B, Arakawa N, Kohler C, Drexler H. a prospective study. Cathet Cardiovasc Diagn.
Vitamin C improves endothelial function of conduit 199 6;3 9:3 65- 3 70.
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39. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D, 53. Barbeau GR, Arsenault F, Dugas L, Simard S,
Slagboom T, van der Wieken R. Incidence and out- Larivere MM. Evaluation of the ulnopalmar arterial
come of radial artery occlusion following transradial arches with pulse oximetry and plethysmography:
artery coronary angioplasty. Catheter Cardiovasc comparison with the Allen's test in 1010 patients.
Diagn. 1997;40:156-158. Am Heart J. 2004;147:489-493.
40. Karlsson S, Niechajev IA. Arterial anatomy of the 54. Gilchrist IC. Is the Allen's test accurate for patients
upper extremity. Acta Radio/ Diagn. 1982;23: considered for transradial coronary angiography?
115-121. JAm Coli Cardiol. 2006;48:1247.
41. Coleman SS, Anson BJ. Arterial patterns in the 55. Saito S. A big challenge to radialists. Catheter
hand based upon study of 650 specimens. Surg Cardiovasc Intero. 2010;76:387.
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42. Ikeda A. Ugawa A, Kazihara Y, Hamada N. Arterial Hildick-Smith D. Transradial coronary intervention
patterns in the hand based on a three-dimensional without pre-screening for a dual palmar blood sup-
analysis of 220 cadaver hands. J Hand Surg. ply. Int J Cardiol. 2007;121:320-322.
1988; 13:5 01-5 09. 57. Biondi-Zocccai G, Moretti C, Zuffi A, Agostini
43. Mezzogiorno A, Passiatore C, Mezzogiorno V. P, Romagnoli E, Sangiorgi G. Transradial access
Anatomic variations of the deep palmar arteries in without preliminary Allen test: letter of com-
man.ActaAnat.1994;149:221-224. ment on Rhyne et al. Catheter Cardiovasc Intero.
44. Ruengsakulrach P, Eizenberg N, Fahrer C, Fahrer 2011;78:662-663.
M, Buxton B. Surgical implications of variations 58. Halpern AA, Nagel DA. Compartment syndromes of
in hand collateral circulation: anatomy revisited. the forearm: early recognition using pressure mea-
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to the wrist with illustrative cases. Am J Med Sci. 1978; 134:225-229.
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46. Cable DG, Mullany CJ, Schaff HV. The Allen test. drome after transradial coronary angioplasty. Int
Ann Thorac Sur. 1999;67:876-877. J Cardiol. 2004;97:311.
47. Starnes SL, Wolk SW, Lampman RM, Shanley CJ, 61. Wang PJ, Tian X, Zhang Q. Acute compartment
Prager RL, Kong BK, et al. Noninvasive evaluation syndrome in a patient after transradial access for
of hand circulation before radial artery harvest for percutaneous cardiac intervention. Zhonghua Xin
coronary artery bypass grafting. J Thorac Cardiovasc Xue Guan Bing Za Zhi. 2007;35:496.
Surg. 1999;117:261-266. 62. Caputo R. Avoiding and managing forearm hemato-
48. Ruengsakulrach P, Brooks M, Hare DL, Gordon I, mas. Card Intero Tod. 2011;5:55-58.
Buxton B. Preoperative assessment of hand circu- 63. Volkmann R. Die ischaemischen muskellahungen
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the modified Allen test. J Thorac Cardiovasc Surg. 801-803.
2001; 121:526-531. 64. Jepson PN. Ischaemic contracture: experimental
49. Weiss BM, Gattiker RI. Complications during and study. Ann Surg. 1926;84:785-795.
following radial artery cannulation: a prospective 65. Qvist J, Peterfreund RA. Perlmutter GS. Transient
study. Intensive Care Med. 1986;12:424-428. compartment syndrome of the forearm after
so. Wilkins RG. Radial artery cannulation and isch- attempted radial artery cannulation. Anesth Analg.
aemic damage: a review. Anaesthesia. 1985;40: 1996;83:183-185.
896-899. 66. Mubarak SJ, Owen CA, et al. Acute compart-
51. Falor WH, Hansel JR, Williams GB. Gangrene of ment syndrome: diagnosis and treatment with
the hand: complication of radial artery cannulation. the aid of the Wick catheter. J Bone Joint Surg Am.
J Trauma. 1976;16:713-716. 1978; 60:1091-1095.
52. Benit E, Vranckx P, Jaspers L, Jackmaert R, 67. Bourne RB, Rorabeck CH. Compartment syndrome
Poelmans C, Coninx R. Frequency of a posi- of the lower leg. Clin Ortho. 1989;240:97-104.
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Cardiovasc Diag. 1996;38:352-354.
chapter 4
Preoperative Evaluation of
the Potential Patient for
Transradial Access
,/
Pierre-Louis Nadeau, MD
Jean-Pierre Dery, MD, MSc
Gerald R. Barbeau, MD
Since its first description in 1989 by Campeau • PATIENT SELECTION FOR THE
et al, percutaneous transradial approach for
coronary angiography and interventions has
TRANSRADIAL ACCESS
seen a constant and progressive increase in At the Quebec Heart and Lung Institute, the
many countries around the world, with the transradial access is the primary approach in
exception of the United States, where it repre- all patients referred for coronary angiography
sents less than 5% of coronary procedures. 1 •2 and interventions. Preoperative patient
At the Quebec Heart and Lung Institute, evaluation is a fundamental step in order to
the transradial program began in 1994 maximize the rate of successful transradial
and since, we have performed more than procedures and prevent potential complica-
75,000 transradial procedures. This tions. If the radial approach is seeing an expo-
chapter will highlight the usual patient nential increase in interest, it is partly because
evaluation for transradial procedure in our there are only few contraindications to its
institution. use, as shown in Table 4.1. Specific evaluation
before transrad.ial access includes evaluation This is why careful evaluation of the patency
of hand collateral circulation, previous bypass of hand collateral arteries via the ulnopalmar
graft location, previous difficulties during arch is a fundamental step before radial artery
radial or femoral access, and so on. Crossover cannulation. Serious ischemic damage after
to the same-side ulnar artery in case of prolonged invasive blood pressure monitoring
puncture failure or, more frequently, to the has been estimated to occur in less than 0.1%
contralateral limb in the event of access failure of casesY The first case of hand ischemia
can often be performed. Table 4.2 summarizes following transradial access for angiography
right- and left-side advantages. Overall, in our was reported in late 2010.14 Given the low risk
experience, these contraindications represent of radial artery occlusion and the extremely
less than 5% of patients. low morbidity rate, some authors have
advocated that the evaluation of collateral
blood supply to the hand was an unneces-
Rationale for Evaluation of Hand
sary step in the preoperative evaluation.15 In
Collateral Circulation fact, there is no evidence in the literature
The most frequent complication associ- of a direct relationship between abnormal
ated with the transradial approach is the hand collateral circulation and subsequent
radial artery occlusion, which occurs in 1% ischemic complication. Some authors have
to 12% of cases.3-u Higher occlusion rates also reported ischemic complications after
have been described in patients with blood radial artery occlusion despite normal modi-
pressure monitoring in intensive care units, fied Allen's test results before radial artery
with catheters left in place for prolonged cannulation, but this could be explained in
periods in patients without systemic anti- part by embolization from prolonged blood
coagulation.13 Rates as low as 1% have been pressure monitoring. Approximately 80%
obtained in small series by avoiding intensive of cardiologists worldwide proceed with the
postprocedure compression techniques to evaluation, however, agreeing that patients
achieve hemostasis and when using smaller with an incomplete palmar arch might be at
catheters. 3·11•13 Recanalization of the radial a higher risk of hand ischemia in the event of
artery may also occur in some patients in the radial artery occlusion. 23 This might also be
first month after the intervention.5 influenced by the medical-legal environment.
Although usually asymptomatic, radial Exceptionally, the transradial approach may
artery occlusion following transradial be attempted in a patient with incomplete
approach has the potential to induce subse- hand collateralization when the risk from
quent hand ischemia. The incidence remains a femoral approach is excessive. In these
very low because the hand is perfused patients, consideration should be given to
primarily from both the radial and ulnar lower the incidence of radial artery occlusion.
arteries through the palmar arterial arches. See Table 4.3.
b. Use of selected catheters (multipurpose, Barbeau's curve, b. Use of selected catheters (Judkin's curves, LIMA, etc)
XB, etc)
c. In very obese patient c. In selected patients (long history of hypertension, the
very old, etc)
d. In patient with bilateral internal mammary artery (IMA) d. In patient with only LIMA graft, postpneumonectomy
grafts
e. In patient with left-side anatomical anomaly or e. Patient with arteria lusoria anomaly, known right-side
contraindication vascular anomaly (arterial loop, etc)
f In patients with planned harvest of radial arteryforgraft f. In patient with right-side contraindications
g. Less x-ray exposure to the operator g. With right-side transradial approach for contralateral
coronary angiography in chronic total occlusion (CTO)
Methods for the Evaluation of Hand obliterans.16 The test was modified by Wright
Collateral Circulation in 1952 to evaluate the patency of collateral
circulation through the ulnar artery. The
A variety of methods have been described modified Allen's test consists of the following
for assessing the presence of a functional steps, as summarized in Figure 4.1. The
palmar arterial arch before a transradial heart modified Allen's test is abnormal or negative
catheterization. The modified Allen's test and if palmar blanching persists for~ 10 seconds
the pulse oximetry and plethysmography (OX and must be considered as a contraindication
and PL) are the first choices given their low for the transradial procedure. The modified
cost and high feasibility. The duplex Doppler Allen's test results can be altered by multiple
ultrasonography may also be performed if factors, including overextension of the wrist,
available. Although numerous other tests have contralateral ulnar compression by skin
been suggested, including measurement of stretching, an examiner error, or inadequate
the thumb pressure and magnetic resonance patient cooperation. Subjective interpretation
angiography, they appear less practical and of the change in hand color also limits the
will not be discussed. diagnostic usefulness of the test. As a result,
Modified Allen's Test. In 1929, Allen an appreciable number of false-positive and
was the first to describe a simple bedside false-negative results have been reported. This
test to assess the patency of the ulnopalmar is reflected by the highly variable reported
arches in patients with thromboangiitis incidence for an abnormal Allen's test in the
available literature (1% to 27%). 17•18 However,
if the modified Allen's test is abnormal in one
Table 4.3 Steps to Decrease the Likelihood of Radial hand, it may be normal in the other hand,
Thrombosis. thus reducing the number of patients with a
a. Proximal artery puncture (larger size) negative modified Allen's test in both arms to
less than 10%.
b. Anticoagulation(> 70 U/kg of unfractionated
heparin)
The inverse modified Allen's test can also
be performed to assess the patency of the
c. Prevention of arterial spasm with a calcium
channel blocker
radial artery. In contrast, occlusion of the
ulnar artery is maintained while pressure on
d. Use of smaller catheter
the radial artery is released. The criteria for a
e. Avoiding prolonged and intensive hemostatic normal or positive test are the same. The test
pressure is helpful to exclude a radial artery occlusion
42 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
in a patient who has already had a cannulation Plethysmography and Pulse Oximetry. As
or in whom an ulnar approach is considered. an alternative to the modified Allen's test, the
It is also helpful for assessment of postproce- use of plethysmography and pulse oximetry
dure radial artery occlusion. (PL and OX) has been proposed for a more
The relationship between an abnormal direct assessment of collateral circulation
modified Allen's test and subsequent ischemic before cannulation of the radial arteryY This
symptoms of the hand was indirectly demon- technique is also more objective, and can thus
strated in a study dosing capillary lactate improve diagnostic accuracy. The equipment
in the thumb after radial artery occlusion. required is available in most catheterization
The patients with abnormal modified Allen's laboratories.
test results had a significantly higher level The sensor of the pulse oximeter is
of lactate. 19 The literature also suggests that applied to the fingernail of the patient's
a normal modified Allen's test safely selects thumb. While recording the pulse tracing
patients for radial artery harvest to serve as and oxygen saturation data, the radial artery
a conduit in coronary artery bypass graft. is compressed for as long as 2 minutes. The
Indeed, most investigators evaluating hand 4 different responses of flow wave on monitor
perfusion days or months after surgery using are described in Figure 4.2.
various methods have reported no significant During radial artery compression, OX
decline in hand perfusion relative to the results (Sp02) are either positive (reading
nonoperated hand. 20 Based on these findings, present and constant) or negative. The occlu-
radial artery catheterization is usually not sion of the radial artery is occasionally seen
performed in patients with an abnormal modi- with a Type A pattern; in such a case, radial
fied Allen's test. However, the clinician must artery compression does not reduce pulsatile
weigh the benefits and risks in a patient for blood flow to the thumb. Radial artery occlu-
whom the femoral approach should be avoided. sion can then be suspected when ulnar artery
chapter4 Preoperative Evaluation ofthe Potential PatientforTransradial Access • 43
B +
U\M + induced by relative hand ischemia).
Panel D Loss of pulse tracing and oximetry with
no recovery within 2 minutes.
Source: Reproduced with permission from Am
Heart J. Mar 2004;147(3):489-493.
I
c +
,f\]\1\
compression produces a Type D reading. In was seen in 96%, 95%, 92.3%, and 98.5% of
Type C, pulsatile blood flow, as well as OX, patients on the right side, left side, both sides,
is abolished temporarily by radial artery or any side, respectively, with only 1.5% of
compression but reappears within 2 minutes, patients (2.0% in men and 0.3% in women;
suggesting collateral recruitment induced by P <.OS) excluded from either the right or left
relative hand ischemia. This phenomenon transradial approach. Multivariate analysis,
cannot be easily evaluated with the modified including the same variables as with the
Allen's test. modified Allen's test, also showed increasing
Because pulsatile blood flow has been age and male sex to be predictors of failure to
correlated with wound healing and the achieve PL and OX Type A, B, or CY
absence of ischemic necrosis, the Type D At the Quebec Heart and Lung Institute,
pattern is considered to be inadequate for the the transradial approach being the primary
transradial approach. 21 Patients in the first entry site, all patients are evaluated by the
3 categories (A, B, and C) are considered to nurse personnel with OX and PL on both
have a patent ulnopalmar arch and can safely arms to evaluate both patency and collaterals
be selected for the transradial procedure. 22 of the ulnoradial system. The information is
The primary advantage of this technique then written in the patient's cath lab report.
over the modified Allen's test is the improved It is then easier to proceed immediately to the
sensitivity, which decreases rejection rates contralateral limb, without extra testing, in
of potential candidates for a transradial case of access failure on one side.
approachY Moreover, excellent correla- Doppler Ultrasonography. The Doppler
tion was found between the assessment of ultrasonography is an alternative to the modi-
collateral circulation obtained by OX and the fied Allen's test or PL and OX to assess the
Doppler ultrasound. 23 In the paper by Barbeau collateral circulation of the hand. Various tech-
et al, the PL and OX Type A, B, or C pattern niques have been described, and the definition
44 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Figure 4.3 Evaluation of the radial and ulnar arteries with Doppler ultrasonography.
Panel A: The Doppler probe is placed over the radial artery.
Panel B: Longitudinal view of a normal radial artery.
Panel C: Axial view of the radial artery. The diameter of the artery is 3.3 x 2.5 mm.
Panel D: Axial view of the ulnar artery. The diameter of the artery is 2.6 x 2.1 mm.
chapter 4 Preoperative Evaluation ofthe Potential Patient forTransradial Access • 45
despite the manual occlusion of the radial 6. Stella PR, Kiemeneij F, Laarman GJ, Odekerken D,
artery, this confirms an intact palmar arch Slagboom T, van der Wieken R. Incidence and out-
come of radial artery occlusion following transradial
with unlar collaterals.] artery coronary angioplasty. Cathet Cardiovasc
Diagn. Feb 1997;40(2):156-158.
7. Kiemeneij F, Laarman GJ. Percutaneous transradial
• suMMARY artery approach for coronary stent implantation.
Cathet Cardiovasc Diagn. Oct 1993;30(2):173-178.
There are few issues to be addressed before 8. Mann T, Cubeddu G, Bowen J, et al. Stenting in
performing a transradial procedure. We acute coronary syndromes: a comparison of radial
versus femoral access sites. JAm Coli Cardiol. Sep
believe that careful evaluation of the patency 1998;32(3):572-576.
of hand collateral arteries via the ulnopalmar 9. Wu SS, Galani RJ, Bahro A, Moore JA, Burket MW,
arch is a fundamental step before radial artery Cooper CJ. 8 French transradial coronary interven-
cannulation. We described in 1994 a new tions: clinical outcome and late effects on the radial
method using combined PL and OX for the artery and hand function. J Invasive Cardiol. Dec
2000; 12 (12): 605-609.
evaluation of the hand collateral circulation.
10. Nagai S, Abe S, Sato T, et al. Ultrasonic assessment
This technique has the advantage of being of vascular complications in coronary angiography
fast, simple, and objective while avoiding and angioplasty after transradial approach. Am J
many of the pitfalls of the modified Allen's Cardiol. Jan 15 1999;83(2):180-186.
test. Although the modified Allen's test could 11. Dahm JB, Vogelgesang D, Hummel A, Staudt A,
Volzke H, Felix SB. A randomized trial of 5 vs.
identify a large proportion of patients suitable
6 French transradial percutaneous coronary
for transradial approach in our series, PL interventions. Catheter Cardiovasc Interv. Oct
and OX had a higher sensitivity. Using this 2002;57(2):172-176.
method during the last 15 years, including 12. Cubero JM, Lombardo J, Pedrosa C, et al. Radial
Type A, B, and C patterns, we have seen no compression guided by mean artery pressure
versus standard compression with a pneumatic
ischemic hand complications in case of radial
device (RACOMAP). Catheter Cardiovasc Interv.
artery occlusion after a transradial procedure. Mar 12009;73(4):467-472.
13. Scheer B, Perel A, Pfeiffer UJ. Clinical review:
complications and risk factors of peripheral arterial
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1989;16(1):3-7. transradial intervention: successful management
2. R.ao SV, Ou FS, Wang TY, et al. Trends in the with radial artery angioplasty. Catheter Cardiovasc
prevalence and outcomes of radial and femoral Interv. Sep 1 2010;76(3):383-386.
approaches to percutaneous coronary interven- 15. GhuranAV, Dixon G, Holmberg S, de Belder A,
tion: a report from the National Cardiovascular Hildick-Smith D. Transradial coronary intervention
Data Registry. JACC Cardiovasc Interv. Aug without pre-screening for a dual palmar blood sup-
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3. Pancholy S, Coppola J, Patel T, Rake-Thomas 16. Allen EV. Thromboangiitis obliterans: methods of
M. Prevention of radial artery occlusion-patent diagnosis of chronic occlusive arterial lesions distal
hemostasis evaluation trial (PROPHET study): to the wrist with illustrative cases. Am J Med Sd.
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patency documented hemostasis after transra- 17. Barbeau GR, Arsenault F, Dugas L, Simard S,
dial catheterization. Catheter Cardiovasc Interv. Lariviere MM. Evaluation of the ulnopalmar arterial
Sep 1 2008;72(3):335-340. arches with pulse oximetry and plethysmography:
4. Sanmartin M, Gomez M, Rumoroso JR, et al. comparison with the Allen's test in 1010 patients.
Interruption of blood flow during compres- Am Heart J. Mar 2004;147(3):489-493.
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dial catheterization. Catheter Cardiovasc Interv. Poelmans C, Coninx R. Frequency of a posi-
Aug 12007;70(2):185-189. tive modified Allen's test in 1,000 consecutive
5. Zankl AR, Andrassy M, Volz C, et al. Radial artery patients undergoing cardiac catheterization. Cathet
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ography: incidence and rationale for treatment of 19. Greenwood MJ, Della-Siega AJ, Fretz EB, et al.
symptomatic patients with low-molecular-weight Vascular communications of the hand in patients
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46 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
phy: is the Allen's test accurate? JAm Coll Cardiol. 24. Agrifoglio M, Dainese L, Pasotti S, et al.
Dec 6 2005;46{11):2013-2017. Preoperative assessment of the radial artery
20. Slogoff S, Keats AS, Arlund C. On the safety of for coronary artery bypass grafting: is the clini-
radial artery cannulation. Anesthesiology. Jul cal Allen test adequate? Ann Thorac Surg. Feb
1983;59(1):42-47. 2005 j 79 (2) :570-5 72.
21. Gibbons GW, Wheelock PC Jr, Hoar CS Jr, 25. Yokoyama N, Takeshita S, Ochiai M, et al. Direct
Rowbotham JL, Siembieda C. Predicting success of assessment of palmar circulation before transradial
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testing. Arch Surg. Sep 1979;114(9):1034-1036. raphy. Am J Cardiol. Jul15 2000;86(2):218-221.
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chapter 5
Howard A. Cohen, MD
be abducted approximately 60-90 degrees artery may be felt much better by the opera-
and placed on an inexpensively constructed tor's left hand standing laterally to the patient
plywood or metal board (Figure 5.1) that or by the right hand when the operator is
is draped in the usual sterile fashion. Mter standing between the patient's arm and chest,
prepping the arm from the hand to the elbow, depending on the anatomy and the position
we place the entire arm in a sterile stockingette of the radial artery relative to the radius (see
(Figure 5.2), which helps to maintain sterility. Figures 5.4a and 5.4b). There are 2 standard
This step is by no means mandatory, and many ways of accessing the artery-one using the
operators just place an aperture drape over the micropuncture technique and the second using
operative area once it has been prepped. The the Seldinger technique with angiocath (cath-
arm is then extended with the hand supinated eter over the needle). With either technique,
and the wrist hyperextended on a rolled sterile the artery may be best accessed proximal to
towel (Figure 5.2). If the stockingette is used, the wrist crease. This is usually approximately
the operative area is exposed by cutting an 2 to 3 finger-breadths proximal to the tip of
opening over the radial artery. Once access is the styloid process of the radius. The radial
achieved and the sheath inserted, an aperture artery is larger and straighter in this area than
drape is placed, and the sheath is secured with it is as it courses more distally and superficially
a Tegaderm® adhesive or a suture. After the (see Chapter 3). Even though it may be easier
sheath is inserted and secured, the arm can be to feel the artery more distally because it is
returned to the side so that the ergonomics are superficial, it is usually more difficult to access
no different from those for transfemoral access because of the smaller size and tortuosity of
as the wrist at the patient's side is at the same the vessel in this area. Furthermore, because
level as the femoral artery. the vessel is smaller distally, it is more prone to
I find it useful to employ an ambidextrous closure as a result of the access. Ninety percent
technique (see Figure 5.4) for access, as the of the time, I stand lateral to the patient and
Figure 5.1 The arm is abducted and supported on an arm board. The patient is prepped and draped in the usual
fashion. The arm is then prepped from the hand to the elbow and placed in a sterile stockingette. A sterile drape is
then placed on the arm board and the arm supported. (See Figures 5.2 and 5.3.) Once access is achieved, the arm is
adducted and placed back in a sterilely draped arm holder next to the body. The arm board is then removed except in
the situation of a very obese patient, when the arm board can be rotated and placed under the body to help support
the arm.
chapter 5 Obtaining Access • 49
Figure 5.2
Preparation of the
patient. To help
maintain sterility
and still be able
to visualize as well
as feel the bony
landmarks, the arm
is placed in a sterile
stockingette. The
arm is supinated
and the wrist
hyperextended
on 2 rolled sterile
towels.
Figure 5.4 Ambidextrous technique. Depending on the location of the artery and the surrounding tissues, the artery
may be better palpated by the left hand while standing lateral to the patient or by the right hand while standing
between the patient's body and the extended arm. I have found it advantageous, therefore, to be able to access with
either hand depending on how easy it is to palpate the artery. (A) Standing laterally to the patient with right arm
extended on an arm board. The artery is palpated by the fingertips of the left hand, and the micropuncture needle is
advanced with the right hand. Notice the shallow angle of approach. (B) Standing between the patient and the right
arm extended on an arm board, the artery is palpated by the fingertips of the right hand, and the needle is advanced
with the left hand. Again, notice the shallow angle of approach.
chapter 5 Obtaining Access • 51
radial artery is stabilized by the first and operator it is rarely necessary. Once there is
second fingers of the left hand. The micro- free flow of arterial blood, an 0.018 slightly
puncture needle is inserted at a shallow angle, angled-tip nitinol guidewire is advanced into
bevel up, toward the pulse; then the needle is the artery. This should go absolutely smoothly
released by the right hand, and the "bounce" and without resistance or any pain felt by the
of the needle is assessed. The shallow angle is patient. On occasion, it may be necessary to
important because the vessel is small, and the torque the guidewire until it advances easily
shallow angle allows for more room to enter and fully into the artery (see radial artery
the artery with an anterior wall puncture access video-Video 5.1). Depending on the
only without engaging the posterior wall. The sheath type used, a small incision may be
operator should attempt to access the artery necessary with a #11 blade either before or
directly above the vessel and not from the after the needle is withdrawn. The operator
side. If the approach is correct, the needle will should be careful to keep the blade "flat to
bounce up and down and not sideways. If the the skin" with a side-to-side incision to avoid
needle is bouncing from side to side or not penetrating the artery. The sheath can then be
bouncing at all, the needle can be withdrawn placed safely over the guidewire.
and readvanced until the appropriate bounce If there is pain, with the initial insertion of
is obtained. I attempt to do only an anterior the wire it is undoubtedly subintimal, and the
wall puncture, and the needle is advanced only wire and needle should be withdrawn and the
1-2 mm at a time and then released to follow process started over again. Advancement of
the bounce (see radial artery access video- the guidewire should be completely painless.
Video 5.1). If the bounce increases, it lets you If there is resistance once the artery has
know that you are getting closer to the artery, been entered without difficulty, the wire tip
and if the bounce decreases, it lets you know is probably in a small side branch (see radial
that you have passed the artery or are going in artery access video-Video 5.1). The wire can
the wrong direction. You can usually feel when be withdrawn slightly and rotated to avoid
the tip of the needle engages the anterior wall the side branch. If the wire cannot be fully
of the artery. Then advancing ever-so-slowly inserted, it is wise in this circumstance to
and with gentle pressure, the artery is entered. advance a short 4-Fr micropuncture catheter
This process takes only about 15-20 seconds and perform an angiogram (digital subtrac-
but allows for confidence in your approach. It tion with road map if possible) through this
is not uncommon that the artery is not well catheter. This will allow for visualization
felt but very well seen by the bounce, and you of the artery with safe navigation with a
are assured that you are going in the right 0.035 hydrophilic, steerable, angled-tip
direction. This technique is a "poor man's wire, mirco J-tipped wire or 0.014 coronary
Doppler" for locating the artery. At times, the guidewire.
patient (usually an obese patient) will have a The artery may also be entered via the
normal Doppler signal but a pulse that is very Seldinger technique. Again, the artery is
difficult to feel. In this setting, the pulse can stabilized with the first and second finger
be identified with a Doppler and marked with of the left hand, and the catheter over the
an indelible pen. This then allows for reliable needle assembly is advanced at a shallow angle
transradial access despite the inability to feel with the right hand with the bevel up. The
the pulse. When the needle is inserted over assembly will pass through the anterior and
the pulse marked by the Doppler, you will be posterior wall of the artery at a shallow angle.
able to see the needle bounce without actually The needle is then withdrawn, and the cath-
feeling the artery. This technique allows for eter is retracted slowly until there is a free,
arterial access despite the inability to feel a pulsatile flow of blood. A 0.25 hydrophilic
good pulse. Alternatively, ultrasound can be guidewire is then inserted in the same fashion
used to visualize the artery in an effort to as noted above with the micropuncture
obtain access. technique, and the dilator and sheath can then
Visualization with ultrasound may be be inserted in the standard fashion. Some
helpful to the novice, but for the experienced hydrophilic sheaths are coated with a thin film
S:Z • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
of silicone. If the silicone comes off the cath- depending on the size of the patient. The
eter when it is removed, it can cause a sterile use of heparin has been shown to decrease
abscess. In an effort to avoid this, wiping the radial artery occlusion postprocedure (see
sheath with a wet sponge will remove the Chapter 6 on patent hemostasis).
excess silicone and avoid the problem of a Finally, it should be noted that the use of
sterile abscess. A hydrophilic sheath is very intra-arterial nitroglycerine and a calcium
useful because it is easy to remove even if channel blocker may predispose the patient
there is some degree of spasm. Because it is to hypotension, particularly if the patient is
slippery, it must be well secured when it is volume depleted as may occur with patients
inserted with either a sterile adhesive or a who have been fasting and who are treated
suture; otherwise, it may inadvertently come late in the day. This hypotension is easily
out during catheter exchanges. treated with volume administration. If there
is evidence of a vasovagal reaction, this is
treated in the standard fashion with volume
• PREVENTING SPASM and intravenous atropine.
AND HYPOTENSION
The radial artery is very susceptible to spasm. • ACCESSING THE CENTRAL AORTA
Once spasm occurs, it may be difficult to
reverse. It is, therefore, imperative to treat
FROM THE RIGHT RADIAL
the patient with medication to prevent spasm Several different types of guidewire may be
because it is much easier to prevent spasm used for accessing the central aorta. We gener-
than it is to reverse it. To begin with, it is ally use a 0.035 small, J-tipped Glidewire•.
helpful to adequately sedate the patient, as The wire generally passes easily into the
anxiety and certainly pain will make spasm brachial artery with the J-tip avoiding small
more likely to occur. Accordingly, treating the side branches. If an angled Glidewire is used,
patient expectantly with sedation is helpful. it is important to fluoroscopically visualize
You must be careful not to make the patient the wire traversing the forearm and the upper
hypotensive because the radial artery will be arm, as well as the subclavian artery, in an
more difficult to palpate in this circumstance. effort to avoid small side-branch access and
In addition, a spasmolytic cocktail may be resultant perforation that can occur easily. If
given through the sheath once access is there is any resistance in advancing a guide-
obtained in an effort to prevent spasm. Every wire or catheter, an angiogram of the radial
operator has his or her favorite combination artery with diluted contrast (50% contrast
of intra-arterial drugs that usually contains and 50% saline) is exceedingly helpful in
100 flg of nitroglycerine plus a calcium delineating the problem encountered (see
channel blocker (verapamil, diltiazem, or brachial loop videos • Videos 5.2 and
nicardipine). In addition, we slowly give ~and radial tortuosity video • Video
90-100 J..Lg of intra-arteriallidocaine, diluting []]} Some operators routinely perform an
it constantly with blood as it gives the patient angiogram prior to advancing a catheter.
a sensation of extreme heat locally. This is Although this may not be necessary in every
well tolerated as long as the patient is averted case, the threshold to perform an angiogram
to the sensation and the drug is diluted as it should be low. Once in the subclavian artery,
is administered. The purpose of the intra- it is obviously important to avoid the carotid
arteriallidocaine is to anesthetize the artery, and vertebral arteries. On occasion, the
which it does very successfully. Once the guidewire will enter the descending rather
artery is anesthetized with intra-arteriallido- than the ascending aorta. In this instance,
caine, intra-arterial heparin may be adminis- it is helpful to have the patient take a deep
tered without any sensation by the patient. breath (see videos from descendin aorta to
Alternatively, the heparin may be given ascending aorta • Videos 5.5 5.6 nd
intravenously, typically 2,500-5,000 units Is.7)) This will elongate the ascending aorta
chapter 5 Obtaining Access • 53
and make it much easier to obtain central • ACCESSING THE ASCENDING AORTA
aortic access. At times, it may be necessary to
advance a catheter to the aorta and ask the
FROM THE LEFT RADIAL
patient to take a deep breath as the guidewire As from the right radial, a J-tipped Glidewire
is then directed toward the ascending aorta may be inserted and advanced without
with the tip of the catheter (see Videos 5.5, difficulty. If an angled Glidewire is used, it
5.6, and 5.7). When the takeoff of the right should be visualized in the forearm, the upper
subclavian artery arises from the left side of arm, and the subclavian artery. Entering
the aorta and courses behind the esophagus the ascending aorta from the left subclavian
(arteria lusoria), it can be difficult to access artery is generally very easy. Some operators
the central aorta, with the guidewire prefer- prefer the left radial approach because, once
entially selecting the descending aorta. In this in the subclavian artery, the remainder of the
circumstance, a Vitek• or Simmons· catheter access of the ascending aorta and the coronary
can be placed in the descending aorta, with arteries is similar to the femoral approach.
the tip pointed cephalad. An 0.035 hydrophilic Once access is achieved, the left arm and wrist
angled Glidewire can then be directed ceph- can be positioned across the body toward
alad and toward the ascending aorta coming the right groin. This allows the procedure to
from below. Once the wire is in the ascending progress as if one were working from the right
aorta, the catheter can be advanced over the radial or right femoral access.
guidewire, with a gentle "pull-push" tech- Please see the chapter on diagnostic and
nique (push on the catheter and pull on the guide catheter manipulation to engage the
guidewire) until it is in the ascending aorta. coronary arteries.
An exchange-length guidewire can then be
placed in the ascending aorta for the delivery
of subsequent catheters. Severe tortuosity and • sUMMARY
radial loops can present technical challenges
Transradial access is technically more difficult
(see dilated and tortuous subclavian and aorta
videos---{@ Videos 5.8 ~n@-and videos
than transfemoral access because of the size
of the artery, the increased incidence of severe
of severe tortuosi straigl:}tened out by guide-
spasm, and anatomic variation such as loops
wire • Videos 5.10 n~ A radial loop
and tortuosity. Nevertheless, the technique
can usually be overcome with a soft guidewire,
can be easily learned and mastered if the
and frequently a coronary guidewire is useful
operator is committed.
(see radial tortuosity video-Video 5.4). Once
the loop is straightened out, a soft catheter
is placed, and a stiffer guidewire is then
introduced, but manipulation of the catheter • viDEO LEGENDS
is usually not a problem (see brachial loop Radial Artery Access Video
videos-Videos 5.2 and 5.3). Smaller cath-
IVid•o 5.1 1 Note the low angle of insertion and the
eters (and hydrophilic catheters, if available) bounce of the needle as it advances slowly toward the
are usually preferable in this situation. Severe artery using gentle palpation of the artery with the
tortuosity and/or marked dilatation of the tips of the first two fingers of the left hand. The needle
subclavian artery can also present a challenge. should be bouncing up and down and not side to side.
This generally can be overcome using a stiffer All you get closer to the artery, the bounce increases. If
you press too hard with your left hand, you may oblit-
guidewire to help straighten out the curves erate the bounce. Apply just enough pressure to trap
(see videos of dilated and tortuous subclavian the needle between your fingertips and the artery. The
and aorta-Videos 5.8 and 5.9). At times, flow may be pulsatile, but in many cases the flow may
it is necessary to place a long sheath in the be slow. The bright red color of the blood will assure
you that the artery has been entered. The wire should
subclavian artery to overcome the tortuosity.
advance easily and without any pain . If there is any pain,
(Please see the excellent and comprehensive it is likely that the wire is subintimal and should be with-
"t ips and t ricks" recommended by Pat el, Shah, drawn with the flow rechecked. If there is resistance to
and Pancholy in Chapter 15. advancement of the wire, it is either subint imal or in a
54 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
side branch. In this case, you can see that the wire can be Ivideo 5.&1Note how the guidewire and the following
torqued and advanced but then meets resistance. Finally, Judkins Left 3.5 diagnostic catheter have straightened
the wire should pass the side branch and advance easily. out the tortuosity, but the tip of the guidewire is now in
The needle is withdrawn, and a small nick in the skin is the descending aorta.
made with a #11 blade. (Some catheter and dilators do Ivideo 5.7 1 With the tip of the diagnostic catheter at
not require a dermatotomy with a #11 blade.) Once the the aortic knob and the guidewire in the descending
sheath has been inserted, medications can be adminis- aorta, the patient is asked to take a deep breath, and the
tered prophylactically to prevent spasm. catheter is torqued toward the ascending aorta as the
guidewire is retracted and then readvanced when the
catheter is pointing toward the ascending aorta. Once
Brachial Loop the position in the ascending aorta is achieved, any cath-
IVideo 5.2 IThe loop in the brachial artery above the eter exchange should be made over a long guidewire to
maintain position in the ascending aorta and to obviate
elbow is overcome with an angled Glidewire gradually the need of renegotiating the severe tortuosity.
advanced through the loop. It is advisable to overcome
the loop with a soft-tipped angled or J-tipped guidewire
followed by a catheter in order not to dissect the artery
Dilated and Tortuous Subclavian and Aorta
Video 5.8 Note extreme tortuosity of subclavian
artery. T ·s may be negotiated with a J-tipped guidewire
advancing a catheter over the curves and ultimately into
the ascending aorta.
Video 5.9 The left main coronary artery (LMCA) is
engage with a 110-cm-long multipurpose catheter with
Severe Tortuosity of the Radial Artery the guidewire in place in order to overcome the extreme
tortuosity. The guidewire is carefully withdrawn once the
lvideo 5.41Note the severe tortuosity of the radial LMCA is approached in the left coronary cusp with the
artery with the angled-tipped Glidewire entering a small adjustment of advancing or withdrawing the catheter
branch at the top of the curve (recurrent radial artery).
until the LMCA is selectively engaged.
You can see how advancing a catheter into this vessel
at the very least would cause severe spasm and at worst
could cause perforation. This is why any resistance of a
guidewire or a catheter should be interrogated with an
Severe Tortuosity Straightened Out
angiogram through the sheath. The severe loop shown in by Guidewire
this example may be overcome with a J-tipped guidewire
(which will probably not enter the small branch) or, if
IVideo 5.10 I Note the severe tortuosity of the subcla-
vian artery that is negotiated with an angled Glidewire.
this is unsuccessful, a transition-less 0.014 soft coronary
A J-tipped Glidewire may be equally effective in nego-
guidewire can overcome the bend. Once the severe curve
tiating the tortuosity. The advantage of the J-tipped
is overcome, a Glide Catheter can be passed over the
Glidewire is that it may be helpful in avoiding side
guidewire and the coronary guidewire then exchanged
branches because it usually selects the large main branch
for an 0.035 J-tipped Glidewire. and stays out of smaller side branches that can be per-
forated by the angled Glidewire. The disadvantage of
the J-tipped Glidewire is that it has no steerability. The
From Descending Aorta to Ascending Aorta angled Glidewire can be "steered away• from unwanted
lvideo 5.51 Note tortuosity of the subclavian artery branches.
with the tip of the angled Glidewire appearing to be in tyideo 5.11 1 The tortuosity is overcome by the angled
the ascending aorta. GHdewire th at is now in the ascending aorta.
chapter 6
Samir B. Pancholy, MD
Tejas Patel, MD, OM
Sanjay C. Shah, MD, OM
is completely asymptomatic and well toler- intravenous administration. The effect also
ated from an ischemia standpoint. From the appears to be dose dependent, as lower doses
outset, it has been realized that prevention have been associated with a higher rate of
of radial artery occlusion is of paramount radial artery occlusion (RAO).
importance, as the majority of patients Postprocedural care has probably the
with coronary artery disease require repeat largest effect on occurrence of RAO. A strong
procedures, and hence maintenance of radial relationship exists between the interruption
artery patency will provide the benefits of of radial artery flow and occurrence of RAO.
TRA for future procedures. Patients with Maintenance of radial artery patency during
smaller-caliber radial arteries and those with hemostatic compression, described as "patent
diabetes mellitus, as well as women and those hemostasis technique,n has been shown to
with end-stage renal disease, have a higher have an incremental effect in lowering the
incidence of radial artery occlusion. incidence of radial artery occlusion. Duration
The pathophysiology of radial artery occlu- of hemostatic compression has also been
sion appears to be a thrombotic process, initi- shown to have an effect, with longer duration
ated by local injury due to introduction of the of compression associated with a higher inci-
introducer sheath in the radial artery lumen, dence of radial artery occlusion. In a systemi-
which forms a nidus for local thrombus forma- cally anticoagulated patient, a 2-hour duration
tion. This is then supported by stasis created of hemostatic compression appears to be an
by a combination of radial artery spasm and optimal duration for achieving hemostasis, as
the profile of the equipment dwelling in the well as providing the lowest incidence of radial
radial artery lumen decreasing the radial flow artery occlusion.
during the procedure, usually to a standstill.
Once the procedure is completed, this
thrombus, formed at the site of entry, usually
progresses to a transmural occlusive thrombus,
• PATENT HEMOSTASIS TECHNIQUE
in the presence of flow cessation, created As the name implies, this technique revolves
by hemostatic compression. The creation of around using the lowest necessary pressure
this occluded segment of the radial artery at for hemostatic compression with establish-
the site of catheter entry leads to excellent ment of hemostasis, as well as maintenance
hemostasis and also creates acute radial artery of radial artery patency. These 2 goals are
occlusion. A large subset of these patients will simultaneously achievable in 60% to 75% of
then recanalize this occluded segment, with patients. The description of the technique is
the establishment of radial artery patency. as follows.
A small portion, though, fails to recanalize, Step 1: Purge the static contents of the
and rapid organization with eventual fibrotic radial artery, proximal to the introducer
obliteration of the lumen results. sheath, by opening the side arm stopcock
Prevention of radial artery occlusion starts bleeding and removing 3 to 5 mL of blood.
at the beginning of the transradial proce- Step 2: Apply the hemostatic compres-
dure, with special emphasis on minimizing sion device, 2 to 3 mm proximal to the skin
trauma to the radial artery. Smaller-caliber entry site (Figure 6.1), and tighten or inflate
introducers, as well as catheters, have been it (Figure 6.2), then remove the introducer
associated with a lower incidence of radial sheath (Figure 6.3).
artery occlusion. Systemic anticoagulation Step 3: Decrease the pressure of the hemo-
using heparin has also been shown to signifi- static compression device, to the point of
cantly reduce the incidence of radial artery mild pulsatile bleeding, at the skin entry site.
occlusion. Other systemic anticoagulants, After 2 to 3 cycles of bleeding, retighten the
such as bivalirudin and enoxaparin, have hemostatic compression device to eliminate
shown similar efficacy. The protective effect this pulsatile bleeding. At this point, you
of heparin appears to be systemic, as there have applied the least necessary pressure to
is no difference noted with intra-arterial or maintain hemostasis.
chapter 6 Closure and Hemostasis afterTransradial Access • 57
Step 4: Documentation of radial artery is not only sufficient but also necessary to
patency status is performed by using the prevent subsequent interruption of radial
reverse Barbeau's test. A plethysmographic artery flow.
sensor is placed on the index finger of the
involved upper extremity, with the obser-
vation of pulsatile waveforms. The ulnar Key Points
artery is then compressed at the level of the
• Use the lowest French size required for
wrist, and the behavior of the waveform
successfully completing the procedure.
is observed. Absence of plethysmographic
waveform is indicative of interruption of • Use at least 50 U/Kg unfractionated
radial artery flow (Figure 6.4). At this point, heparin administered intra-arterially or
the hemostatic compression pressure is intravenously at the beginning of the
promptly lowered (Figure 6.5), to the point procedure after obtaining radial artery
where plethysmographic waveform returns, access, or at the latest after entering
confirming the establishment of radial artery ascending aorta. Bivalirudin may be
flow (Figure 6.6). If bleeding occurs before the substituted for heparin for percutaneous
return of plethysmographic waveform, hemo- coronary intervention.
static compression pressure is increased to
• Never leave the introducer sheath in
eliminate bleeding, as this is the primary goal
place after completion of the procedure.
of the process of hemostasis. In 25% to 35%
Reaccess, if needed, for a following
of patients, the radial artery patency cannot
procedure, even if it is anticipated on the
be maintained while achieving hemostasis.
same day.
These patients are especially at a high risk for
developing radial artery occlusion. • Patent hemostasis technique is a must.
Step 5: Periodic evaluation of radial artery
• Wean the hemostatic pressure to zero
patency is necessary to prevent subsequent
before removal of the band.
flow cessation causing radial artery occlusion.
Our protocol presently requires evaluation • Never apply hemostatic compression
of radial artery patency by monitoring staff longer than 2 hours, except when subse-
every 15 minutes throughout the duration of quent bleeding occurs.
compression by using the reverse Barbeau's
test. If plethysmographic evidence of absence
of radial flow is noted, hemostatic pressure • suMMARY
is further decreased, as long as hemostasis is
maintained. Hemostasis after radial artery access is
Step 6: Mter 2 hours of hemostatic a simple, highly successful, cheap, and
compression, gradually decrease the pressure extremely effective portion of the transradial
of compression, weaning the pressure to zero. procedure. Its effect on subsequent radial
Carefully remove the hemostatic pressure artery occlusion is frequently unrecognized
device without tenting the skin, as this may and needs to be underscored, with special
dislodge the hemostatic plug and restart attention paid to maintenance of radial artery
bleeding. flow throughout hemostatic compression in
order to prevent radial artery occlusion. Radial
artery occlusion, although asymptomatic from
an ischemia standpoint, eliminates the use of
• PREDISCHARGE CARE that radial artery in the future. Radial artery
After removal of the hemostatic compres- occlusion deprives the patient of a low-risk
sion device, it is especially important to not vascular access site for future percutaneous
apply encircling dressings with compression coronary intervention. Patent hemostasis
bandages. Covering the entry site with a is an extremely successful technique that
bandage, without application of any pressure, preserves the radial artery as an access site.
chapter 6 Closure and Hemostasis afterTransradial Access • 59
femoral access are often the most difficult to radial will work from the left side and reverse
approach transradially, and the use of radial the monitors and the the radiation shielding.
access should not be limited to these patients.
injection system may improve angiographic mentioned, keeping the J-wire within the
images.U Furthermore, the use of a 5-Fr guide catheter during this maneuver may be neces-
catheter as opposed to a diagnostic catheter for sary. A Judkins 3.5 curve rather than the
angiography may provide better opacification standard femoral4.0 curve is preferred from
in high-flow states. the right radial approach.
It should be emphasized that adequate Cannulation of the right coronary is usually
sedation and intra-arterial verapamil to reduce easily accomplished with the standard Judkins
spasm, heparinization (50 units/kg), and R4 catheter. Occasionally, a Judkins RS or an
minimization of catheter exchanges will all Amplatz R2 is required, particularly when the
reduce postprocedural radial occlusion after takeoff of the coronary is inferior. An Amplatz
diagnostic procedures. Hemostasis devices R2 or an Amplatz L1 is used for anterior
must be applied using patent hemostasis takeoff of the right coronary (Figure 7.3).
and removed as rapidly as possible after
angiographic procedures.12- 15 Transradial
angiography is often criticized for subselective Universal Curves
injections with poor opacification, but excel- Many experienced radialists prefer to use
lent angiography can always be attained using universal curves for angiography of both
proper technique. The debate of "transfemoral coronary arteries, thus avoiding catheter
versus transradial" is very reminiscent of the exchanges. Most catheter manufacturers
"Sones versus Judkins" debate in the early currently have a 5-Fr diagnostic universal
days of coronary angiography. The differences curve. These curves are essentially variations
are clearly a reflection of the experience of the of the Kimny curve originally designed by
operators with either technique. Dr. Ferdinand Kiemeneij (Figure 7.4).
Cannulation of the left coronary with
these curves involves torquing the catheter
Left Radial Approach into the left cusp and then advandn forward
Catheters utilized from the left radial into the left coronary ostium emvideo 7.1).
approach are essentially the same as from Alternatively, the catheter is positioned
femoral access. Standard Judkins curves work above the left coronary cusp, the U is opened
well although a variety of femoral catheters with a J-wire, and the left corona ostium
including Amplatz curves may also be used in is engaged from above • Video 7.2) As
special situations. Positioning the left wrist previously noted, the J-wire, is actively used
near the left femoral area either before or after with these universal curves for support and
access allows the procedure to be performed to straighten the curve through subclavian
from the right side of the table with minimal tortuosity, thus improving tortuosity, and
back strain. Left subclavian tortuosity is to make subtle changes in the curve itself to
usually not an issue, and catheter manipula- actively engage the coronary ostium.
tion is similar to the femoral approach. The right coronary cusp is lower than the
left in most patients. Thus, to engage the
right coronary ostium, the catheter must be
Right Radial Approach advanced forward in addition to being torqued
The most common diagnostic catheters used clockwiselcm video 7.3)~ It is recommended
from the right radial approach worldwide are that new operators practice this maneuver
standard Judkins curves.16 Cannulating the initially with a 6-Fr Kimny catheter using
left coronary ostium involves torquing the the J-wire through the Tuohy to allow
catheter 180 degrees into the left coronary visualization.
cusp followed by advancement or withdrawal An important criticism of universal cath-
into the coronary ostium. This maneuver is eters is their lack of coaxial alignment within
distinctly different from the femoral approach the proximal segment of the coronary arteries.
and may be challenging, particularly when These curves tend to point superiorly in both
right subclavian tortuosity is present or coronaries, potentially causing subintimal
the ascending aorta is short. As previously dissection. The initial contrast injection in the
chapter 7 Basic Catheter Techniques for Diagnostic Angiography and PCI • 65
Figure 7.4 Kimny guide catheter (Boston Scientific, Watertown, MA) can be utilized for both left (A) and right (B)
coronary interventions. It is uniquely applicable for patients with STEM I.
vessel must be done carefully, and compulsive optimum angiography. The Jacky (Terumo
attention must be paid to damping of the Corporation, Somerset, NJ) catheter may
arterial pressure. The TIG catheter (Terumo cannulate coronaries with better coaxial align-
Corporation, Somerset, NJ) is particularly ment (Figure 7.5).
prone to select the conus artery branch of the A minority of operators, particularly
proximal right coronary, but active use of the those with experience using the Sones
J-wire can usually redirect the tip into the technique, may use a multipurpose catheter
primary lumen (see Figure 7.2). The operator as a universal curve to select both coronaries.
should have a low threshold to exchange In most centers, this technique is a lost art,
catheters to attain coaxial alignment and but skilled operators may obtain excellent
66 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
arteriograms relatively quickly using this usually preferable to use an alternative access
technique. such as left radial when encountered.
Arteria lusoria is a congenital condition in Diagnostic angiography in patients with
which a retroesophageal right subclavian joins previous bypass surgery may be challenging.
the arch on the left side, creating an extremely Cannulating the left internal mammary graft
acute angle to access the ascending aorta. This or left coronary saphenous vein bypass grafts
anatomical challenge can usually be overcome from the right radial approach is challenging
with either a JL 3.5 or universal curve with a and may involve specialized techniquesY It
0.035 unit angled Glidewire, having the patient is generally best to perform diagnostic
take very deep breaths. However, cannulation angiography from the femoral approach
of the coronary is extremely difficult, and it is in these patients and subsequently stage
chapter 7 Basic Catheter Techniques for Diagnostic Angiography and PCI • 67
interventional procedures. In the presence of a radial occlusion can often be prevented (see
compelling indication for ad hoc intervention, Chapter 6). Using the smallest catheter
diagnostic angiography should be performed possible for a given lesion complexity is essen-
from the left radial approach. tial. Most straightforward interventions today
can easily be performed using 5-Fr guides.
This is particularly important in women with
• CATHETERS USED FOR PCI smaller radial arteries.
JR4 is used for 6- and 7-Fr guide catheters LAD and provides excellent support from the
(Figure 7 .6). contralateral aortic wall. This catheter is also
These sheathless guides are inserted over currently available in 5 Fr. The RBLBT (Cordis
a 0.035-in J-wire positioned in the ascending Corporation, Bridgewater, NJ) and MRADIAL
aorta. The issue of transitioning from a (Medtronic, Minneapolis, MN) are also excel-
0.018-in guidewire utilized for radial access to lent 5-Fr guides. The lkari guide (Terumo,
this J-wire is overcome by using 1 of 2 tech- Somerset, NJ) was specifically designed to
niques. The first is simply to obtain access provide excellent backup from the right radial
with a standard 4- or 5-Fr sheath through approach. The size of the curve corresponds
which the J-wire is inserted. The second to Judkins sizes. The Cordis Fajadet L4 is
technique is to use a Cook Silhouette double an excellent guide for the LAD and circum-
dilator. With this system, an inner 0.018-in flex, particularly if there is a long left main
compatible dilator is removed, leaving a coronary artery.
0.036-in compatible introducer for deploy-
ment of the J-wire.
The transition between the "pseudodilator" Right Coronary Interventions
and the standard guide catheter, whether it The most frequently used guide catheter for
is 5 or 6 Fr, is not smooth as a designated right coronary interventions is a Judkins
introducer. Thus, care must be taken in intro- curve, either JR4 or JRS, with an Amplatz
ducing the guide catheter to avoid damage at Right being a distant second.16 However,
the arteriotomy site. Although this technique neither of these catheters provides excellent
has theoretical advantages due to the smaller support from the contralateral wall that
external diameter of the guide catheter, a is attained using universal curves. Thus, a
definitive study demonstrating actual reduced Kimny or other universal curve is useful in
radial occlusion is not available. this situation. Other catheters that provide
better backup are an Amplatz Left 0.75 or 1 or
an Ikari Right. The Cordis Hockey Stick also
Catheter Selection for PCI is an excellent guide catheter for the majority
Once catheter size has been determined, of right coronary artery (RCA) interventions.
consideration should be given to the shape This catheter can be "deep seated" safely, by
of the guide catheter curve. Although experi- experienced operators, and provides excellent
enced operators can utilize universal curves support. All RCA guides need to be "coaxial"
for interventions in both coronary arteries, and not merely engaged in the ostium of the
most operators will vary catheter shape selec- RCA. This is best seen in the right anterior
tion depending on the artery involved. This is oblique (RAO) projection and can be achieved
particularly true for more complex interven- by a gentle clockwise rotation of the guide
tional procedures. In a recent survey, standard when it appears to be not coaxial.
femoral curves were most commonly used for
transradial interventions; however, specific
transradial curves may improve backup in Left Circumflex Interventions
certain situations.16 Interventions involving the left circumflex
are often the most difficult encountered
by the interventionalist. Therefore, careful
LAD Interventions guide catheter selection is imperative. In
The most commonly utilized guide catheters the Bertrand survey, EBU 3.5 (26%), XB
for radial LAD interventions in the Bertrand 3.5 (21 %), and Judkins Left (12%) were the
survey were EBU 3.5 (28%), Judkins Left most commonly utilized.16 A Voda 3.5 is also
3.5 (22%), andXB 3.5 (18%). Downsizing an option. Generally speaking, Judkins curves
to the JL 3.5 has been shown to increase are avoided in LCX interventions because they
backup support in in vitro studies.21•22 The tend to point superiorly into the LAD. For
Kimny guide (Boston Scientific Corporation, 5-Fr circumflex interventions, the EBU 3.5 or
Watertown, MA) tends to be coaxial with the 3.75 or MRADIAL (Medtronic, Minneapolis,
chapter 7 Basic Catheter Techniques for Diagnostic Angiography and PCI • 69
MN) provides satisfactory backup and opaci- to reach even distal lesions in the LAD. Right
fication. The Cordis Fajadet L4 is similar in IMA interventions are performed from right
shape to the Voda catheter and is quite good radial access.
for the circumflex. Clearly, these choices are Right saphenous vein bypass graft inter-
personal, just as they are when working from ventions can be performed from the right
femoral access. radial artery using an Amplatz R2, multipur-
pose, or Amplatz Left catheter. An Amplatz
Ll curve is used in 59% of right saphenous
Bypass Graft Interventions vein graft interventions in Japan. With a
Left internal mammary artery (IMA) graft dilated aortic root, an AL2 catheter may be
interventions are performed from the left helpful (Figure 7.8).
radial artery. 23 A standard IMA guide catheter Left saphenous vein bypass graft interven-
or a Mann IM (Boston Scientific, Watertown, tions are best performed from the left radial
MA) is utilized (Figure 7.7). The latter cath- approach. These interventions, particularly
eter provides excellent support and is 90 em high-takeoffleft circumflex vein grafts, are
in length, thus allowing balloons and stents difficult and should not be performed until
well into the learning curve. Amplatz Left and much less frequently now with the continued
left bypass graft curves are most commonly improvements in the deliverability of balloons
used. However, the K.imny catheter provides and stents. However, when additional support
excellent support from the left radial artery is necessary, a mother-daughter extension
and is also an excellent option (Figure 7.9). catheter (GuideLiner, Vascular Solutions,
A buddy wire is commonly used for stability, Minneapolis, MN) may be useful. When
particularly during deployment of embolic used transradially, the proximal port of the
protection devices. A GuideLiner will provide GuideLiner may be located in an angulated
additional support and is commonly used for segment in the shoulder and may entrap
these interventions. the stent (Figure 7.11). Thus, stents should
be passed into the GuideLiner in a straight
segment, and then both should be passed
. TIPS TO IMPROVE TRANSRADIAL together into the target vessel.
Rotational atherectomy may be a necessary
PCI SUCCESS pretreatment in heavily calcified vessels and
Buddy wires positioned either in the target lesions. Burr sizes up to 1.75 mm can be used
vessel or in an adjacent vessel are very useful for standard 6-Fr guide catheters. A 1.25-mm
to improve guide catheter coaxiality and Burr can be passed through a 0.058-in
support (Figure 7.10). Operators should 5-Fr guide catheter such as the Launcher
have a low threshold to insert a second wire MRADIAL (Medtronic, Minneapolis, MN)
if difficulties are encountered with either (Figure 7.12). Although standard-shape curves
predilatation or stent deployment. They can are generally utilized, Q curves provide good
be utilized with any size or shape catheter but support and allow smooth passage of the Burr
are particularly useful with 5-Fr guides. into the target vessel.
Deep seating of 5-Fr guide catheters is a In patients with STEMI, most operators
technique that has been long associated with utilize catheters with which they are most
transradial access. This technique is utilized familiar. Experienced radialists will perform
chapter 7 Basic Catheter Techniques for Diagnostic Angiography and PCI • 71
the entire procedure with a universal guide is one clinical situation where 6-Fr guides are
catheter to eliminate time-consuming catheter preferred because insertion of a thrombec-
exchanges. This benefit is obviously negated tomy catheter may be necessary.
if the coronaries cannot be expeditiously If Burrs larger than 1. 75 mm are required,
cannulated, and previous experience with a 7-Fr guide catheter should be inserted using
these curves in elective procedures is manda- the sheathless technique; it should be pointed
tory. In these emergency procedures, catheter out that the external diameter from a 7-Fr
exchanges should be made over an exchange- guide catheter is actually smaller than that
length guidewire or a standard guidewire of a 6-Fr sheath. Thrombectomy catheters
anchored in the right coronary cusp to avoid including the AngioJet system are all compat-
renegotiating subclavian tortuosity. STEMI ible with 6-Fr guide catheters.
chapter 7 Basic Catheter Techniques for Diagnostic Angiography and PCI • 73
Guide catheter use in women requires primary angioplasty and abciximab. Catheter
special mention. In general, the radial artery Cardiovasclnterv. 2004;61:67-73.
5. Saito S, Tanaka S, Hiroe Y, et al. Comparative study
is a small artery and more prone to spasm. on transradial approach vs. transfemoral approach
Thus, smaller guide catheters are required, in primary stent implantation for patients with
and operators should have a low threshold acute myocardial infarction: results of the test for
to repeat doses of spasmolytic agents if arm myocardial infarction by prospective unicenter
pain is encountered; intra-arterial verapamil is randomization for access sites (TEMPURA) trial.
Catheter Cardiovasc Interv. 2003;59:26-33.
utilized in 3-mg increments. Straightforward 6. Hetherington SL, Adam Z, Morley R. Primary
interventions should be performed with percutaneous coronary intervention for acute
5-Fr guide catheters, which can be utilized in ST-segment elevation myocardial infarction: chang-
most women. If a 6-Fr guide is thought to be ing patterns of vascular access, radial versus femo-
necessary, consideration of insertion using a ral artery. Heart. 2009;95:1612-1618.
7. Pancholy S, Patel T, Sanghvi K, Thomas M, Patel T.
sheathless technique is appropriate. For the Comparison of door-to-balloon times for primary
smallest arteries, a 5-Fr guide catheter can PCI using transradial versus transfemoral approach.
be inserted sheathless using the 4-Fr Terumo Catheter Cardiovasc Interv. 2010;75:991-995.
glide catheter as an introducer. 8. Weaver AN, Henderson RA, Gilchrist IC, Ettinger
In conclusion, patient selection, appro- SM. Arterial access and door-to-balloon times
for primary percutaneous coronary intervention
priate use of the right as opposed to left radial in patients presenting with acute ST-elevation
access, and thoughtful catheter selection are myocardial infarction. Catheter Cardiovasc Interv.
crucial to easing the transition to the radial 2010;75:695-699.
approach. The benefits of transradial access 9. Sciahbasi A, Romagnoli E, Burzotta F, et al.
are well documented but are fully experienced Transradial approach (left vs. right) and procedural
times during percutaneo us coronary procedures:
only with its routine use. A commitment to TALENT study. Am Heart J. 2011;161(1):172-179.
transradial access is essential. 10. Saito S, Ikei H, Hosokawa G, Tanaka S. Influence
of the ratio between radial artery inner diameter
and sheath outer diameter on radial artery flow
after transradial coronary intervention. Catheter
• sUMMARY Cardiovasclnterv. 1999;46:173-178.
This chapter recognizes that patient selection, 11. Hou I, Wei YD, Song J, et al. Comparative study of
4 French catheters using the ACIST variable rate
appropriate use of right as opposed to left
injector system versus 6 French catheters using
radial access, and thoughtful catheter selec- hand manifold in diagnostic coronary angiography
tion are crucial to easing the transition to the via transradial approach. Chin Med J(Engl). 2010;
radial approach. The benefits of transradial 123:1373-1376.
access are well documented but are fully expe- 12. Pancholy S, Coppola J, Patel T, Rake-Thomas
M. Prevention of radial artery occlusion- patent
rienced only with its routine use. A commit- hemostasis evaluation trial (PROPHET study):
ment to transradial access is essential. a randomized comparison of traditional versus
patency documented hemostasis after transradial
catheterization. Catheter Cardiovasc Interv. 2008;72:
• REFERENCES 13.
335-340.
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1. Geijer H, Persliden J. Radiation exposure and Interruption of blood flow during compression and
patient experience during percutaneous coronary radial artery occlusion after transradial catheteriza-
intervention using radial and femoral artery access. tion. Catheter and Cardiovasc Interv. 2007;70:
Bur Radiol. 2004;14:1674-1680. 185-189.
2. Neill J, Douglas H, Richardson G, et al. Comparison 14. Cubero J, Lombardo J, Pedrosa C, et al. Radial
of radiation dose and the effect of operator experi- compression guided by mean artery pressure
ence in femoral and radial arterial access for coro- versus standard compression with a pneumatic
nary procedures. Am J Cardiol. 2010;106:936-940. device (RACOMAP). Catheter and Cardiovasc Interv.
3. Louvard Y, Ludwig J, Lefevre T, et al. Transradial 2009;73:467-4 72.
approach for coronary angioplasty in the setting of 15. Gilchrist I. Laissez-faire hemostasis and transradial
acute myocardial infarction: a dual-center registry. injuries. Catheter Cardiovasc Interv. 2009;73:473.
Catheter Cardiovasc Interv. 2002;55:206- 211. 16. Mamas MA, Fath-Ordoubadi F, Fraser DG.
4. Philippe F, Larrazet F, Meziane T, et al. Comparison Atraumatic complex transradial intervention using
of transradial vs. transfemoral approach in the large bore sheathless guide catheter. Catheter
treatment of acute myocardial infarction with Cardiovasc Interv. 2008;72:357-364.
74 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
e
J:
C'IS
allows for a larger internal
(I) diameter. Source: From AM,
J:
t/J Gulati R, Prasad, A, Rihal
CS. Sheath less transradial
intervention using
standard guide catheters.
1.67 mm Cath Cardiovasc lnterv.
1.98 mm 2.31 mm 2.64mm
201 0;76(7):91 1-916. Used
e e e
with permission from Wiley.
(I)
"C
·:; I
(!)
carry the outer footprints equivalent to 5- and exchange-length 0.035-in stiff guidewire.
6-Fr introducer sheaths. Although a number A regular wire will also work, but the stiff
of series have shown feasibility and safety of wire will serve as a stronger rail over which
these guides, 1•2 it should be noted that their the guide/dilator can be advanced into the
cost is significantly greater than the cost of radial artery. To create a taper for standard
standard guides and that they are not available 7- and 8-Fr guides of any configuration,
in all countries, including the United States. insert a 125-cm 5- or 6-Fr multipurpose
It is also possible to use standard equip- diagnostic catheter (Figure 8.2) or a 125-cm
ment available in all cath labs to fashion an 6.5-Fr Shuttle Select hydrophilic catheter
inner dilator for use with standard guiding through the guide. The Shuttle catheter has a
catheters. 3•4 Although we have not found gentle taper on its tip and is therefore easier
spasm to be a limitation, the lack of a hydro- to pass through the skin than multipurpose
philic coating on standard guiding catheters diagnostic catheters and creates a smoother
makes this theoretically more likely to be transition from diagnostic catheter to guide.
an issue compared with the custom-made After removing the sheath, advance the
devices. Likewise, we have not yet encoun- guide/dilator over the 0.035-in wire into the
tered problems at the radial entry point, but radial artery (Figure 8.3). It is helpful for the
the lack of a protective sheath raises the prob- assistant to apply traction on the wire, actu-
ability of hematoma formation or ongoing ally physically pulling it back slowly, as this
oozing during the procedure, particularly if provides a taut rail that facilitates guide entry.
significant guide torquing is required. Our A quick moderately forceful push may be
approaches are as follows. required to enter the radial because the transi-
tion between wire, dilator, and catheter is not
perfect. Remember to keep forward pressure
Larger-Caliber Guides on the dilator at the same time. Once the
First, obtain access to the radial artery with a guide is in the radial artery, it can be advanced
5- or 6-Fr sheath in a standard manner. The with its dilator and then used to cannulate the
entry site arteriotomy created by the sheath coronary in the usual manner. On occasion,
will facilitate subsequent guide advancement. there may be minor ooze at the skin entry
Next, advance any diagnostic catheter into site, but this will settle with a minute of gentle
the aortic root and use this to switch for an compression.
chapter 8 Sheath less Transradiallntervention • 77
•••
Smaller-Caliber Guides
For 5- and 6-Fr sheathless guide insertion,
first access the radial with a micropuncture kit Figure 8.3 Tapering of a standard guide catheter
and advance an exchange-length 0.035-in wire for sheathless insertion in the radial artery using a
to the aortic root. The dilator that is associ- telescoping shuttle select diagnostic catheter. Source:
ated with the greatest ease of guide catheter From AM, Bell MR, Rihal CS, Gulati R. Minimally invasive
transradial intervention using sheathless standard
insertion is a 110-cm Cook 4-Fr sheath dilator guiding catheters. Catheter Cardiovasc lnterv. 15 Nov
through a 5-Fr guiding catheter (Figure 8.4). 2011 ;78(6):866-871. Used with permission from Wiley.
For a 6-Fr guide, a 5-Fr x 125-cm Shuttle
Select diagnostic catheter also provides a
reasonable transition. Alternatives include a
4-Fr 125-cm multipurpose diagnostic catheter
or a 5-in-6 GuideLiner, but these require more
forward push for successful guide entry to the
radial artery.
• cASE EXAMPLE
An 84-year-old female with a body mass index Figure 8.4 Tapering of a standard 6-Fr guide
catheter for sheath less insertion into the radial artery
(BMI) of 18, history of mild chronic renal by insertion of a 5-in-6 Guideliner catheter (Vascular
insufficiency, and chronic anemia presented Solutions Inc, Minneapolis, MN) over a 0.035-in wire.
with chest pain at rest, ST-segment depression Source: From AM, Bell MR, Rihal CS, Gulati R. Minimally
in V2-V5, and a positive troponin-T. Despite invasive transradial intervention using sheath less
immediate commencement of antiplatelet standard guiding catheters. Catheter Cardiovasc lnterv.
15 Nov 2011 ;78(6):866-871. With permission from Wiley.
and anticoagulant therapy, she experienced
recurrent chest pain with dynamic electrocar-
diogram (ECG) changes on the day of admis- intravenous heparin bolus were administered.
sion, prompting urgent angiography. A right Angiography with 5-Fr Judkins Left 3.5 and
radial approach was selected. After adequate Judkins Right 4 diagnostic catheters indicated
intravenous sedation, a 6-Fr short hydrophilic critical bifurcation disease in mid-left anterior
sheath (Terumo) was placed uneventfully. descending (LAD) and second diagonal branch
A standard intra-arterial vasodilator cocktail (Medina classification 0,1,1) with additional
and an activated clotting time (ACT)-guided distal LAD disease (Figure 8.5a).
78 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Figure 8.5 (A) Transradial left coronary angiography in the left anterior oblique (LAO) cranial projection indicating a
critical LAD bifurcation stenosis. (B) Excellent final result after sheath less transradial intervention using an 8-Fr XB 3.5
guiding catheter. A simultaneous V stent approach was employed at the bifurcation with an additional distal LAD stent.
the uptake in the United States remains as low be discharged on the same day of procedure.
as 5%-10%. Parallel to the expected increase Limited-risk PTCA was performed through
in the use of TRAin the United States, it can the brachial artery using 6-Fr catheters in
be anticipated that current reform in the US 61 patients (70 lesions); 2 were excluded
health care system will promote same-day- due to failed access. Following this, patients
discharge programs as well. At this time, with angiographic evidence of dissection
several reasons play a part in the limited and/or thrombosis and complications were
utilization of the TRAin the United States; the assigned to an inpatient group, and those
most important is that only a relatively small with good angiographic result were assigned
percentage of interventional cardiologists in to an outpatient group. Following successful
the United States are trained in this technique, PTCA, 50 patients (82%) with 57 lesions
although this is changing rapidly. Other (81 %) were considered eligible for discharge
reasons for this low penetration may include but remained hospitalized overnight without
lack of financial incentive due to the reim- monitoring. No ischemic complications
bursement structure in US health care institu- occurred in this group. Eleven patients (18%)
tions and relative lack of patient lmowledge in whom 13 lesions (19%) were attempted
that this alternative access exists. In addition, were assigned to the inpatient group. Three
the relatively steep learning curve for transra- of these sustained abrupt vessel closure
dial access probably plays a role as well. Most (2 within 1 hour of observation, and 1 just
operators in the United States are 1ow-volume 20 minutes post PTCA). Out of all61 patients,
operators" performing fewer than 200 cases only 5 had vascular complications (despite
per year, making it difficult for them to learn using the brachial access and 6-Fr catheters),
and to feel comfortable with the technique. On and 2 of those required local surgical repair.
the other hand, the high-volume operator may This pilot study highlighted the importance
feel "too busy" to learn and apply transradial of defining patients at ischemic risk following
access to routine angiography and PCL PTCA and demonstrated the potential feasi-
bility of discharging low-risk patients after a
short observation period post PTCA.
Out of 1,911 elective PTCA patients,
• SAME-DAY-DISCHARGE PCI: Knopf et al18 stratified 262 (14%) as low-risk
BUILDING THE EVIDENCE IN candidates for same-day discharge, and out of
these, 90 patients (34%) were prospectively
EARLY DAYS randomized to either an inpatient (n =47) or
The concept of outpatient PCI is not new. an outpatient (n = 43) strategy. Similar proce-
Over the past 2 decades, a series of registries dural and clinical outcomes were observed in
and a number of randomized trials with the 2 groups, with 33 out of 43 outpatients
same-day discharge after transradial PCI (77%) discharged on the same day of the
have been reported (Table 9.1). These studies procedure. Crucially, no late complications
utilized well-defined clinical criteria for care- (between 1 and 7 days postprocedure) were
fully selecting patients who would be eligible observed in the outpatient group. A satisfac-
for same-day discharge, and those who had tion survey of all patients and their families
predictors of adverse outcome were naturally showed an overwhelming preference for same-
excluded. day discharge. Similarly, Koch et al evaluated
The upsurge in PTCA activity urged the safety of short-term observation (4 hr)
Laarman et al in the early 1990s to assess after elective PTCA in a prospective study
the practicality and safety of same-day of 1,900 patients. 19 One of 1,680 patients
discharge after uncomplicated transbrachial triaged to discharge after 4 hours developed
PTCA.U They tested the hypothesis that acute recurrent ischemia, and 7 patients
by carefully selecting a group of patients (0.4%) required repeat PTCA during the
(stable angina) who are at low risk of postpro- observation period. Of the 187 patients
cedural complications identified using pre- assigned for overnight hospitalization,
and post -PTCA criteria, these patients may mainly due to suboptimal angiographic
Table 9.1 Published Studies of PCI with Same-Day Discharge.
..,
Ill
•
~
"'
:::;)
""
Kiemeneij et al.
Koch et al.
ISC, NR, p
SC, NR, R
I 188/100
1,015/922
I Radial
Femoral
I Heparin, Coumadin 16
Heparin -8
INone IPalmaz-Schatz stent used; on Coumadin INR > 2.5
Many patients •discharged• back to referring hospital for care
ill
c._
iii'
Carere et al. I SC, R, P I 50/41 I Femoral I Heparin I Mean 11.2 I None I Suture closure of site and same-day discharge versus manual n~
~
compression and discharge the following day; no :::J
EJ'
difference in events c
(1)
Slag boom et al. I sc, NR, p 1 159/106 I Radial I Heparin 14-6 I None I Balloon angioplasty alone in some patients; exclusions from ""
Q'
early discharge defined 0
iii"
lC
Gilchrist et al. SC, NR, R -/26 Radial Heparin Mean 6.5 None Only stents used; 6-hr infusion of eptifibatide after bolus :::J
0VI
~.
Ormiston et al. SC, NR, P 100/26 Femoral Bivalirudin Mean -7 None Restrictions to early discharge, but safe n
Dalby et al. SC, NR, P 70/51 Femoral Heparin -4 None Angio-Seal closure used >
:::J
lC
Banning et al. SC, NR, P 487/409 Femoral Heparin 6-12 None Manual compression, high patient satisfaction a·
Ziakas et al. SC, NR, R 2,072/943 Radial Heparin -4 No serious Outcome data self-reported by questionnaire lC
ill
complications sent to patients -o
~
'<
Porto et al. I SC, NR, P I 1961233 I Femoral I Heparin 16-10 I None 70% of PCis were excluded, manual compression used, "'c._
:::;)
Bertrand et al. I SC, NR, P I 504/444 I Radial I Heparin+ 14-6 INone IRandomized to radial, bolus-only abciximab, and early a·
:::;)
abciximab discharge (n =504) versus femoral, bolus, and infusion
abciximab and overnight stay (n = 501)
Wiperetal. SC, NR, R 442/378 Radial Heparin Mean 9.75 None Abciximab used in some, mostly bolus-only
Heyde etal. SC, R, P 403/326 Femoral Heparin -4 None Randomized (n =800) to early discharge versus overnight stay
Jabara et al. SC, NR, R 450/12 Radial Heparin Unknown None No adverse events occurred between 6 and 24 hr with no
discharge delays in this interval
Ml, myocardial infarction; NR, not randomized; P. prospective data collection; PCI, percutaneous coronary intervention; R, retrospective data collection; SC, single center. Source: Modified from Blankenship JC. Here today, gone
today: time for same-day discharge after PCI. CatheterCardlovasclnter. 2008;72:626-628. Reprinted with permission.
chapter 9 Transradial Access and Outpatient PCI: State-of-the-Art and Persisting Challenges • 83
result, 66 developed complications. It could, for short-term observation, and to study the
therefore, be concluded that a short observa- predictors of failure of same-day discharge
tion period after uncomplicated PTCA is safe, after elective PTCA, 1,015 consecutive patients
and a large proportion of patients could be were prospectively included for short-term
safely discharged home the same day, with observation, and patients with unstable angina
a trivial risk of recurrent ischemia (abrupt Braunwald Class 3 were excluded. In all,
vessel closure) after this period. Similarly, 922 (90.8%) patients were selected for short-
based on the angiographic postprocedural term observation and had an uncomplicated
result, patients could be triaged for overnight course for the next 72 hours. Observation
hospitalization as appropriate. was prolonged in 87 patients (8.6%), and
40 patients developed complications. Two
patients died, including 1 of 6 patients who
• OUTPATIENT PCIIN THE ERA OF required emergency bypass surgery. Several
independent predictors of procedural compli-
CORONARY STENTS cations emerged from this study, including
After the Laarman et al PTCA pilot study in acute target vessel closure, side branch
1994,17 Kiemeneij and Laarman et al were occlusion, ostial lesions, lack of angiographic
keen to explore the feasibility of coronary success, and female sex. It is imperative to
Palmaz-Schatz stent implantation on an note that, despite its growing use during the
outpatient basis. 20 A total of 188 patients study period, the rate of stenting was still very
who underwent stent implantation through low at< 30%. Once again, this study showed
the radial artery were recruited between May the safety of a short 4-hour observation period
1994 and July 1995 for this prospective after PTCA. Furthermore, it also emphasized
study. In the initial phase, patients received the strength of procedural and periprocedural
anticoagulation with Coumadin, and stenting variables as predictors of complications, and
performed at an international normalized that immediate procedural results can safely
ratio (INR) of> 2.5, but from December permit triage for short observation.
1994 onward, patients were treated with As PCI techniques evolved, the outpatient
aspirin and ticlopidine, and heparin was approach was also introduced with the
administered during the procedure. Suitability transfemoral access. Wilentz et al22 reported
for same-day discharge was determined on the use of vascular sealing devices, in conjunc-
the basis of pre-, post-, and periprocedural tion with small transfemoral guiding catheters
criteria. Of the 188 patients included, 88 were to decrease time to mobilization and achieve
assigned for overnight hospitalization for early discharge. They recruited both stable and
various reasons. In the 100 outpatients, unstable patients (unstable angina or posi-
110 lesions were covered with 125 stents, tive ETT following a recent MD into their
92 patients were discharged home the same study. Of the 50 patients originally recruited,
day, and 8 returned to their referring center. 49 underwent vascular sealing, and 45 were
In the outpatient group, no cardiac or bleeding safely discharged home the same day without
complications were encountered in the first ischemic or bleeding adverse events. One
24 hours. At 2 weeks' follow-up, only 1 patient patient developed a femoral pseudoaneurysm
was readmitted (Day 4) due to a bleeding requiring surgical repair.
abdominal aortic aneurysm, which was treated In a retrospective study of 539 patients
surgically. The authors concluded that after an who underwent PCI in the province of Quebec
optimal-result Palmaz-Schatz coronary stent between January 1997 and December 1999,
performed transradially, patients could safely via either femoral or radial approach, Clement-
be discharged home the same day. Major and Lemire23 demonstrated that
Following their initial report of the safety of 383 patients (71%) were discharged home
short-term observation of patients for 4 hours the same day, and 156 patients were hospital-
post PTCA, Koch et al21 reported an update of ized overnight after suboptimal PCI results.
their experience between January 1995 and Although the use of stents was heterogeneous
May 1997. To evaluate the triage of patients during the study period, ranging from < 25%
84 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
in the first 6 months to 75% in last 6 months, PCI in 159 patients treated with PTCA or coro-
this analysis showed the feasibility and the nary stent implantation exclusively performed
potential safety of outpatient angioplasty. through the radial artery using 6-Fr guiding
Ziakas et aF4 described the first western catheters. This was intended to substantiate
Canadian experience on same-day discharge the significance of their sets of 7 clinical and
after transradial PCI. Between April1998 and 5 angiographic criteria barring same-day
March 2001, a total of 943 had same- discharge. One hundred and six patients
day-discharge radial PCI and represented (66%) were selected for same-day discharge in
patients with stable and unstable angina, the absence of any adverse predictors of acute/
single or multilesion PCI, and all types of subacute vessel closure or unfavorable clinical
lesion characteristics. Out of 943 patients outcome in the first 24 hours post successful
who were discharged the same day of PCI, PTCA. Despite the low use of stents, only
811 responded to a mailed questionnaire, 40% in total, there were no cardiac or vascular
38 patients had died, and 94 refused to complications during the observation phase
participate. Within 24 hours post discharge, or up to 24 hours post PTCA in the outpatient
27 patients (3.3%) visited their doctor and/or group. One hospitalized patient had acute
the hospital for access site-related complica- in-lab vessel occlusion, and 3 others required
tions, and 38 (4.6%) visited within 1 month. repeat PTCA during the observation period.
Notably, however, none of these patients had Following this, and utilizing these
a major entry site complication or required predefined clinical and angiographic predictors
hospital admission. Only 1 patient (0.1 %) of adverse outcomes, Slagboom et al7 went
underwent a repeat coronary angiogram in on to conduct a randomized trial in which
the first 24 hours because of chest pain but 644 patients were randomly assigned to either
did not require repeat intervention. During transradial or transfemoral PTCA (322 in each
the first month,11 patients (1.4%) needed group) using 6-Fr guiding catheters and same-
a repeat coronary angiogram, out of which day discharge. After successful PCI (62% were
4 had subacute vessel closure. Overall, stented in both groups), 177 patients (55%)
718 patients (89%) affirmed their satisfaction in the femoral group and 198 patients (61 %)
with same-day discharge. in the radial group were selected for same-
As time evolved in the last decade, outpa- day discharge based on the predefined set of
tient PCI was described in different scenarios, predictors of an adverse outcome. Outpatient
using both radial and femoral access, PTCA management appeared to be safe, with only
with or without stenting, and with or without 1 major adverse outcome (stent thrombosis)
glycoprotein IIb/IIIa inhibitors. in 375 patients (0.3%) and 5 bleeding events
Carere et al25 sought to determine whether (1.3%) in the first 24 hours after successful
immediate suture closure of 8-Fr femoral PCI. Predictably, more ischemic and bleeding
puncture site could facilitate same-day events were observed in the higher-risk group
discharge after PCI. They randomly assigned staying in the hospital overnight, as 19 (7%) of
100 patients to immediate femoral arterial the 269 patients sustained an adverse event.
sheath removal and suture-based device
closure versus delayed sheath removal with
the application of a C-clamp. Following • TRADE-OFF BETWEEN ISCHEMIC
pertinent bed rest and subsequent mobiliza- AND BLEEDING RISK AND
tion, same-day discharge was possible in
41 patients (84%) assigned to a closure device,
OUTPATIENT PCI
with economic analysis indicating potential With the higher rate of stenting and inclu-
hospital cost savings. Overall, patients sion of higher-risk patients, several registries
preferred the suture closure method when and randomized studies have demonstrated
they answered a simple questionnaire. the feasibility and safety of same-day
In 2001, Slagboom et al6 reported the discharge after successful PCI (through
results of the OUTCLAS pilot study that either the TRA or the TFA once hemostasis is
tested the feasibility and safety of outpatient achieved). Using a combination of clinical and
chapter 9 Transradial Access and Outpatient PCI: State-of-the-Art and Persisting Challenges • 85
primary endpoint was in-hospital adverse of a CTO. Fifty-seven patients (13%) had
clinical outcomes between 6 and 24 hours prolonged hospitalization, but only in 3.8%
postprocedure. Indications for intervention was the reason for this procedure related.
included stable angina (49%), unstable angina In this observational study, Jabara et al
(31 %), non-ST-elevation MI (NSTEMI, demonstrated that no ischemic or bleeding
17%), and STEMI (3%), with primary PCI adverse events occurred between 6 and 24
performed in 11 cases. Fourteen percent of hours, and no discharge delays occurred,
patients received Gpiib!IIIa inhibitors, and further emphasizing the importance of a
bivalirudin was used in 41%. In 450 patients, short observation period but also demon-
a total of 630 lesions were treated, and strating the safety of this approach in selected
540 stents were implanted. Of the lesions patient groups. This was a key observation.
treated, 20% were complex, including chronic Importantly, any adverse events occurring in
total occlusion (CTO), calcified lesions, and the first 6 hours post PCI would have disquali-
bifurcations (treated using 7-Fr catheters). fied the patient from early discharge, and
The right transradial access was used in 99% complications after 24 hours would not have
of cases, and left radial and ulnar composed been influenced by overnight hospitalization.
the remainder. Procedural success was 96%. More recently, Rao et al32 reported
In total, in-hospital adverse clinical events the prevalence and outcomes of same-
occurred in 24 patients (5.3%). Based on the day discharge after elective PCI among
timing of these events, they were divided older patients in the United States. In
into 3 groups: those that occurred between this multicenter cohort study, data from
0 and 6 hours, between 6 and 24 hours, and 107,018 patients 65 years or older under-
beyond 24 hours. Twenty postprocedural going elective PCI procedures at 903 sites
complications (4.4%) were observed during participating in the CathPCI Registry between
the first 6 hours, and 4 (0.9%) occurred after November 2004 and December 2008 were
24 hours. Crucially, no complications occurred included and divided into 2 groups based
between 6 and 24 hours (ie, the assessed time on their length of stay post PCI: same-day
interval between same-day and following- discharge or overnight stay. The primary
day discharge). Minor access site-related endpoints for this study were death or rehos-
bleeding complications were observed in 2.4% pitalization for any cause occurring within
of patients in the first 6 hours and resolved 2 days of discharge and at 30 days. The 2 days'
with manual compression. Postprocedural MI time was selected to reveal an early outcome
occurred in 8 patients (1.8%), all within the that might be influenced by overnight obser-
first 6 hours post PCI. Four underwent repeat vation. Other endpoints included procedural
revascularization. Likewise, 4 patients (0.9%) success, bleeding, and vascular complications.
suffered acute stent thrombosis in the first Of the total107,018 patients included,
6 hours, and all underwent successful revas- only 1,339 (1.25%) were discharged home
cularization without in-hospital mortality. on the same day after their elective PCI.
Not surprisingly, al14 patients were high risk, Procedural characteristics varied between
with initial indication for PCI being STEMI in the 2 groups. Patients who were discharged
2 patients and NSTEMI in 2 patients. All had home the same day underwent shorter, less
complex lesions. complex procedures and received a lower
In the third group(> 24 hours post PCI), contrast volume. Overall, the transfemoral
procedural complications occurred in 4 cases: approach was utilized in the majority of
One patient suffered a cerebrovascular patients (97.7%), with transradial in 1.55%
accident (CVA), and a second developed parox- and brachial in the remainder. A slightly
ysmal atrial fibrillation (PAF), 28 and 30 hours higher proportion of same-day-discharge
post PCI, respectively. A third patient was patients underwent transradial interventions
referred for CABG 2 days after unsuccessful (3.14%) compared to the overnight group
PCI of aCTO, and the fourth (0.2%) patient (1.55%). Adjuvant pharmacotherapy differed
died 3 days post complicated attempt at PCI significantly between the groups, with
88 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
•
~
"'
:::;)
""
ill
c._
iii'
Table 9.2 Exclusion Criteria for Early Discharge in Randomized Reports of Early Discharge Following PCI.
~
~
Clinical Operator did not believe early discharge appropriate Recent(< 72 hr) STEM! Hospitalized patient n
~
:::;)
Clinical evidence of peripheral artery disease LVEF~30% Acute coronary syndrome EJ'
c
Preexisting femoral artery hematoma Allergy or intolerance to aspirin or thienopyridines Ad hoc PCI rt>
Serum creatine> 150 mmol/1 INR> 2.0 Need for long-term oral anticoagulation ""
Q'
BP > 180/100 mm Hg Contraindication to abciximab 0
iii'
lC
Procedural In-lab transient vessel closure during PCI Catheters > 6 Fr :::;)
Sl~.
Hemodynamic collapse during PCI GP lib/Ilia inhibitors used n
Access other than radial artery Severe dissection with failed or suboptimal stent ~
lC
PCI without stent placement Occluded side branch
Stented length > 25 mm in one vessel Angiographic thrombus/no reflow
2'
ill
Compromised or suboccluded branch with diameter Suspected guidewire perforation "'0
~
'<
>lmm Suspected CVA
Residual dissection of~ B of NHLBI classification "'c._
:::;)
-o
Persisting chest pain after PCI ro
n
c
TIMI flow< 3 after stenting
Entry site complication
or
:::;)
No transportation available
0/A, cerebrovascular accident; GP, glycoprotein; INR, international normalized ratio; LVEF, left ventricular ejection fraction; NHLBI, National Heart, Lung, and Blood Institute; SfEMI, Sf-segment elevation myocardial infarction;
TIMI, thrombolysis in myocardial infarction; PCI, percutaneous coronary intervention.
chapter 9 Transradial Access and Outpatient PCI: State-of-the-Art and Persisting Challenges • 91
net to ensure short- as well as long-term recovery room in Europe (see Figure 9.1). His
safety of such patients, a built-in feedback idea was to create a cafe-like atmosphere, with
and follow-up program to ensure patient and reclining chairs (instead of beds) and Internet
family satisfaction is also vital. access, where independently ambulant radial
PCI patients will be able to surf the net and
be less anxious about having an invasive
Radial Lounge procedure.
A dedicated "Radial Lounge" for patients' Following their successful experience,
recovery following transradial procedures can more and more health institutions in Europe,
significantly enhance the patients' experi- Asia, and North America have adopted this
ence, save money, and reduce workload on patient-friendly and cost-effective approach
hospital staff. Inspired by an idea from a KLM of a dedicated minimalistic recovery lounge,
airport lounge, Dr. Ferdinand Kiemeneij, moving away from the sterile look of tradi-
Department of Interventional Cardiology, tional hospitals to a warm, inviting, and
Onze Lieve Vrouwe Gasthuis, Amsterdam, friendly atmosphere, which immediately
The Netherlands, created the first "elite-class," makes patients feel more comfortable and in
airport-like lounge, dedicated radial access control (see Figure 9.2).
Brewster et al reported their first-year 2. Platelet glycoprotein IIb/IIIa receptor blockade and
experience after the introduction of such a low-dose heparin during percutaneous coronary
revascularization: the EPILOG Investigators. N Eng/
lounge in a tertiary center in London, UK J Med. 1997;336:1689-1696.
(European Heart Journal [2011] 32 [Abstract 3. Umans VA, Kloeg PH, Bronzwaer J. The CAPTURE
Supplement, 399]). During the 1-year study triaL Lancet. 1997;350:445.
period, 1,548 patients were managed in the 4. Braunwald E, Antman EM, Beasley JW, et al.
radial lounge. Of these, 1,109 patients under- ACC/AHA guideline update for the management
of patients with unstable angina and non-ST-
went coronary angiography, 114 of whom also segment elevation myocardial infarction-2002:
underwent PW study or intravascular ultra- summary article: a report of the American College
sound (IVUS), and 439 had PCI. The latter of CardiologyI American Heart Association Task
was performed radially in 81.8%, allowing Force on Practice Guidelines (Committee on the
same-day discharge in 84.7%. No postpro- Management of Patients With Unstable Angina).
Circulation. 2002;106:1893-1900.
cedural complication was observed in the 5. Lincoff AM, Popma JJ, Ellis SG, et al. Abrupt vessel
radial lounge during the observation period closure complicating coronary angioplasty: clini-
prior to discharge. In Pilsen Hospital (Czech cal, angiographic and therapeutic profile. JAm Coil
Republic), elective patients are offered to Cardiol. 1992;19:926-935.
transit only through a dedicated radial lounge. 6. Slagboom T, Kiemeneij F, Laarman GJ, et al. Actual
outpatient PTCA: results of the OUTCLAS pilot
Every day, 4 patients are treated in this more study. Catheter Cardiovasc Interv. 2001;53:204-208.
relaxed environment. This further emphasizes 7. Slagboom T, Kiemeneij F, Laarman GJ, van der
the fact that a dedicated radial lounge free Wieken R. Outpatient coronary angioplasty:
of cardiac monitors is a safe environment in feasible and safe. Catheter Cardiovasc Interv.
which the majority of patients undergoing 2005;64:421-427.
8. Rodes J, Tanguay JF, Bertrand OF, et al. Late
elective PCI procedures could be managed. (> 48 hr) myocardial infarction after PTCA: clini-
cal and angiographic characteristics of infarction
related or not to the angioplasty site. Catheter
Cardiovasc Interv. 2001;53:155-162.
• sUMMARY 9. Cutlip DE, Bairn DS, Ho KK, et al. Stent thrombosis
in the modem era: a pooled analysis of multi-
In summary, same-day-discharge practice after
center coronary stent clinical trials. Circulation.
uncomplicated PCI is both safe and extremely 2001;103:1967-1971.
effective in selected patients. In this regard, 10. Urban P, Gershlick AH, Guagliumi G, et al. Safety
the transradial approach offers a tremendous of coronary sirolimus-eluting stents in daily clinical
advantage over the conventional femoral practice: one-year follow-up of the e-Cypher regis-
try. Circulation. 2006;113:1434-1441.
approach as hemostasis can be obtained while
11. Iakovou I, Schmidt T, Bonizzoni E, et al. Incidence,
the patient is already ambulatory. As hemo- predictors, and outcome of thrombosis after suc-
stasis is usually completed within 2 hours of cessful implantation of drug-eluting stents. JAMA.
radial access, it remains prudent to have an 2005; 293:2126-2130.
observation period of 4 to 6 hours to detect 12. Mann T, Cowper PA, Peterson ED, et al. Transradial
coronary stenting: comparison with femoral ac-
any severe complications prior to hospital
cess closed with an arterial suture device. Catheter
discharge. Because a recent survey revealed Cardiovasc Interv. 2000;49:150-156.
that less than 50% of radial operators in the 13. Kiemeneij F, Laarman GJ. Percutaneous transradial
world discharge patients the same day of the artery approach for coronary stent implantation.
procedure,35 several nonmedical issues and Cathet Cardiovasc Diagn. 1993;30:173-178.
14. Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of
obstacles remain to be resolved in order to
transradial access on quality of life and cost of car-
promote outpatient practice. diac catheterization: a randomized comparison. Am
Heart J. 1999;138:430-436.
15. Choussat R, Black A, Bossi I, et al. Vascular com-
plications and clinical outcome after coronary
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chapter 10
Sameer J. Khandhar, MD
Oscar C. Marroquin, MD
Suresh R. Mulukutla, MD
the Centers for Medicare & Medicaid Services more than 80% receive thienopyridine-based
(CMS) have included bleeding postcardiac therapy.14--15 In addition, revasculariza-
catheterization as an indicator of quality, and tion rates have increased to 70%-80% of
it may ultimately be linked with reimburse- STEMI and 50%-55% of NSTEMI patients.
ment for procedures (see Chapter 14). Thrombolytic use has significantly decreased
Transfemoral access historically has been over time, and even STEMI patients initially
the preferred method of access for PCI in the treated with those thrombolytics are more
United States over the past 30 years. Despite often referred for cardiac catheterization.
comfort with femoral access, it remains one Increasing revascularization and more
of the most common sites of bleeding. 3- 11 The aggressive utilization of antiplatelet and
relationship between bleeding complications antithrombotic agents over the past decade
and poor outcomes has now made preven- have led to an important reduction in
tion a priority. A major strategy to reduce cardiogenic shock, recurrent ischemia, and
bleeding is radial arterial access because it is a 30-day mortality rates from 10.5% to 7.8%
superficial artery that is easily compressible. (P < 0.001), after ACSY-15 We have clearly
Performing PCI by means of radial access can witnessed the benefits of modem-day therapy;
be challenging initially and require training however, strategies to identify patients at risk
and experience in the nonacute setting to gain of bleeding and to reduce their risk are critical.
proficiency. However, ACS patients have a
higher risk of bleeding, and therefore, despite
the technical challenges, performing PCI Transradial Access in ACS
by means of the radial artery may improve As revascularization rates have grown, the
outcomes. Given the potential benefit of majority of cases worldwide (80%) and in
radial access in ACS, considerable research has the United States (98%) continue to be
been done to answer concerns of whether the performed via femoral access. 1s.-17 There is
radial approach can be performed safely and great variability in radial access use between
effectively. Specifically, these studies address countries and regions, with Japan and France
whether equal rates of success can be achieved performing the highest percentage at 60% and
while effectively reducing major adverse 55%, respectivelyP The use of radial access
cardiac events (MACE) without a delay in has grown recently, albeit slowly, especially in
door-to-balloon times or need for crossover to the United States. It is also important to note
femoral access. that these numbers are for all coronary inter-
This chapter is dedicated to reviewing ventions, and reports show lower usage rates
(1) the procedural component of performing in ACS patients despite potentially having
radial catheterizations in the ACS setting, a greater benefit in this group. The reason
(2) the harmful effects of bleeding, and for slow adaptation to radial access revolves
(3) the role of radial access in acute coronary around the fact that most interventionalists
syndromes. and laboratory personnel are trained and
comfortable with femoral access. Only lately
has there been a focus in fellowship training
to teach radial artery access, and most recently
. TRENDS IN ACS MANAGEMENT even simulation-based learning has been
It is currently estimated that there are about developed specifically for this purpose.
1.1 million hospitalizations a year in the
United States for ACS, and between 29% and
48% of these are for STEMI. 12 This is despite
a decline in the overall number of Mis in the
• PROCEDURAL ASPECTS
past decade due to advancements in medical In this section, we will review techniques
therapy. and recommendations for use of transradial
More than 90% of patients presenting access (TRA) in coronary interventions for
with ACS now receive the combination of ACS. Detailed descriptions of the technique
aspirin and at least 1 anticoagulant, and are described in earlier chapters, and from
chapter 10 Transradial Access for PCI in Acute Myocardial Infarction • 97
a procedural standpoint, many aspects of non-access site bleeding, though further data
performing PCI by means of radial access are needed to define the potential benefit and
for ACS are similar to the elective setting. cost-effectiveness of this strategy.
Conversely, performing PCI in this setting Please refer to Chapter 5 for the combi-
can be more challenging and carry greater risk nation of medications to prevent spasm
than in an elective case. Rapid and successful and radial artery thrombosis. Intra-arterial
revascularization is essential, and therefore nitroglycerin and calcium channel blockers
it is prudent to be comfortable and proficient should be used cautiously in patients with low
with TRA prior to attempting its use for ACS. blood pressures or in cardiogenic shock due to
Studies have shown that there is a learning their ACS as this can worsen hypotension. At
curve with TRA, and we recommend that the conclusion of the case, the sheath should
operators be proficient with TRA in the elec- be removed, and a hemostasis device of choice
tive setting prior to attempting TRA in ACS should be placed.
patients and particularly in STEM I patients.
There is no formal training requirement,
but based on studies, at least 50 cases are Technique
required for proficiency. For most operators, When the patient arrives emergently for PCI
performing 50-100 cases appears to signifi- in the ACS setting, we quickly obtain consent
cantly increase success rates to 98% while and transfer the patient to the catheterization
decreasing procedure times, contrast use, table. Usually preparing the arm for a radial
and radiation exposure. 18- 21 (See Chapter 13 approach can be done simultaneously as the
on the learning curve for TRA.) ACS patients patient, the equipment, and the catheteriza-
stand to benefit the most, but these are also tion lab are being readied. Radial arterial
the patients at highest risk. Operators should access can be obtained once the patient's arm
feel totally comfortable with all aspects of the is sterilized, even before the drapes over the
technique prior to utilizing in this high-risk rest of the body are placed. We do recommend
cohort. also sterilizing and preparing the femoral
In the ACS setting, it is imperative that the region in the event that need for crossover or
operator and the staff are comfortable with additional mechanical assistance is required.
radial access as the RIVAL trial demonstrated Choice of right or left radial artery is based
that centers with the highest radial volumes on the discretion of the performing physician
achieved the best outcomes. 22 Just as it is and patient preference as both have similar
important for the operator to be well trained, success rates and procedural times.26 Once
it is crucial that the staff be trained with radial access is obtained, we usually reposition the
access cases prior to use in ACS. arm next to the patient's body and begin the
procedure. Most PCI equipment including
aspiration catheters, balloons, and stents
Medication and Anticoagulation will fit through a 6-Fr system; therefore,
Regional practices for anticoagulation vary we recommend placing a 6-Fr radial sheath
greatly when treating ACS. We recommend as the initial sheath in acute MI patients.
that once a patient is identified as having ACS, This avoids complications related to sheath
aspirin, a thienopyridine, and an antithrom- exchange especially given that less than 10%
botic be administered in conjunction with of PCis worldwide are performed with a 5-Fr
ACC/AHA guidelines. 1 - 2 Forms of antithrom- system.27 It is operator choice whether to start
botics supported by the ACC/AHA include with diagnostic catheters or to start with a
unfractionated heparin, low-molecular-weight guiding catheter appropriate for the suspected
heparin, and bivalirudin. Bivalirudin in the infarct artery.
ACUI1Yl3 - 24 and HORIZONS-AMF5 trials In a worldwide survey, the Judkins Right
was associated with a decrease in bleeding guiding catheter was preferred for right
and improvement in outcomes. The concept coronary artery (RCA) interventions, and
of combing radial access with bivalirudin is extra backup guiding catheters such as the
very appealing to prevent both access site and EBU 3.5 (Medtronic, Minneapolis, MN)
98 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
or XB 3.5 (Cordis, Bridgewater, NJ) were Radial access should not be dismissed
preferred for the left coronary system. 27 The in ACS, as its benefit may be larger in this
lkari guides (Terumo, Somerset, NJ) are population that is at higher risk for bleeding.
also gaining popularity and offer additional However, prior to attempting radial access
backup support compared to the Judkins for PCI in the ACS setting, it is important
catheters. Once proper guide position is that operators and staff be comfortable and
obtained, the remainder of the procedure proficient with this means of access.
is similar compared to the femoral route. It
is important when performing PCI through
radial access to be flexible in choice of guiding
catheters and to adapt to allow for the best fit
• BLEEDING IN ACS
and support. Familiarity with various guiding The principal benefits of TRA revolve around
catheters allows the operator to select the reducing bleeding, so it is important to
best guide for a particular clinical scenario. understand the consequences of bleeding
Gaining experience with various guides during when it occurs in this setting. In this section,
non-ACS cases when time to reperfusion is we will review bleeding specifically in the ACS
not as critical allows one to gain comfort prior setting, whereas other chapters discuss in
to attempting radial access in ACS. detail bleeding complications during and after
We advocate for also sterilizing and PCI. Historically, the cardiology community
preparing the groin for femoral arterial access has focused its efforts on strategies to reduce
up front in the event crossover or additional mortality associated with ACS by lowering
access is necessary. Especially as operators ischemic events, and until recently, little
are gaining experience with TRA, having the attention was paid to bleeding and its poten-
femoral artery accessible allows for quick tial negative role in outcomes.
conversion if necessary. Up to 10% of early The notion that bleeding or need for
cases may require crossover, and if the femoral blood transfusion after PCI was associated
site is already prepared and draped, additional with poor outcomes including death was
time is not wasted. Also, in the event of hemo- starting to be accepted based on registry and
dynamic instability, having the femoral artery retrospective data; however, OASIS-5 was the
site easily accessible can allow for prompt first randomized study to support this.29 This
insertion of additional support such as brought scientific and public attention to the
intra-aortic balloon pump, Impella (Abiomed, detrimental effects of bleeding and began the
Danvers, MA), TandemHeart (CardiacAssist, search for bleeding avoidance strategies.
Pittsburgh, PA), or extra-corporeal membrane Contemporary studies have now clearly
oxygenation (ECM0).28 Use of femoral shown that bleeding and transfusions after
arteries for mechanical support in conjunc- PC! for ACS are associated with an increase
tion with radial access for PCI also has several in mortality and other MACE such as repeat
benefits in the setting of cardiogenic shock. ischemic events, stent thrombosis, and
First, in the event of acute collapse, guide stroke. 30-31 The effect of bleeding and anemia
catheter and wire position does not have on outcomes is complex and multifactorial.
to be sacrificed for arterial access to insert Despite advances in our understanding of
additional support. And second, the most the harm associated with bleeding, further
common complications with mechanical research is still warranted on the true inci-
support are access site related and from poor dence of bleeding, the significance of the site
distal extremity perfusion. When mechanical of bleeding, and mechanistically how bleeding
support and PC! are performed by the femoral leads to adverse outcomes.
route, both lower extremities are at jeopardy Comparing bleeding events between trials
for complications related to poor perfusion, is difficult because important variables differ
whereas utilizing the radial artery for the PCI significantly. These include clinical presenta-
component only puts llower extremity at risk tion for PCI (stable coronary artery disease,
for hypoperfusion and allows the operator to NSTEMI, or STEM!), choice of arterial access
choose the leg with better perfusion. site, anticoagulation strategy (antiplat elet
chapter 10 Transradial Access for PCI in Acute Myocardial Infarction • 99
and antithrombotic) being utilized, and patients are most susceptible to bleeding and
perhaps most importantly the definition of associated harmful consequences, a bleeding
bleeding. Despite attempts to control for these avoidance strategy such as TRA can be imple-
variables, comparing results between trials is mented to improve clinical outcomes.
difficult and may lead to error.
Periprocedural bleeding is in large part
related to access site and the anticoagula- Definitions of Bleeding
tion regimen utilized during the procedure. Table 10.1 summarizes the definition of
Of bleeding events, 30%-70% are related bleeding from various trials, and demon-
to femoral access site,3-11 although bleeding strates how some are based on clinical events
does occur at other sites such as the gastro- while others are based on lab values. Again,
intestinal tract, genitourinary system, and these differences make the comparison of
intracranial. Causality of femoral access site definitions difficult. Combining data from
bleeding and death has not been finnly estab- various trials and implementing a single
lished. However, bleeding does lead to patient definition further support that all levels of
dissatisfaction and morbidity, and may affect bleeding are associated with mortality, 30•32 and
mortality. Patients certainly find radial access consistent across studies is that the more
more comfortable and prefer this method of severe the bleeding, the greater the risk of
access. 22 Ultimately, if we can identify which death as seen in Figure 10.1. However, there
OASIS-5 DEFINTION29
Minor Clinically significant but does not meet definition of major, and leads to interruption of study drug for
> 24 hours, surgical intervention, or transfusion of 1 unit of PRBC
Major Fatal, symptomatic ICH, RP, intraocular leading to vision loss, decrease in Hgb > 3 g/dl adjusted for
transfusion, or requiring transfusion of>2 units
TIMI DEFINITION 85
Minimal Any sign of bleeding but decrease in Hgb of< 3 g/dl
Minor Observed bleeding with decrease in Hgb 3-5 g/dl, unobserved bleeding but decrease in
Hgb > 4 g/dl, hematuria, or hematemesis
Major Decrease in Hgb > 5 g/dl or any ICH
16
NCDR Hematoma> 10 em, RP, Gl, GU, transfusion, prolonged hospital stay due to bleed or
Hgb drop > 3 g/dL
RIVAL-major22 Fatal bleed, transfusion > 2 units, hypotension requiring inotropes, surgical intervention, disabling
sequelae, ICH, intraocular
ICH: intracranial bleed, Hgb: hemoglobin g/dl. RP: retroperitoneal bleed, Gl: gastrointestinal bleed, GU: genitourinary bleed.
100 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
0.8.
0.7:;.
Days to Death
remains to be a consensus among trials for bleeding, making comparison of trials more
the optimal definition of bleeding that is most meaningful.
predictive and representative of outcomes.
Fortunately, the Academic Research
Consortium created a committee with the Incidences of Bleeding in ACS
task to develop a standard bleeding scale to Relying on trials and registries to estimate the
be utilized in future trials. This committee, true incidence of bleeding in ACS is difficult
named the Bleeding Academic Research given the influence of multiple confounders.
Consortium (BARC), has created a scale Key confounders include definition of
with 5 levels of bleeding, which are listed in bleeding, trial design, and anticoagulation
Table 10.2. The final definitions of bleeding strategy being studied. Because of these
will be published once the scale is validated issues, the true incidence of bleeding after PCI
and will soon provide a universal definition of for ACS ranges between 1% and 10%. 3•24-25•33-37
Table 10.2 Bleeding Definition from the Bleeding Academic Research Consortium (BARC).
TypeO No bleeding
Type 1 Bleeding that does not require action and requires no further testing or treatment
Type2 Any overt sign of bleeding (but notType 3-5) that requires evaluation (visit to health care
professional or diagnostic testing), requires intervention to stop bleeding (surgical treatment,
medical treatment, altering of medications), or leads to change in routine care (require
hospitalization, prolong hospital stay, or increase level of care)
Type3
Type 3a Overt bleeding with Hgb drop between 3 and 5 g/dl, tamponade, bleeding requiring surgical or
percutaneous intervention
Type 3b Need for transfusion or overt bleeding with drop in hemoglobin of> 5 g/dl, tamponade, or bleeding
requiring surgical/percutaneous intervention or inotropes
Type 3c Intracranial bleed, intraocular bleed
Type4 CABG-related bleeding
TypeS Fatal bleeding (bleeding primary cause of death)
loss. Acute blood loss can lead to hypotension bleed, retroperitoneal bleed, hematocrit drop
and shock, and worsen coronary ischemia. > 12%, and any red blood cell transfusion when
In addition, acute blood loss will activate the baseline hematocrit was either> 28% or< 28%
adrenergic system, therefore increase oxygen with a witnessed bleed. The algorithm devel-
demand, and further worsen myocardial oped is based on 8 clinical factors (baseline
ischemia. 40 When bleeding occurs in areas that hematocrit, creatinine clearance, heart rate,
cannot accommodate this large volume, such sex, signs of congestive heart failure [CHF],
as intracranial, the mass effect can directly prior vascular disease, diabetes, and systolic
lead to death. blood pressure), and the scoring system can be
Patients who experience bleeding or found at www.crusadebleedingscore.org. The
present with anemia are more likely to have sum of these points predicts major in-hospital
proven beneficial therapies withheld. Trials bleeding as defined above, and scores are
show that 13%-23% of patients presenting graded from very low risk to very high risk43 as
with ACS have baseline anemia, and these seen in Figure 10.2.
patients are treated less aggressively. They The NCDR developed another risk score
have lower rates of aspirin, clopidogrel, from its database of 300,000 PCI procedures
and heparin use combined with higher performed at more than 400 US hospitals.
rates of blood transfusion, all of which are Bleeding was defined as femoral hematoma
associated with higher rates of short-term of> 10 em, retroperitoneal bleed, gastrointes-
mortality. 37.41.42 Even medical therapies such tinal bleed, genitourinary bleed, blood trans-
as beta-blocker and angiotensin-renin-aldo- fusion, prolonged hospital stay, or drop in
sterone inhibitors that do not cause bleeding hemoglobin > 3 g/dL. Although this risk score
are more likely to be withheld. These agents wasn't created in ACS patients, calibration
blunt the negative effects of the adrenergic plots testing the bleeding risk score in ACS
and neurohormonal systems that are activated patients were performed and showed that the
during ACS, and withholding can accelerate model was in fact predictive in this setting.
negative left ventricular remodeling. This scoring system assigns a point value for
Long-Term Effects of Bleeding. Bleeding 9 clinical variables (ACS type, angina, shock,
and anemia may activate clotting factors and sex, previous heart failure, previous PCI, New
platelet aggregation, and promote erythro- York Heart Association Class IV heart failure,
poietin release. These adaptive mechanisms peripheral vascular disease, and estimated
were meant to prevent further blood loss and glomerular filtration rate) and generates a risk
be protective. However, in the ACS setting, score based on the sum of these44 as seen in
this creates a relative hypercoagulable state Figure 10.3.
that can worsen ischemia and lead to future Both of these scoring systems are easy
myocardial infarctions. These effects likely last to use and allow for quick and accurate risk
beyond the acute phase, and may explain why assessment for bleeding. Therefore, routine
patients are at increased risk for MACE up to a use of these bleeding calculators prior to PCI
year after the index event. may allow for better planning and implemen-
tation of bleeding reduction strategies.
Predicting Bleeding
Bleeding Avoidance Strategies
Identifying patients prior to PCI at increased
risk of bleeding is crucial so that bleeding As the negative effects of bleeding are better
reduction strategies can be implanted. Clinical recognized, ways to improve outcomes have
risk scores assigning point values have been been sought. The evolution of medical therapy
developed from 2 large registries and validated over the past decade has led to a reduction in
to predict bleeding in the ACS setting. unfractionated heparin and glycoprotein Ilb/
The CRUSADE bleeding score was created Ilia use, with an increase in LMWH, bivali-
from a registry of 71,000 real-world patients rudin, and thienopyridine use. 13- 14•33 Despite
and validated in nearly 18,000 patients with the potential benefits of new anticoagulation
NSTEMI. Bleeding was defined as intracranial strategies, use remains low even in groups
chapter 10 Transradial Access for PCI in Acute Myocardial Infarction • 103
50 .
45
40 . /
~ 35 .
/
:c /
30 .
ftl
..c
...0
11. r.~te :medi te-.:isk / - - probability of major bleed
25
C1
Low
1::
:ccu
~
20 . risJC r'-.19 7
"tr" /
.,., ~
a:! 15
10
0
~ ----- '
0 10 20 30 40 50 60 70 80 90 100
Figure 10.2 Probability of major bleeding based on CRUSADE bleeding risk calculator.43
8 -
High
7
risk
-
6 -
5
Low risk Intermediate risk
-
4 f-- -
''6*
Cl
1: 3
L
r-- .- f-- - • Bleeding%
Ill
Ill
iii 2 r-- f-- r-- f-- -
1
0 1"""1
011
I I
213
II
415
II
6fl
1
819
r n- - r- -- r- r-- r-
'
10/11 12113 14/15 1 6/17 18119 20/21 22123 >24
-
Figure 10.3 Probability of major bleeding based on NCDR bleeding risk calculator.44
Bivalirudin and ACS. Most recently, The NCDR found that both bivalirudin
bivalirudin, a direct thrombin inhibitor, has and VCD were associated with lower rates of
gained popularity as studies showed its use bleeding, and the combination of the 2 was
led to lower rates of bleeding in both NSTEMI even more beneficial. This was especially true
and STEM! settings. The ACUITY trial, in the group with a predicted risk of bleeding
which enrolled NSTEMI patients, found that greater than 3% based on the NCDR calcu-
bivalirudin alone was noninferior in rates lator, where the number needed to treat was
of composite ischemic endpoints, but had only 33 patients to prevent 1 episode of major
statistically lower rates of bleeding (3.0% vs. bleeding. However, this higher-risk group was
5.7%, P < 0.001) compared to heparin and found to be the least likely to receive a VCD,
glycoprotein IIb/IIIa inhibitors. 25 providing more reason to identify and target
Of the 13,819 patients enrolled in the strategies toward this higher-risk group. 44
ACUITY trial, only 6.2% underwent PCI by Similarly, the authors from the ACUITY
TRA, and this was based on physician and trial found VCD reduced both access site
patient preference. In a retrospective review bleeding (ASB) (2.5% vs. 3.3%, P = 0.01)
of this population, there was no difference in and ACUITY major non-CABG (coronary
ischemic outcomes between radial and femoral artery bypass graft) bleeding (3.9% vs. 5.3%,
access at 30 days (8.1% vs. 7.5%, P =0.18) or P = 0.0003). The combination of a VCD and
at 1 year, although the radial access group had bivalirudin was associated with the least
fewer major bleeding events (3.0% vs. 4.8%, amount of bleeding (0.7%).47
P =0.03). This is likely because bivalirudin Again, there is limited head-to-head data
lowered access site bleeding in the femoral on TRA versus femoral access with bivalirudin,
group and non-access site bleeding in both VCD, or both. All are acceptable strategies to
groups.23 lower risk of bleeding, and further studies are
The HORIZONS-AMI trial showed warranted to determine the most beneficial
bivalirudin lowered 30-day adverse event rates combination. Perhaps the most important
(death, reinfarction, target-vessel revascu- message from these trials is that patients at
larization, stroke, and major bleeding) from the highest risk of bleeding are not receiving
12.1% to 9.2% in STEMI patients compared to these strategies and need to be identified and
heparin plus glycoprotein IIb/IIIa inhibitors. targeted.
This was driven primarily by a significant
reduction in bleeding from 9.6% to 5.9% when
defined by TIMI criteria and from 5.6% to • STUDIES COMPARING RADIAL WITH
3.5% by the GUSTO definition.25 This study
further supported the notion that bleeding
FEMORAL ACCESS
was associated with poor outcomes. Current treatment for ACS involves intensive
Bivalirudin is clearly beneficial at lowering anticoagulation often combined with an early
bleeding events in the ACS setting and is now invasive strategy. This approach has dearly
a Class I recommendation for use in patients lowered adverse ischemic events, however,
at increased risk of bleeding. 1•2 Further studies at the expense of bleeding and its associ-
and randomized trials are needed to assess ated poor outcomes. Radial access nearly
if radial access and bivalirudin together are eliminates access site bleeding and therefore
superior to either alone for reducing bleeding has been felt to be of greatest benefit in ACS
events. patients who are at higher risk for bleeding.
Vascular Closure Devices for Femoral The radial artery is a superficial artery that
Access in ACS. Vascular closure devices can be easily compressed, nearly eliminating
(VCDs) have gained tremendous popularity large hemodynamically significant bleeds. The
with both physicians and patients given their concern with radial access has been whether
ease in placing and greater patient comfort. it can be performed with equal efficacy in the
However, their safety and role in reducing ACS setting as femoral access. Specifically,
bleeding have not been dear and previously can TRA be successfully utilized without an
have even been thought to be harmful. 45 •46 increase in procedure/door-to-balloon times
chapter 10 Transradial Access for PCI in Acute Myocardial Infarction • 105
and need for crossover to femoral access, all Several years later, the TEMPURA trial
while reducing MACE and bleeding events? randomized 157 patients with STEMI to radial
Retrospective, observational studies, and or femoral access in Japan. This trial was
now large multicenter international random- powered to prove equivalence for in-hospital
ized trials, have attempted to answer these MACE between TRA and TFA. The average
questions. The number of studies and the age was 67 years, 82% were male, and
amount of coverage this topic has received in thrombolytics and Ilb/IIIa inhibitors were not
recent years point to how important an issue used in this trial. Successful reperfusion of the
this has become. In this section, we will review infarct-related artery was achieved in> 95%
key trials and the data on transradial success, of patients in both groups (P = 0.94), and no
door-to-balloon times, and outcomes with patients in the TRA group required crossover
radial access. to femoral access. Surprisingly, the TRA group
was even associated with a shorter procedural
time by 6 minutes (P =0.033).50
Transradial Procedural Success In the FARMI trial, 114 patients with
Multiple observational studies have compared STEMI were randomized to either femoral
the feasibility of TRAin the setting of ACS with access or radial access with 5-Fr interventional
femoral access. Prompt revascularization in equipment being utilized. Greater than 90% of
this setting is of the utmost importance and patients in both groups had successful reper-
requires a high rate of success. Early observa- fusion (P =0.43); however, 12% of patients in
tional studies suggested that TRA was feasible the TRA group required crossover to femoral
in the ACS setting as summarized in Table 10.3. access due to technical difficulties compared
Most of these series were small and nonran- with 1.8% of femoral patients requiring
domized, were conducted at single centers, and crossover to radial access (P =0.03).51
only involved experienced operators, allowing In a single-center study from Poland,
selection bias and other confounders to poten- 100 patients with STEMI were randomized to
tially affect outcomes. Despite limitations, femoral or radial access. In the radial group,
these trials demonstrated that 88% success 8% of patients were unable to have PCI
rates with acceptable low levels of crossover to performed via the radial approach (1 due to
femoral access could be achieved. excessive tortuosity and 3 due to abnormal
Several randomized trials provide further Allen's test), and procedural success defined as
insight into the role and benefits of radial TIMI III Flow at the completion of the proce-
access in ACS and are summarized below and dure was similar between groups (88% vs.
in Table 10.4.48 The first and only multicenter 92%, p > 0.05).52
international trial to date on this issue was The results of the above-mentioned trials
recently published and will therefore be support radial access as feasible and perhaps
discussed separately. 22 even superior to femoral access for ACS
Shortly after Kiemeneij et al first described patients; however, a large randomized inter-
radial artery use for PCI, the first randomized national trial had been lacking. In response
clinical trial (RCT) in ACS was conducted. to this, the RIVAL trial was designed to help
In this single-center trial, 142 consecutive compare outcomes based on access site.
patients were randomized to femoral or radial RIVAL Study. The trial was designed
access, and only 2 experienced operators to compare femoral and radial access in the
performed the radial cases. Although this ACS setting, began as a substudy of the
was an ACS trial, more than SO% of patients CURRENT-OASIS 7 study,68 and continued
had unstable angina, and only 14% were as an independent trial after its completion.
truly STEMI patients. Also, 20% of patients Patients were eligible for enrollment if their
received thrombolytics and therefore under- presenting diagnosis was either STEMI or
went rescue PCI. Success rates were high NSTEMI and if they underwent an invasive
(96%) with 12% of patients crossing over to strategy. Patients had to be suitable candi-
femoral access (8% due to negative Allen's test dates for either access route, meaning they
and 4% due to access failure). 49 had to have palpable radial pulse with normal
Table 10.3 Summary of Observational Studies. 1 ..
i
•g
m!m
I
radial
#
Patients Patients Age
femoral rs Male%
llblllla
use%
Antithrombotic
imen ~Gtmnt~J,Ii@}l
Radial Femoral
Radial
bleeding
I .
'
• '
'
::::l
"'c._
QJ
I~
Kim 53 - -
Mulukutla54 Aspirin+ clopidogrel/ -
"'
Y1
~
n
Louvard-Site N 5 180 889 60 80 6.1 Hgb drop> 3g 98 97 0 2 1 ::J
::::l
Louvard-Site 855 87 58 59 79 79.3 Hgb drop> 3 g 96 98 0 7 3.5 15'
t:
ro
Valsecchi 56
163 563 61.5 77 - 96.9 95.5 0 1.2 1.2 "'
Q'
Philippe57 64 55 59.1 75 100 Aspirin/clopidogrel/ 0 5.5 0 0
iii'
abcximab lO
::::l
0
Diaz de Ia Llera 58 1 103 I 59 I 55 190 I 68 I Transfusion, hematoma pro- 96.1 94.9 0 8.5 4.6 ~
n·
)>
PancholyM 1 109 1204 166.4 161 1 98 I Heparin Transfusion, hematoma, 89 91 0.9 9.8
pseudoa neu rysm,
bleed
WeaverM 11MI major 4.8
26
Larsen Heparin (97%) or bivalirudin 0.7
(3%)
llblllla: glycoprotein lib/lila inhibitor, Hgb: hemoglobin g/dL. CABG: coronary artery bypass grafting, LMWH: low-molecular-weight heparin, llMI: thrombolysis in myocardial infarction.
Table 10.4 Summary of Randomized Clinical Trials.
~
Mann 48
#
radial
I 65
#
patients patients Age in
femoral
177
rs
I 62
%male
I 64
Antithrombotic
imen
I Aspirin, heparin,
+/-lib/lila
II
113 --
1-
I I
I 96 I 96 10
Radial
blelding
events
Femoral
blelding
events
14 15
Femoral
crossover MACE
need radial
10 •
10
l..
RADIAL-AMI66 I 25 I 25 I ss I 88 I Aspirin/clopidogrel,
heparin, lib/lila
94 ICH, RP, Hgb drop
> 5 g/dl, transfusion
87 88 0 0 4 0 2
..
Q
FARMI51 I s? I s? l s9 l s4 I Aspirin, heparin/ 100 TIM I 91 97 5.3 5.3 12.3 5.3 5.3 g
LMWH, lib/lila ::;l
"'
iil
Lj67 I 184 I 186 I 56 I 67 I ASNclopidogrel 0 Hematoma, A-V fistula, 95 94 1.1 3.8 1.6 - - a_
~
and heparin pseudoaneurysm,
spasm ~
h1
RADIAMI52 I so I so 160 I 68 I Heparin +/-lib/lila
inhibitor
143 I Fatal, transfusion,
operation, ICH, Hgb
88 92 6 14 8 2 4 "'
"'
Q'
""Cl
drop> 3 g/dl 0
s
RIVAL22 I 3,507 13,514 162 174 I Discretion of
physician
125 I ACUITY 95 95 1.9 4.5* 7 3.7 4 )>
n
c
.....
rD
•..
....Q
108 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Allen's test. Operators had to perform at least did require more frequent crossover. It is
50 radial interventions in the previous year to important to stress again that the interven-
be eligible to participate as a means to ensure tionalists performing radial artery access in
competency. Patients were then randomized these trials were proficient in this technique,
1:1 to either radial or femoral access. Choices and once one is comfortable with radial access,
of antithrombotic medications and VCDs were data support its use in the ACS setting. (The
at the discretion of the performing physician. high crossover rate to femoral suggests that
The primary outcome of this trial was there were some inexperienced operators.
the combined endpoint of death, MI, or Furthermore, it is also likely that if the change
non-CABG-related major bleeding within were from right to left radial, there would be
30 days. Major bleeding was defined as any of a lower crossover rate. This is clearly more
the following: mortality, transfusion of 2 or cumbersome than changing from right to left
more units of blood, hypotension requiring femoral, particularly in an emergency setting.)
inotropes or surgery, disabling sequelae, symp-
tomatic intracranial hemorrhage, or intraocular
leading to vision loss. Post hoc analysis was
Transradial Procedural Times and
also performed with the ACUIJY31 definition Door-to-Balloon Times
of bleeding. Initial sample size was estimated The initial hesitation with TRA for acute
to be 4,000 patients based on 80% power for myocardial infarctions, especially STEMI,
the detection of a 25% relative risk reduction was the concern that it would lead to a
with radial access assuming a 10% rate of the delay in door-to-balloon (D2B) times. In
primary outcome. However, during the trial, fact, early studies did show that TRA was
the actual event rate was much lower, so a new associated with an average increase in D2B
sample size of 7,000 was recalculated based on times of 6 minutes, which was primarily due
an observed rate of 6% in the femoral group. to increased time in obtaining access. 51- 52•66
In total, 7,021 patients (3,507 random- However, subsequent studies (Figures
ized to radial and 3,514 to femoral) were 10.4 and 10.5) have shown that TRA can be
enrolled from 158 hospitals in 32 countries, performed with comparable procedural and
with only 23% being from North America. door-to-balloon times. In almost all trials,
The average age was 62 years, 73% were radial access was only attempted by those
male, and indication for PCI was STEMI proficient in this method, again highlighting
(28%), NSTEMI (27%), and unstable angina the importance of competency with radial
(45%). Antithrombotic and antiplatelet use access prior to utilizing in ACS patients where
were similar between groups: aspirin (99%), procedural time is of utmost importance.
dopidogrel (96%), LMWH (52%), glycoprotein
IIb/IIIa inhibitors (25%), heparin (21 %),
Outcomes and Bleeding Events Associated
fondaparinux (11%), and bivalirudin (2.6%).
After randomization, 99.8% underwent cath- with Transradial Access
eterization; however, only 66% had a stent The above trials show similar success rates
implanted, and almost 9% underwent CABG. without negatively affecting D2B times in
PCI success rates were similar between ACS. This section will focus on the effect
the groups (95.4% vs. 95.2%), but the radial of radial access on actual outcomes and
group required significantly more crossover bleeding events. Observational studies are
to femoral access (7.6% vs. 2.0%, P < 0.0001). best designed to look at radial success rates,
Reasons for crossover from radial to femoral procedural times, and frequency for crossover
access included radial spasm, radial artery loop, to femoral access. However, several of these
and subclavian tortuosity. Reasons for cross- studies also attempted to compare hard
over from femoral to radial access included iliac endpoints such as death and MACE between
tortuosity or peripheral vascular disease. 22 access methods. One has to be careful drawing
Cumulatively, these trials have shown conclusions on these hard endpoints due to
similar success rates between radial and the nonrandomized design and significant
femoral access; however, the radial group possibility of selection bias. The data from
chapter 10 Transradial Access for PCI in Acute Myocardial Infarction • 109
100 ~"'~28-fimes--
90
I
80 L *
Procedure Time
70 - ,--
60 1- - -
...."'::;,cu ____:!.
50 f- I-- -
~
r::::
90
80
70
60
50
• femoral time
40
....Ill"'::;, • radial time
r::::
~ 30
20
10
0
Saito {50) RADIAL-AMI FARMI {51) Li (67) RADIAMI (52) RIVAL (22)
(66)
these observational studies were useful and statistically no different between groups. PCI
provided the framework for further random- procedural time and hospital length of stay
ized trials better designed to study outcomes were similar between groups, but radial access
of death, stroke, and MACE. was associated with greater fluoroscopy time
Table 10.4 summarizes the randomized (9.8 minutes vs. 8.0 minutes, P < 0.0001).
clinical trials comparing radial access with The unanticipated aspect of this trial was
femoral access. Mann et al conducted the first the lower-than-expected rates of bleeding
randomized trial comparing radial and femoral and lack of correlation between bleeding and
access and found that no patients in either hard endpoints. Bleeding rates were compared
group died, required emergent CABG, or had between the groups using the RIVAL, TIMI,
a procedural MI. However, 4% of patients in and ACUITY definitions because no standard
the femoral group had an access site-related definition exists. Comparing groups utilizing
hematoma prolonging hospital stay. Due to the RIVAL and TIMI definitions found no
this, the radial group had a shorter hospital difference; however, the femoral access group
length of stay (3.0 vs. 4.5 days, P < 0.01) did have higher rates of vascular complica-
and lower total hospital costs ($20,4 76 vs. tions (Table 10.5). The ACUITY definition
$23,389, p < 0.01).49 of bleeding incorporates access site bleeding
The TEMPURA trial found that both complications, and with this definition, radial
in-hospital (5.2% vs. 8.3%, P = 0.444) and access was superior to femoral access (1.9%
90-day MACE (17.8% vs. 24.2%, P = 0.351) vs. 4.5%, P < .0001). It is also important to
were statistically no different between groups. note that in the femoral group, major access
Major bleeding occurred in 3% of patients in site bleeding occurred in 0.5% of patients
the femoral access group and 0% in the TRA while major bleeding not related to access site
group.5° Brasselet et al found that radial access occurred in 1.6% of patients.
was associated with decreased time to ambula- There was no significant difference between
tion and decreased peripheral arterial compli- radial access and femoral access in the prespec-
cations (hematomas), but TIMI minor and ified subgroups of age, sex, BMI, or radial
major bleeding were statistically no different volume by operator. There was a significant
between groups. 51 Similarly, the RADIAMI reduction in the primary outcome with radial
trial found that in-hospital outcomes including artery access in the subgroups of patients
mortality, stroke, and MI were alike between presenting with STEMI and who underwent
groups with radial access trending toward PCI at centers with the highest radial artery
fewer episodes of major bleeding.52 volume. This further supports the idea that
RIVAL Study. The primary outcome of outcomes are superior in centers with high
death, MI, stroke, and non-CABG-related radial access use where staff and physicians
major bleeding occurred in 3.7% of patients in have higher proficiency and comfort.
the radial group and 4.0% in the femoral group Perhaps the most striking result of the
(P = 0.50). Secondary outcomes at 30 days of trial was the benefit in the STEMI subgroup
death, MI, stroke, and the combination were in which radial access reduced 30-day MACE
(3.1% vs. 5.2%, HR 0.60 [95% CI 0.38-0.94], indications. This meta-analysis has a broad
P = 0.026), and death (1.3% vs. 3.2%, HR inclusion and may underestimate the
0.39 [95% CI 0.20-0.76], P= 0.006). Major potential benefit of radial access for acute
non-CABG bleeding was similar between the Mls given that these patients are at higher
groups, but major vascular complications were risk of bleeding compared to elective PCI.
significantly lower with radial access. These authors combined trials to include
This trial concludes that there is no differ- nearly 11,000 patients and found a signifi-
ence between radial and femoral access in cant benefit with radial access in reducing
terms of the primary outcome of death/Mil non-CABG major bleeding, transfusions,
stroke/major bleeding in all patients with ACS. and major vascular access site complications
However, it does support the idea that radial (Figure 10.6). There was, however, no benefit
artery access can be performed with equal in reducing death, MI, or stroke except when
success rates, without prolonging the total performed by radial experts at the highest-
procedure time, and with lower vascular access tertile radial volume centers. This again
site complications. Specifically in patients stresses the importance of proficiency in this
presenting with STEMI and to centers with technique by both the operator and catheter-
the highest radial volume, radial artery access ization laboratory staff and stresses how it
was associated with lower rates of death.22 affects outcomes. 22
The meta-analysis by Vorobcsuk et al only
included patients undergoing PCI for ACS.
Meta-Analyses A total of 3,324 patients from 12 observa-
Individually, the above trials did not show tional and randomized trials were included,
a benefit in mortality with radial access, and the 3 primary outcomes looked at were
and therefore data have been pooled into death, MACE, and bleeding (Figures 10.7A-C).
meta-analyses in an attempt to increase Based on pooled data, radial access was associ-
power. Two meta-analyses have been ated with a reduction in death (2.59% vs.
performed comparing radial access to femoral 3.18%, OR 0.54 [95% CI 0.33-0.86], P = 0.01),
access,22•69 and despite limitations of these MACE defined as death, Ml, or stroke (3.65%
meta-analyses, they do provide further insight vs. 6.55%, OR 0.56 [95% CI 0.39-0. 79],
into the benefits of radial access. P = 0.01), and major bleeding was reduced by
The first meta-analysis performed by 70% (0. 77% vs. 2.61% [95% CI 0.16-0.55],
the RNAL authors includes patients who P = 0.001). Radial access was associated with
underwent PCI for both elective and ACS shorter hospital stays and similar procedural
Major Vascular
access compilation
Death/MI/Strok.e
10,862
13,793
12,487
43/5,424
(0.8%)
70/6,776
(1.0%)
67/5,438
(1.2%)
211n.o11
(3.0%)
0.65 (0.44-Q.94)
0.35 (0.28-Q.44)
<0.000
1
0.170
.. ---
Death/MI/Strok.e 6,342 7613,346 10612,996 0.66 (0.48-Q.88) 0.005
(radial experts) (2.3%) (3.5%)
.. .
0.25 1.00 4.00
Favors Radial Favors Femoral
Figure 10.6 Forest plot from RIVAL trial meta-analysis.22 Source: Courtesy of Elsevier.
11 :Z • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
29
50
1,421
13
1 50 3.0%
480 28.5%
55
0.33 [0.01' 8.21]
0.45 [0.18, 1.13]
1,800 100.0% 0.54 [0.33, 0.86]
2007
2009
--•
Heterogeneity: Chi* = 1.57, df =9 (P = 1.00); F= 0% .
0.01 0.1 10 100
Test for overall effect: Z = 2.59 (P = 0.01 O)
Favors Radial Favors Femoral
Overall risk of death.
44
57
1
9
32
6
25 1.7%
132 12.3%
243 10.6%
57 6.1%
0.32 [0.01' 8.25]
0.52 [0.19, 1.37]
0.31 [0.07' 1.36]
1.00 [0.30, 3.31]
2005
2005
2007
2007
- ~
--•
RADIAMI 1 50 4 50 4.4% 0.23 [0.03, 2.18] 2007
YanZX 3 57 2 46 3.6% 0.80 [0.15, 4.14] 2008
Hetherington 5L 15 571 25 480 29.9% 0.49 [0.26, 0.94] 2009
0.005 0.1
• 10 200
Test for overall effect: Z =3.89 (P =0.0001)
Favors Radial Favors Femoral
Figure 10.7 Odds ratio for death (A), major adverse cardiac events (B), and bleeding (C) for transradial percutaneous
intervention versus femoral access.69 Source: Courtesy of Elsevier.
chapter 10 Transradial Access for PCI in Acute Myocardial Infarction • 113
times, but increased need for access site presenting for angiography at 4 European
crossover and fluoroscopic time. 69 centers to either femoral or radial access.
These meta-analyses further support a Operators were well experienced in both
trend toward a benefit in hard endpoints forms of access and were required to have
such as death and MACE with radial access, performed greater than 500 cases with each
especially in the ACS setting. This is especially form of access. The primary outcome included
true in the hands of proficient operators. any of the following vascular events: complica-
Despite combining multiple studies, these tion requiring surgical intervention, blood
meta-analyses are limited by the small transfusion, hemoglobin drop> 3 g/dL, distal
number of studies published on this topic. extremity ischemia, or delay in discharge
Other limitations of these meta-analyses due to bleeding. A total of 377 patients were
are the fact that several studies included are randomized (192 radial and 185 femoral);
observational studies, anticoagulation strate- however, only 10% of patients presented
gies varied greatly between trials, and some with an acute coronary syndrome/STEM!,
trials included rescue PCI after failed throm- making firm conclusions in this subgroup
bolytic therapy. Although further studies not possible. Both groups had high rates of
are warranted, these meta-analyses further success (95.8% vs. 96.6%) and equal need for
support the benefits of radial access. crossover (8.9% vs. 8.1 %). (This appears to be
a high rate of crossover particularly for experi-
enced operators. Frequently when an operator
fails from the right radial, the crossover is to
• GROUPS THAT MAY FURTHER femoral rather than to left radial. When there
BENEFIT FROM RADIAL ACCESS is failure from right femoral, frequently the
Certain groups of patients are at higher risk operator will switch to left femoral, and no
of bleeding following PCI in the ACS setting crossover is recorded. Nevertheless, the cross-
and therefore at higher risk for adverse over rate appears to be high for both groups.)
events. 33 Radial access is appealing in the However, radial artery access was associated
elderly, women, and those undergoing rescue with a reduction in the primary outcome of
PCI after failed thrombolytics as a strategy bleeding (0.5% vs. 7.5%, P = 0.0001). 73
to lower bleeding and improve outcomes. Subsequent randomized and observational
However, because these subgroups of patients trials have specifically looked at radial access
were not well represented in the above trials, for STEMI in the elderly. The next random-
the safety and efficacy of radial access are ized study assigned 103 patients over the
not clear. Therefore, small observational age of 65 with STEM! to either radial or
and randomized studies have specifically femoral access. All patients were pretreated
attempted to evaluate these subgroups. with aspirin and clopidogrel600 mg prior to
catheterization and received unfractionated
heparin and tirofi.ban during the procedure.
Elderly The average age was 70 years, and 74% were
Older patients are at increased risk of vascular male. Procedural success and total procedure
complications, bleeding, and poor outcomes time were similar between access site groups.
with PCI in the ACS setting.16•70•71 Therefore, Radial access was associated with significantly
the ability to lower bleeding is very appealing fewer vascular complications such as major
as a means to improve outcomes. However, bleeding and hematoma (1.8% vs. 13.1%,
age over 75 years was a predictor of procedural P < 0.05) and a shorter hospital length of stay
failure when attempting transradial PCI in (7.2 days vs. 10.1 days, P < 0.05); however,
1 study72 and therefore raises concern of its death at 30 days was similar between groups
safety in this population. (5.3% vs. 6.5%, P > 0.05). This trial supported
The OCTO PLUS study was the first to that primary PCI in the setting of STEM! was
prospectively randomize elderly patients feasible and associated with fewer vascular
114 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
complications and shorter hospital stays in the (66 years vs. 63 years), but had similar risk
elderly population. 74 factors. PCI in women had equal success rates
Two other retrospective observational compared to men, but women did require
trials compared outcomes in patients with more frequent crossover to femoral access
STEMI stratified by age and access site from (14% vs.1.7%, P = 0.00001). Femoral access
a single center in Germany75 and Canada. 76 in women was associated with higher rates
A total of 115 patients at a single center in of major (4.1% vs. 1.5%, P = 0.0001) and
Germany were analyzed with 34% undergoing minor bleeding (39.4% vs. 10.4%, P = 0.0001)
PCI by radial access. Patients over the age of compared to men. Major bleeding was defined
75 had higher mortality rates (13.0% vs. 6.4%, as retroperitoneal bleed, death, requiring
P = 0.03) and bleeding compared to a cohort of surgical intervention, blood transfusion, drop
younger patients despite having similar rates in hemoglobin of> 5 g/dL, or large hematoma.
of success. Radial access in the elderly when All other access site bleeds were considered
compared to femoral access was associated minor. Despite the significant limitations of
with lower rates of transfusion and bleeding this study and possibility for confounders, it
(0% vs. 6.6%, P = 0.04). 75 The observational does provide some insight into the benefits of
study from Canada included patients over radial access in women. 79
the age of 70 and found similar success rates, In the RIVAL trial as mentioned above,
door-to-balloon times, and in-hospital MACE gender was a prespecified subgroup. In this
rates between radial and femoral access. Radial large randomized trial, no difference in
access was associated with fewer access site outcomes of death/Milstroke/bleeding was
complications (0% vs. 2.9%, P < 0.05). 76 found in women compared to men.22 There are
Although larger randomized clinical trials limited data specifically looking at outcomes
looking at safety and efficacy of radial artery in women, and further studies are necessary.
catheterization for ACS in the elderly are still
necessary, these few studies suggest that
radial access is equally successful and reduces
Rescue PCI
bleeding. Thrombolysis is indicated for patients
presenting with STEMI to facilities without
a cardiac catheterization laboratory or when
Women transfer times would prohibit achieving a
The role of gender in outcomes with ACS is 90-minute door-to-balloon time. Although
still being evaluated. When women undergo thrombolysis can be an effective therapy,
PCI for ACS, they are at higher risk of adverse nearly 40% of patients fail this initial therapy.
events compared to men,16•78 in part because Studies have found that after thrombolytic
they tend to present later, have more comor- failure, urgent PCI is superior compared to
bidities, and are less likely to be referred for repeat administration of thrombolytics or
invasive procedures. 77 Therefore, the ability to medical therapy. 80--a1 This invasive strategy is
decrease adverse events by lowering bleeding favored to reduce ischemic events but does
is attractive in this group. increase the risk of bleeding, 80•82 and therefore
Women tend to compose only a minority radial access may be of utility.
in the above studies as seen in Tables 10.3 and The role of radial access in this setting is
10.4; therefore, limited data exist in this again limited to a few studies. Kassam et al
group. In a retrospective observational describe their experience in 111 patients after
manner, Pristipino et al reviewed their data failed thrombolysis that required rescue PCI.
from a single hospital in Italy and identified Radial access was attempted in 47 (42%) of
2,919 patients, of which 838 were women these cases, with 4% requiring crossover to
who underwent PCI over a 2-year span. Of femoral access. Radial access was associated
these women, 30% presented with ACS, and with fewer blood transfusions (4% vs. 19%,
33% underwent PCI through radial access. P < 0.05) and less access site-related major
When compared to men, women were older bleeding (0% vs. 9%, P < 0.05), but after
chapter 10 Transradial Access for PCI in Acute Myocardial Infarction • 115
excluding patients requiring balloon pumps, been shown in multiple trials to achieve equal
this difference was no longer significant. 83 success rates without prolonging door-to-
Cruden et al described their experience balloon times in the setting of STEMI. Despite
of 287 consecutive patients undergoing trends toward lower rates of mortality by
rescue PCI in which 15% were performed radial access utilization, further trials are
by radial access with baseline characteristics still necessary to precisely define the benefit.
being similar between groups. The radial and Nonetheless, improved patient satisfaction
femoral groups had similar primary access site and the potential for decreased bleeding
success (97%), procedure times (71 minutes complications are compelling reasons to
vs. 65 minutes, P = 0.17), and MACE rates increase utilization of transradial PCI in this
(5% vs. 13%, P = 0.13). However, radial access clinical population.
was associated with fewer vascular complica- Certainly, several studies have shown that
tions (0% vs. 13%, P < 0.01) and shorter there is a learning curve with TRA, and we
hospital length of stay (7.0 days vs. 7.9 days, recommends that operators be proficient with
p < 0.005). 84 TRAin the elective setting prior to attempting
The only randomized trial on this topic is in ACS patients. In addition, we advocate
the RADIAL-AMI trial, in which 50 patients for identifying patients at risk of bleeding
with STEMI randomized to either radial or using the predictive models discussed in
femoral access, and 66% of these patients this chapter. This will help to identify those
underwent PCI after failed thrombolysis. patients who are at highest risk for bleeding
Procedural success was similar in both groups and those who may benefit the most from
(88%), but the radial group required crossover bleeding-avoidance strategies such as TRA.
in 4% of cases. The femoral access group had
more hematomas (28% vs. 8%, P = 0.07) and a
trend toward requiring more transfusions. 56 • REFERENCES
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chapter 11
John T. Coppola, MD
Cezar Staniloae, MD
These abnormalities could significantly limit because the prolonged exposure of the radial
the procedural success. artery to the large-sized sheath may lead to
It is also important to discern the caliber significant spasm.
of the radial artery, as this factor has Anthropometric data, including arm and
implications regarding equipment selection. torso length, are important considerations
Abnormally small caliber of the radial artery in the TRA because there are limitations
may be due to spasm, hypoplasia, or athero- to equipment use in taller individuals.
sclerosis. In regard to the latter, the radial Depending on individual variability, different
artery is not protected from atherosclerotic catheter lengths are required to reach various
disease; histopathologic studies examining vascular beds as shown in Figure 11.1.
the radial artery in patients with coronary
artery disease have shown that up to 7% have
severe plaque burden and near 21% have . GENERAL TECHNICAL
medial calcification. 6•7 These diseased arteries
are more likely prone to spasm. Given that
CONSIDERATIONS
the long sheaths used during peripheral The routine approach to the peripheral
interventions must traverse the entire length vascular intervention starts with gaining
of the upper extremity, particular atten- access to the radial artery of choice. When
tion must be devoted to the administration possible, the left radial artery is the first
of appropriate spasmolytic cocktails and choice because it has the advantage of
sedation. This is of even greater importance traversing a shorter distance to the descending
at the end of the case during sheath removal aorta and not crossing the aortic arch and
\
\
L Wrist -
~/
FA= 12.."-1 35cm :__ -
L Wrist - Popliteal = l5S- 170cm
cerebral vessels. The left subclavian artery for other revascularization purposes. Because
most often directs the angiographer toward most of the time the radial artery pulse is
the descending aorta, so we usually begin the not easily palpable, the information provided
procedure with a 125-cm multipurpose cath- by the duplex ultrasound is valuable in these
eter and an angle-tipped hydrophilic-coated situations. Once the patency of the radial
0.035-in wire. Occasionally, an internal artery is confirmed, the access is gained with
mammary shape catheter may be required relative ease, in spite of lack of a palpable
to negotiate the descending aorta due to a pulse. A long, 5- or 6-Fr introducer sheath
Type III aortic arch. Regardless of the wire (55-65 em) is then advanced just distal to the
used, it is mandatory to carefully monitor its occlusion site, and a selective angiogram is
passage via fluoroscopy to its destination in performed (Figure 11.2). Various techniques
the lower abdominal aorta. Severe complica- could be used depending on the severity and
tions can result from "blind" advancement the location of the obstruction. The majority
of the wire into tributaries of the thoracic or of the time the lesion can be crossed with a
abdominal aorta. 0.018-in wire. We predilate the lesion with an
Current stent and balloon platforms of all undersized balloon, which is then followed
major manufacturers can be safely accommo- by stenting, with either a self-expandable or
dated in 6-Fr-diameter sheaths, and there are a balloon-expandable stent (Figure 11.3)_12
stent platforms now available in 5 Fr. Should the lesion be located at the ostium of
the subclavian artery, a balloon-expandable
stent provides a better radial force, and
• SUBCLAVIAN ARTERY ANGIOPLASTV it becomes preferable. Currently, most
balloon-expandable stents fit a 5-Fr introducer
AND STENTING
sheath, and at least one manufacturer
Atherosclerotic subclavian artery stenosis is (Cook Medical, Bloomington, IN) has a
a recognized cause of various symptoms such self-expandable stent platform that can be
as presyncope with upper extremity exercise, accommodated in a 5-Fr introducer sheath.
myocardial ischemia in patients with internal One should be aware that all the low-profile
mammary bypasses, upper extremity claudica- stent platforms require 0.014-in or 0.018-in
tions, or even embolic events. 8- 10 The tradi- guidewires.
tional revascularization method for subclavian
artery obstruction was surgical bypass. 11 Over
the last several years, balloon angioplasty
and stenting of the subclavian artery have
become the established therapy, and current
recommendations suggest the endovascular
approach as the first-line therapy for patients
with symptomatic subclavian artery stenoses.
The technique of subclavian artery
angioplasty using a transfemoral approach
is well established. For the purpose of this
review, we describe the transradial approach
to subclavian artery stenting. The first step in
preparation for the procedure is to document
the patency of the ipsilateral radial artery.
This should be done ideally by arterial duplex
ultrasound because obstruction of the radial
artery is encountered relatively frequently
in this patient population, either due to
embolization from the diseased subclavian Figure 11.2 Subclavian angiogram via radial
artery or from prior use of the radial artery approach.
124 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Figure 11.4 Panel A: Type 3 arch. Panel B: Normal arch. Panel C: Bovine arch (left carotid arising from right carotid).
chapter 11 Transradial Approach to Peripheral Interventions • 125
As an alternative to the 6-Fr guiding cath- the need to compress the common femoral
eter, one could use a 5-Fr 110 Ansel-l shape artery after the procedure, which in the pres-
introducer sheath. The procedure is being ence of occlusive disease may lead to ischemia
performed in the same manner, but there are or even thrombosis. Third, this approach facili-
2 advantages: first, it allows for reaching the tates same-day discharge, even in the presence
renal ostia, even in very tall subjects; second, of aggressive antithrombotic treatment.
it accommodates stents with diameter larger
than 6 mm, which would otherwise not fit a
6-Fr guiding catheter. • ANATOMICAL CONSIDERATIONS
For obvious reasons, transradial intervention
• TRANS RADIAL INTERVENTION OF of the lower extremities, including the iliac
arteries, may be more difficult in taller people
THE ILIAC ARTERY STENOSIS and those with longer upper extremities, due
Current ACC/AHA guidelines support to limitations of the length of equipment.
endovascular intervention with stenting of Using the left versus the right radial artery
most symptomatic iliac stenosis after a trial for access has the advantage of a shorter
of medical therapy. 17 However, iliac disease distance to the descending aorta and allows
may be less responsive to medical therapy the operator to avoid crossing the aortic arch
alone compared to superficial femoral artery and cerebral vessels. The left subclavian artery
stenoses.18 Surgical revascularization of the most often directs the angiographer toward
iliac lesions carries a significant morbidity the descending aorta, so we usually begin
and should be reserved for patients with low the procedure with a multipurpose catheter
surgical risks and for lesions not amenable and standard 0.035-in J-wire. If needed due
to percutaneous therapy. Symptoms of iliac to tortuosity or Type III aortic arch, a soft,
arterial insufficiency may be atypical for angle-tipped hydrophilic 0.035-in wire may
classic lower extremity claudication; in fact, be used with the aid of an internal mammary
some patients present only with lower limb artery diagnostic catheter to facilitate entry
weakness. Exercise ankle-brachial index may into the descending aorta. Regardless of the
be necessary to unmask aortoiliac occlusive wire used, it is mandatory that its passage
disease, as robust collaterals may provide be carefully followed with fluoroscopy to its
adequate lower extremity perfusion at rest. destination in the lower abdominal aorta.
Severe complications relating to renal,
mesenteric, or even spinal vessel (artery of
• ADVANTAGES OF TRANSRADIAL Adamkiewicz) injury can result from "blind"
advancement of the wire into tributaries of
APPROACH FOR ILIAC ANGIOPLASTY the thoracic or abdominal aorta.
The transradial approach is particularly We recommend that in most cases,
beneficial for patients undergoing peripheral angiography of the aortoiliac system begin
interventions for multiple reasons. First, these with a pigtail "power" injection of the lower
patients frequently present with bilateral abdominal aorta (typically 20 cc over 1 second
disease that makes them more susceptible in the anteroposterior projection). This
to local vascular complications. Frequently, initial scout film may help define any aortic
the crossover technique is hampered by aneurysms, collateral vessels, and presence
severe tortuosity; this situation is particularly of ostial disease of the common iliac arteries.
difficult when dealing with distal external iliac This initial view may be forgone only in
disease. The close proximity of the stenosis the presence of renal insufficiency with the
makes an ipsilateral approach difficult for backup of excellent noninvasive imaging.
distal external iliac interventions. A second Selective angiography of each iliac artery may
benefit of the radial approach is to eliminate be performed with 5-Fr,l25-cm multipurpose
128 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
catheters. lnfrainguinal anatomy and internal and 93.9% vs. 100%, P = 0.17, respectively).
iliac disease are important to assess not only Postintervention hemodynamics, as measured
for the appropriateness of endovascul.ar by ankle-brachial index, showed similar
intervention but also to assess postprocedure degrees of improvement (TRA: 0.64 to 0.77
complications. and TFA: 0.67 to 0.85, P = 0.77).
Once the decision to proceed with stenting Our experience with TRAin aortoiliac
is made, the 5-Fr diagnostic catheter is interventions clearly demonstrated that
exchanged over a long (260-cm) 0.035-in despite the worse case mix that was present
guidewire for a long introducer sheath. in the TRA group, this technique could be as
Usually, we use 5-Fr, 110-cm-long straight successful as the TFA. Furthermore, radial
introducers (Cook Medical, Bloomington, IN). access can be a viable option, even for more
The only time we use a 6-Fr, 110-cm sheath complex peripheral lesion types, as the
is in the situation where we anticipate the use prevalence ofTASC C and D lesions in our
of specific crossing devices (ie, chronic total study approached 40%. There are 2 additional
occlusions). We routinely use long (300-cm) issues that concern beginner radial operators.
0.014-in or 0.018-in wires. Once the sheath The first has to do with the anticipated need
is positioned in the proximity of the iliac for larger balloon and stent sizes requiring
artery, the procedure is performed in the bigger delivery sheaths, given the larger vessel
same fashion as from the groin (Figure 11.9, diameters of the iliac arteries, and the second
Figure 11.10). has to do with the longer distance from the
puncture site to the target lesion. In our study,
we were able to perform all aortoiliac interven-
• sAFETY AND EFFICACY OF tions via a 6-Fr introducer sheath. Recently,
most necessary equipment fits in 5-Fr
TRANSRADIAL ILIAC INTERVENTIONS introducers, and we shifted our approach to
We reviewed procedural data and outcomes using preferentially 5-Fr introducers. Finally,
from 80 consecutive aortoiliac interventions the distance to the target lesion was never an
treated either via transradial (n = 33) or trans- indication to abort the TRA and resort to the
femoral (n = 4 7) approach. 19 Both the TRA TFA in order to complete the procedure.
and TFA groups showed similar mean baseline
Rutherford category (2.9 vs. 2.6, respectively)
and preintervention ankle-brachial index • sUMMARY
(0.64 vs. 0.67, respectively). However, lesion
Peripheral vascular interventions can be safely
parameters differed, as the TRA group was
performed using the radial artery as an access
characterized by a 3-fold higher presence of
point. This approach is particularly beneficial
total occlusions (27.3% vs. 8.5%, P =0.03)
because the patients with severe peripheral
and a greater baseline-diameter stenosis
arterial disease are at higher risk for access
(89.2% vs. 82.3%, P = 0.003). Despite this
site complications. The main limitation to this
inequality in lesion types, there was no
approach is the lack of equipment that could
difference in mean procedural time (TRA:
easily access every vascular bed, particularly
97.9 minutes vs. TFA: 83.4 minutes, P = 0.08)
at the level of superficial femoral artery and
or contrast volume requirement (TRA:
tibial vessels.
238.7 mL vs. TFA: 213.1 mL, P = 0.35).
Interestingly, during the course of the study,
the procedural time became shorter by an
average of 25 minutes in the TRA group
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Figure 11.9
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Med J (Eng/). 2009;122(18):2097-2102. Prevalence of atherosclerotic renal artery stenosis
6. Oshima A, Takeshita S, Kozuma K, Yokoyama in patients with atherosclerosis elsewhere. Am
N, Motoyoshi K, Ishikawa S, et al. Intravascular J Med. 1990;88(1N):46N-51N.
ultrasound analysis of the radial artery for 17. Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW,
coronary artery bypass grafting. Ann Thorac Surg. Creager MA, Halperin JL, et al. ACC/AHA guide-
2005;79(1):99-103. lines for the management of patients with pe-
7. Staniloae CS, Mody KP, Sanghvi K, Mindrescu C, ripheral arterial disease (lower extremity, renal,
Coppola JT, Antonescu CR, et al. Histopathologic mesenteric, and abdominal aortic): a collaborative
changes of the radial artery wall secondary to trans- report from the American Associations for Vascular
radial catheterization. Vase Health Risk Manag. Surgery/Society for Vascular Surgery, Society for
2009;5 (3): 5 27-53 2. Cardiovascular Angiography and Interventions,
8. Bryan AJ, Hicks E, Lewis MH. Unilateral digi- Society for Vascular Medicine and Biology, Society
tal ischaemia secondary to embolisation from of Interventional Radiology, and the ACC/AHA
subclavian atheroma. Ann R Coll Surg Engl. Task Force on Practice Guidelines (writing com-
1989;71(2):140-142. mittee to develop guidelines for the management
9. Sueoka BL. Percutaneous transluminal stent place- of patients with peripheral arterial disease): sum-
ment to treat subclavian steal syndrome. J Vase mary of recommendations. J Vase Interv Radiol.
Interv Radio!. 1996;7(3):351-356. 2006;17(9):1383-1397; quiz 1398.
10. Olsen CO, Dunton RF, Maggs PR, Lahey SJ. Review 18. White CJ, Gray WA. Endovascular therapies for pe-
of coronary-subclavian steal following internal ripheral arterial disease: an evidence-based review.
mammary artery-coronary artery bypass surgery. Circulation. 2007 ;116(19) :22 03-2215.
Ann Thorac Surg. 1988;46{6):675-678. 19. Staniloae CS, Korabathina R, Yu J, Kurian D,
11. Edwards WH Jr, Tapper SS, Edwards WH Sr, Coppola J. Safety and efficacy of transradial aor-
Mulherin JL Jr, Martin RS III, Jenkins JM. toiliac interventions. Catheter Cardiovasc Interv.
Subclavian revascularization. A quarter century 75(5):659-662.
experience. Ann Surg. 1994;219{6):673-677; discus-
sian 677-678.
chapter 12
Jan C. Gilchrist, MD
was limited by the ability to reliably find distal All veins below the antecubital fossa eventu-
veins and ultimately by the inability to secure ally drain into the subclavian vein by coursing
a continued source of 125-cm catheters. up either the lateral system of the cephalic
Subsequently, the technique evolved so that vein or the medial system of the axillaryI
the venous access was obtained initially basilic vein. Medial (ulnar) side veins form
outside the catheterization laboratory by IV the most direct route to the central system
teams placing heparin-well venous access passing up the basilic, then the axillary vein,
anywhere between the antecubital fossa and and subsequently the subclavian vein. The
the wrist. This temporary access was then basilic and axillary veins may be quite large
exchanged in the laboratory for a vascular with diameters of> 1 em. Veins on the lateral
sheath that would then subsequently permit (radial) side of the arm below the antecubital
passage of a central venous catheter. This fossa tend to pass either medially or laterally
approach resulted in reliable central venous in a 50/50 distribution above the antecubital
access3 that has been reported by several fossa. 7 The lateral veins of the hind arm join to
different groups using analogous techniques.4-6 form the cephalic vein that is usually signifi-
cantly smaller in diameter than the axillary
vein. The cephalic vein makes a right-angle
• PERIPHERAL VENOUS ANATOMY turn at its junction with the axillary vein
defining the origin of the subclavian vein as
AND PHYSIOLOGY pictured in Figure 12.2. This junction, also
There are several distinguishing features of referred to as a "r junction, may represent a
the peripheral venous system that distin- technical challenge that should be recognized
guishes it from the arterial system and must but is easily met with forethought.
be considered by the radial operator. These are The physiology of veins is slightly different
outlined in Table 12.1. The venous system is from that of arteries, and in particular, the
low in pressure and reacts differently than the forearm veins represent vessels that are
arterial system. Veins are more distensible and significantly smaller in diameter than the
far less likely to respond with spasm compared femoral venous structures. Veins in general
to the arterial system. Although conceptually, are significantly less muscular and have
catheterization in the venous system that is much thinner walls than arteries. Although
far more anatomically complex than the arte- they are less muscular than arteries, veins
rial tree appears difficult, the realities are that are still capable of spasm, especially when
most who venture into the venous system find an indwelling catheter diameter is similar in
it relatively easy compared to the arterial tree size to the vein. Venospasm was historically a
and far more forgiving. hazard reported in the literature when venous
Although variability is the rule, there cutdowns were common and catheters were
are some general anatomical principles that larger (8 Fr) and stiffer compared to present
forearm veins follow, as shown in Figure 12.1. equipment. Modem experience with smaller
Table 12.1 Anatomical Comparison and Pharmacophysiology of Arterial and Venous System of the Forearm.
Pharmacoreactivity
Prophylactic antispasm medicat ions required Yes No
Calcium channel blocker responsive Yes No
Nitrates responsive Yes Yes
chapter 12 Right Heart Catheterization and Transradial Access • 133
Cephalic
vein
\ Subclavl <~n Vein
vein l
Axillary Vein
Median
vein
vein
Figure 12.2 Venogram of cephalic-axillary vein
junction. This is known as the "T" junction because the
cephalic vein intersects at a 90° angle. This combination
Radial forms the subclavian vein that continues into the
vein vein central venous system.
Figure 12.3
Heparin locks,
angiocaths, access
needles, and vascular
wires used to
exchange peripheral
intravenous access for
vascular sheaths in the
cardiac catheterization
laboratory.
chapter 1:Z Right Heart Catheterization andTransradial Access • 135
between sterile work gloves and the chemi- If the catheter is in the subclavian vein or
cally treated intravenous device (heparin lock) proximal axillary vein, the balloon can be
placed outside the laboratory. The vascular inflated and continue through the right heart,
sheath is then placed on the wire and slid into often just under pressure monitoring.
the venous system with subsequent removal If the catheter has passed up the cephalic
of the wire and sheath's associated dilator. vein, its crossing into the axillary-subclavian
junction needs visual supervision. The
cephalic vein enters in a 90" fashion, and the
Venous ucocktails" for the Vascular Sheath balloon should be inflated only when it is
Venospasm is rare. Many operators do not clear that the tip of the catheter is freely in
use preemptive antispasm medication in the subclavian and heading toward the heart.
the venous system. If an antispasm cocktail Difficulty maneuvering the "T" junction can
is desired or needed due to spasm, nitrates be remediated with the help of a deep breath
should be used in dosages similar to those by the patient or through the use of a wire
used in the arterial tree. Calcium channel in the catheter to redirect the device. Once
blockers are less effective in contradistinction the catheter is correctly positioned in the
to the arterial system's response to these subclavian, it can be advanced under pressure
agents. Whether or not an antispasm cocktail monitoring through the right heart unless
is added, the side arm of the vascular sheath fluoroscopy is needed to confirm location of
should be flushed to reduce the risk of throm- the catheter tip. Overall, once the peripherally
bosis. Due to the low vascular pressure in the placed devices reach the subclavian vein, they
peripheral veins, there may be no drawback behave very similarly to those placed in any
of blood on aspiration of the sheath. As long central chest vein and can be advanced to their
as the sheath flushes without resistance or desired location using standard approaches.
patient pain, the lack of blood aspiration is
not indicative of poor venous position.
• POSTPROCEDU RAL ACCESS SITE
MANAGEMENT
• PASSAGE TO THE CENTRAL VENOUS
At the conclusion of the procedure, the central
AND PULMONARY CIRCULATION venous catheter should be removed from
Right heart catheters from several manufac- the central system with the balloon deflated.
turers are available in a variety of sizes from The side arm of the introducer sheath is
4 to 8 Fr. These can be obtained in balloon- once again flushed, noting that blood return
tipped, both single-lumen and multilumen may still not be possible on aspiration due
devices with thermodilution capabilities to venous collapse, and a vasodilator cocktail
depending on the operator's preference. is not normally needed. The vascular sheath
Industry has failed to manufacture catheters can then be removed and pressure applied
beyond the 110-cm length, although access to to prevent bleeding without waiting for any
long lengths such as 125 em would be helpful periprocedural anticoagulation to dissipate.
in individuals with long arms, especially if Due to the low venous pressure, relatively low
more distal extremity venous access is used. external pressure is required to obtain hemo-
Initially, the catheter should be passed up static control. The venous site can typically be
the arm with the flow-directing balloon tip managed with sterile pressure dressing and no
deflated. As long as no resistance is encoun- specific hemostasis device. If the venous site
tered, one does not have to watch this under is in close proximity to the radial arterial site,
fluoroscopy. When the catheter reaches the the hemostatic device for the artery may also
level of the shoulder, it is often useful to be used to control the venous site. Venous
spot-check the location under fluoroscopy. hemostasis usually is readily obtained and
This fluoroscopy is needed to confirm whether occurs before arterial hemostasis.
the catheter has passed up the basilica/axillary A summary of the venous procedure is
system or the lateral cephalic venous system. outlined in Table 12.2, as discussed in the
136 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Pre procedural
Identify potential need for venous access
Slide heparin lock with insertion needle off the wire and dispose off field
Pass equipment up arm without resistance watching under x-ray at the cephalic-axillary·r junction
After Procedure
Source: Adapted in part: Gilchrist IC. Radial approach to right heart catheterization and intervention: state of the art paper. Indian Heart J.
201 0;62:245-250.
preceding section. Using this type of approach patients with severe pulmonary hyperten-
to right heart catheterization, it is possible to sion, particularly in the presence of tricuspid
get procedural results consistent with those regurgitation, procedural time is probably
using the femoral vein without the risks of shorter from the arm.]
femoral trauma. The potential complications
of directly puncturing a central vein in the
neck are also avoided, and the benefits from • OVERCOMING POTENTIAL
the safety and convenience of the transradial
approach remain with this addition to the CHALLENGES
transradial toolbox. As noted in Figure 12.4,
procedural times and x-ray times 3 are similar Difficult Venous Access
when the forearm approach is compared to Several different techniques have been used to
the femoral approach for central venous and help find concealed forearm veins. Ultrasound
right heart catheterization. [Editor's note: In equipment can also be helpful to map out the
chapter 12 Right Heart Catheterization and Transradial Access • 137
100
I t
discretion of the operators.
50
0 --
Femoral Radial
(n = 175) (n= 105)
~
+
Femoral
(n= 175)
-~
Radial
(n= 105)
location of deeper veins such as the axillary Resistance to Forward Passage of Catheter
vein or deep antecubital veins. Even at the
Resistance is a sign of either venospasm,
level of the wrist, a vein usually accompanies
entrapment in a side branch, a venous valve
both the radial and the ulnar artery similar
sinus, or venous obstruction. Using the
to the femoral artery and its vein. Whether a
modern hydrophilic-coated, flexible catheters,
vein lies lateral or in a medial position to that
true venospasm is rare. If venospasm does
of the artery is patient specific, but a vascular
occur, intravenous nitroglycerine in 100- to
ultrasound device can localize the vein in
200-flg dosages is the best approach, although
relationship to the arterial pulse. The operator
it is rarely needed. Nitrates can also be
can then approximate the venous position by
delivered cutaneously or sublingually. Further
palpating the arterial pulse and often obtain
manipulation of the vein should be minimized
venous access in patients who otherwise
while pharmacologic or other changes are
appear to have little hope for peripheral access.
made to reduce the tone of the vein. Other
An alternative approach, when radial artery
causes of spasm that should be corrected
access is available, is a levophase angiogram. 9
include patient anxiety and cold ambient
In this case, diluted contrast is injected into
temperatures. Finally, changing brand of
the radial artery and observed during the
catheter may help as coatings differ by manu-
venous phase. The venous system can then be
facturer and at times may make a difference.
visualized. If a tourniquet is placed to trap the
If resistance occurs with passage of a
contrast, the operator can have some time to
catheter or wire, it is especially important not
further localize the vein. This technique works
to push. Pushing will cause perforation or
best in the antecubital region where the veins
tearing of the vein that is less resilient than
pass superficially in front of the elbow bones.
the artery. A small contrast injection can often
Care needs to be taken to not puncture a
define the issue of whether there is spasm,
neighboring artery or nerve in this region.
perforation of the vein, or perhaps another
Finally, if one arm does not have a reason-
route to the heart that may be better, as the
able vein, the contralateral arm may work.
venous system often has redundant systems
Patients typically would rather have venous
that lead to the central system.
and arterial access in opposing arms versus
being subjected to the risks of either neck or
groin access. Once removed, the venous site Congenital Venous Anomalies
care is not much greater than removal of any Left arm approaches can be potentially
superficial venous access and does not add challenged by a persistent left-sided superior
significantly to the postprocedural morbidity. vena cava. This results in left-sided arm blood
138 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
draining into the coronary sinus and then catheterization by cutdown at the brachial site
right atrium. With modern flow-directed may have resulted in surgical destruction of
catheters, passage through the right heart the venous system and resulting collaterals
and out into the pulmonary artery may still that cannot be transversed. Brachial arterioto-
occur, although the course will appear radio- mies were usually repaired, but venotomies
graphically unusual. If a persistent left-sided were usually ligated with the vein's integrity
superior vena cava is encountered and cannot sacrificed. In such instances, contralateral
be passed due to tortuous vascular course, an access may be required.
alternative right-sided approach will need to Motor vehicle and other traumatic inju-
be found. ries of the upper arm and chest need to be
considered because venous trauma may have
also rendered the central venous system
Electrophysiological Devices damaged even without overt signs of chronic
The leads on electrophysiological devices may venous obstruction (Figure 12.6). If resistance
obstruct the venous system, and even without to passage occurs, a limited angiogram may
arm swelling, extensive collaterals may be define whether there is an insurmountable
present (Figure 12.5). Whether thrombosis is challenge for which an alternative venous
present is difficult to predict. Transit past the approach will be needed.
site of lead entry may require extra manipula- Another group of patients who are
tion with a wire in the hemodynamic catheter. occasionally problematic includes those who
The option to use the contralateral side is also have received chemotherapy or radiation
reasonable. to the chest. These patients may have had
long-term indwelling central venous ports for
chemotherapy, and extensive sclerosis may
Previous Upper Extremity/Shoulder Trauma impede catheter passage to the central venous
Prior procedures or major trauma to the ipsi- system. Likewise, high-dose radiation may
lateral shoulder or upper arm, even decades have similarly resulted in obstructive changes
earlier, can be problematic. Prior cardiac to the normal venous channels. A limited
\ Venous
Occlusion
Yves Louvard, MD
Hakim Benamer, MD
Thierry Lefevre, MD
hands. Previous as well as current publications procedures were performed via the transradial
report preliminary or low-volume personal route.
experiences. The large series of transradial This tends to show that the 5% rate of
procedures that could potentially be reported failure after 50 to 100 procedures is an artifact
is currently performed in countries where this associated with an intuitive or recommended
vascular route has gained wide acceptance. As selection of patients. Kiemeneij's recom-
a consequence, the procedures are no longer mendation in 1994 was to begin with big,
submitted and/or accepted for publication. young male patients with a simple coronary
The first author of the present review anatomy.
recorded the clinical and procedural charac- This is further supported by a study
teristics as well as complications associated performed in 2003 in our institution (Institut
with more than 2,400 separate, consecutive, Cardiovasculaire Paris Sud, Massy, France) by
diagnostic, and/or interventional procedures 3 interventional cardiology fellows 8 who had
he carried out between 1994 and 1999. 8 The no experience in the transradial approach but
success criterion of the transradial procedure were able to perform transfemoral angiog-
was the achievement of catheter penetration raphy on their own, and 3 senior operators
into the ascending aorta. The rate of failure with wide experience in transradial diagnosis
is shown in Figure 13.1. It was close to 5% and PCI. Figure 13.2 shows the rate of success
after 100 procedures, which supports the achieved in the first 90 transradial procedures
frequently mentioned observation that 50 to performed without assistance from junior
100 cases are sufficient to achieve an accept- operators (higher panel), and the final rate
able 95% rate of success. After performing of success of procedures carried out with the
800 procedures, the rate of failure is 3% and help of senior operators (lower panel) in a
decreases to 1.5% after 2,400 procedures. nonselected population of patients (> 95%
However, in 1994, the first 100 transradial of procedures). This study showed the actual
procedures accounted for 51% of all interven- rate of procedural success achieved in a
tions whereas in the last 800 patients, 81% of nonselected population and underlined the
%
8
7
6
~
5
~ •
---
4
3 ~
....
2
1 • •
0
0 400 800 1200 1600 2000 2400 2800
Figure 13.1 Evolution of the radial approach failure rate (failure to enter the ascending aorta) of a single operator
in 2,400 consecutive patients from the first one in 1994 to 1999. Evolution of certain clinical factors and rate of radial
approach attempt in the same population.
144 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
100 ~----------~~------------------------------~~----~
9 0 -+-----,_...,~ .... 52%
10 A---""""~l\-----'"----
7 0 ;-~----~~------~~--,~~----~ 89%
60
5 0 -1---=.
4 0 -+-----------~--~------------------------------4a~--~
1 0 -+-----------~~~----------------------------------~~ -+- Fellow 1
zo -+-----------~~--------------------------------------~ Fellow2
10 ;---------------------------~ - - Fell o w:!
0 ;------.------.------.------.------,------.------,----_,
1- 10 11 - 20 21 -~ 0 ~1- 40 4 1 - 50 51 - 60 61 -7 0 71 -1 0 11 -9 0
. . -- . . * . . ...
---....._ -_ ...-- ...
.......__ ..,."'"'
-
1 00
•9 0 ~~ - ........_~ - 96%
"0
'7 0
.... 'IIIII
98%
60
'5 0
40
u -+- + Sen ior
zo - +Senior
.1.0 ~ +Senior
0
1-1 0 1 1-2 0 21 - 30 11 - 40 41 - 5 0 51- 60 6 1 - 70 7 1 - 10 11- 90
Figure 13.2 Radial approach success rate (catheterization of the ascending aorta) achieved by 3 fellows (upper
panel), and with the help of a senior radial operator (lower panel) in the first 90 transradial cases performed by the
fellows.
variability between operators, as well as the This does not mean that procedural
excellent rate of success achieved by the senior duration does not decrease with experience;
operator following failed attempts by the it means only that comparisons involve
fellow (no disadvantage for the patient). seasoned operators with wide experience in
In a large population of consecutive transradial angiography. Moreover, there are
patients (N = 1,826) referred for angiography few specific differences between transfemoral
and/or angioplasty in 2005-2007, 2 operators and transradial PCI procedures. The vascular
with wide experience, Guedes and Dangoisse, 15 access route, therefore, does not seem to be a
implemented the same strategy as for the discriminating factor.
femoral approach (ie, first attempt on one side, However, the findings associated with coro-
then on the other side in cases of failure). They nary angiography are different. Indeed, the
achieved a 98.8% rate of approach success duration of a coronary angiogram decreases
(the failure rate for the first attempt was 6.8%, with operator experience. Analysis of the first
and 4.9% when patients with previous CABG 1,000 transradial coronary angiograms (no
were excluded; the rate of failure was shown to graft, 2 left ventricular angiographies) by the
regress by about 40% per year and was 3.2% in same operator18 showed that the procedural
the last year of the study). duration decreased from 23.3 minutes for
the first 100 angiograms to 13.1 minutes for
the last 100 (Figure 13.3). The analysis of
Procedural Duration this reduction in procedural time takes into
The total duration of a coronary angioplasty account the various catheterization strategies
procedure has often been reported in random- implemented: from the initial use of one
ized trials as similar for transfemoral and catheter for each artery to the systematic
transradial procedures alike. 16•17 quest for an ideal multipurpose catheter. It is,
chapter 13 The Learning Curve forTransradial Access • 145
1-100 101~ 201- 301- -Wl- 501- 601- 701- 8JJ- 901-
.200 300 400 ~ ,( )00 700 fm 900 1000
however, difficult to distinguish between the and dose area product, radiation received by
effect of operator experience and the advan- transradial operators is 2-fold compared with
tages provided by new catheter shapes that transfemoral procedures. This can probably
have not yet been adequately evaluated. In an be attributed to correctable factors such as
early dual-center study involving 4 operators, the distance between the operator and the
Spaulding19 reported a decrease in procedure x-ray source, which should be increased during
duration from 25.7 ± 12.9 minutes after transradial procedures, or to the inadequacy
80 cases (20 per operator) to 17.48 ± 4.71 or inappropriate positioning of protective
minutes in the last 100 cases. One of the main equipment. With appropriate shielding, there
reasons for this improvement is the reduction should be little difference between femoral
in radial cannulation time (10.2 ± 7.6 minutes and radial access because when the arm is
to 2.85 ± 2.53 minutes) whereas the rate of placed next to the body, the wrist is exactly
failure decreased from 14% to 2%. at the same level as the femoral artery. In
some instances, however, there are anatomic
and technical issues in transradial access that
X-ray Exposure may prolong fluoroscopy time and therefore
X-ray exposure has often been reported as radiation exposure.
nondifferent between transradial and trans-
femoral procedures in high-volume random-
ized angioplasty studies. 16·17 The influence Complications
of the operator seems to be more significant No systematic analysis was carried out on the
than the influence of the vascular route. 20 evolution of the rate of transradial procedural
A higher duration of x-ray exposure complications in relation to increasing operator
has been observed in transradial angiog- experience. However, in the series published by
raphy.17·21·22 Such a difference generally the first author of the present review, 2 forearm
decreases with growing operator experience. compartment syndromes requiring surgical
A study reported by Pezzano et al23 showed repair occurred in 1995, and no complications
that although procedural duration is similar of this nature have been reported since.
with both routes, the x-ray duration and the The meta-analysis performed by Jolly
area exposure product are higher in transradial underlined a difference in terms of frequency
procedures, due exclusively to fluoroscopy between radial experts and nonradial experts
(catheter handling, guiding of the catheter with respect to the occurrence of major
all along the route, systematic antebrachial bleeding. 24
angiography, etc). Lange22 underlined the fact The data of the Swedish Coronary
that despite similar duration of x-ray exposure Angiography and Angioplasty Register
146 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Most interestingly, this study analyzed Systematic use of the transradial route in
the evolution in x-ray time during procedures all patients requires a long learning curve,
carried out by fellows, according to experi- well beyond 50 to 100 procedures, before a
ence.29 In 532 and 935 angioplasty procedures 95% success rate can be obtained. However,
performed by 6 fellows and senior opera- 50 procedures are probably enough for an
tors, respectively, x-ray exposure times were operator to be able to reach this reasonable
compared and divided into 3 periods: < 100 objective in selected patients. Except for radial
procedures, between 100 and 200 procedures, artery cannulation (no difference), the left
and > 200 procedures for the right and the left radial approach is easier to learn than the
transradial approach, respectively. X-ray expo- right radial route.
sure duration did not vary in senior operators,
whereas it decreased with experience in fellows.
After more than 200 procedures performed • wHAT DOES THE LEARNING
by fellows, the difference in x-ray time for left
radial approach was borderline compared with PERIOD INVOLVE?
senior operators, whereas it remains consider-
able for right transradial procedures. DAP did Clinical Predictors of Failure
not vary in right transradial procedures and The predictors of failure were identified by
was significantly reduced in left transradial Barbeau et al30 in a multivariate analysis
procedures performed by fellows. In both involving 6,962 coronary procedures with
operator groups, radial cannulation time was a 7% rate of failure . By decreasing order of
identical and rapidly decreased with experience. importance, these predictors were female
As a consequence, it appears clear that gender, operator experience, advanced age,
transradial catheterization following sheath and low body mass index. The univariate anal-
insertion is more difficult to learn via the right ysis of the first 2,400 procedures performed
radial route. This is probably mainly related to by a single operator in our center identified
the anatomy, which is more favorable through the following predictors of failure: low patient
the left approach (fewer subclavian tortuosi- weight, small patient size, more advanced age,
ties, etc). Coronary engagement from the left and female gender. 8 The presence of diabetes
radial approach is similar to the femoral was found to be a predictor of failure in female
approach and requires little manipulation of patients. Hypertension also emerged as a
the catheter as with the Judkins technique predictor of failure in the first 1,677 angio-
as compared to angiography from the right plasties carried out by a single operator.8
radial approach that is similar to the Sones After exclusion of patients with previous
technique. CABG, Guedes15 identified four predictors of
failed transradial approach: operator experi-
ence, as assessed by the year of the procedure
Differences Compared with the Learning
(P < 0.001), history of peripheral arterial
Curve of the Transfemoral Approach disease (P = 0.016), "small radial artery size"
There are no reports in the literature on the (P = 0.003), and "difficult access" by clinical
learning curve associated with transfemoral evaluation (P = 0.006). By univariate analysis
interventional cardiology procedures, nor of the prespecified clinical characteristics,
are there any randomized or nonrandomized only gender was predictive of the need for a
comparisons other than the experience- nonradial access (procedural failure in female
related decrease in the crossover rate between patients: 2.1% vs. 0.9%; P = 0.036); there was
the radial and femoral routes observed in the also a trend for diabetes (P = 0.099).
RIVAL trial.27 However, any interventional In a consecutive series of 1,052 transradial
cardiologist with wide experience in the trans- procedures, Pristipino 31 did not identify any
femoral approach who undertook transradial clinical predictor of the selection of transradial
procedures would confirm the greater diffi- cardiac catheterization (no patient selec-
culty posed by the transradial route. tion). However, high-volume centers and
148 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
high-volume radial operators were predictors failed transradial catheterization were more
of the choice of transradial route. Predictors frequent in the presence of radial anatomical
of failure were found to be the presence of variations (14% vs. 0.9%, P < 0.0001).
peripheral obstructive vascular disease and Procedural failure was 4.6% with high radial
lower use of the transradial approach (failure bifurcation, 23.3% with severe radial tortu-
for > 85% radial approaches: 3.8% vs. 33% osity, 37.1% with radial loop, and 12.9% with
when < 25%, P < 0.001). other anomalies.
The presence of subclavian tortuosities
(10.8% in right subclavian arteries in the
Difficulties and Technical Predictors series reported by Cha) is also a predictor
of Failure of transradial failure (4%).35 Tortuosities
In the series reported by Guedes,15 failed are a much less frequent occurrence in left
attempts at radial puncture accounted for subclavian arteries, 0 in 232, compared to the
52.6% of all failures. It was 69% in the series right, 20 in 205 (9.8%), in the series reported
of Barbeau et aP0 Other failed attempts by Kawashima. 36 Such a difference seems to
involved the crossing of the brachial, axillary, account for prolonged procedural duration and
or innominate arteries (11.1%); selective higher x-ray exposure when using the right
catheterization of a coronary artery or bypass radial approach.
graft (9.6%); and catheterization of the
controlateral mammary artery (26.7%).
In 2,211 consecutive patients undergoing Anticipating Technical Difficulties
transradial coronary angiography, Valsecchi In the study by Guedes,15 bedside clinical
et al32 conducted a systematic analysis of evaluation identified the radial access of
the anatomic variations and their influence 253 patients (13.8%) as "difficult" due to a
on the rate of failure. Anatomic variations weak pulse, "small vessel" size, or both. This
of upper limb arteries were noted in 22.8% assessment was more frequent for females
and included tortuous configurations (3.8%), (28.3% vs. 7.6%; P < 0.001), diabetics (19.5%
stenosis (1.7%), hypoplasia (7.7%), radio- vs. 12.4%; P = 0.001), patients with peripheral
ulnar loop (0.8%), abnormal origin of the artery disease (17.4% vs. 12.6%; P = 0.012),
radial artery (8.3%), and retro-esophageal and hypertensive patients (17.8% vs. 10.5%;
right subclavian artery (0.45%). Patients with P < 0.001). Puncturing was actually less
anatomic variations of radial artery had a difficult than anticipated.
significantly lower puncture (96.2% vs. 99.7%, Radial tortuosities have been shown to
P < 0.0001) and procedural (93.1% vs. 98.8%, be associated with arterial hypertension37
P < 0.0001) success rate. The procedural and right subclavian tortuosities with
failure rates were 1.2% for tortuous configura- hypertension, advanced age, and higher body
tions, 3.3% for radial coming from axillary mass index.38 Small radial arteries are more
origin, 6.1% for hypoplastic radial arteries, frequent in women39 and diabetic patients.40
8.1% for radial stenosis, 16.7% for radio-ulnar Radial calcifications are also found in diabetic
loops, and 40% for retro-esophageal right patients.40 There is no predictor for the
subclavian artery. 33 presence of a radio-ulnar loop, 41 but they can
In a study involving 1,540 consecutive be identified by systematic echography, which
transradial procedures where retrograde complicates the procedure and reduces the
transradial angiography was systematically cost-effectiveness associated with transradial
performed, 34 the observed frequency of radial catheterization.42 Although angiographic
artery abnormality was 13.8%: 7.0% ofhigh identification of any unfamiliar anatomical
radial takeoff, 2.3% of complete loops, 2.0% variation hindering catheter advancement
of extreme radial tortuosities, and 2.5% of does not result in a reduction of the failure
various abnormalities such as atheroscle- rate, it may allow a reduction in the occur-
rosis or accessory branches. Instances of rence of complications.
chapter 13 The Learning Curve forTransradial Access • 149
• HOW TO BEST TEACH AND LEARN Self-teaching. An option that was success-
fully adopted by the pioneers of transradial
THE TRANSRADIAL APPROACH catheterization is self-teaching. This relies
on two principles: the volume of transradial
Teaching the Transradial Approach procedures and the selection of patients (see
It can be accomplished using multiple tools, Figures 13.4, 13.5, and 13.6). Appropriate
such as dedicated textbooks, 43•44 websites, 45•46 patient selection results in an acceptable
dedicated courses, and virtual bench or radial success rate of transradial angiography and
sessions held during major interventional angioplasty in a reasonable procedural time,
cardiology courses. However, practical in accordance with x-ray protection standards,
learning is irreplaceable, hence the hands-on in the best interest of patients, operators,
workshops organized in centers where the rate cath-lab staff, and cath-lab management (in
of transradial coronary procedures is more the event of conflicts, beginning operators are
than 90%. Regular practice of the transradial supported by the rest of the team). Patient
approach in an adequate number of cases selection, as well as crossover to the trans-
is the most efficient means oflearning. femoral route, relies on the analysis of various
However, this must be combined with the previously described predictors of failure: clin-
tools mentioned above in order to be able to ical, technical (vessel route abnormality, lesion
identify and overcome difficulties that are less issues for PCI), and practical factors (pulse,
frequently encountered. radial artery size, tortuosities). It is possible
Fellowship. In a high-volume radial to "manage the learning curve" by gradually
center, fellowship enables beginners to learn introducing new operators to increasingly
transradial catheterization in a population of complex cases, based on previously collected
unselected patients. Fellows can be gradually data in a prospective database. 15 Each new
introduced to cases of increasing complexity. difficulty encountered can be overcome with
Overcoming difficulties by learning estab- the help of various media sources and by
lished tips and tricks can be achieved with the seeking the advice of experienced colleagues.
help of several experienced senior operators. Several simple tips and tricks may prove
This learning method is indeed efficient, extremely efficient, such as the successful
though it requires both a significant invest- crossing of nearly any obstacles in the right
ment in terms of availability and the ability to subclavian artery by using the deep breathing
take time off from one's own cardiac catheter- maneuver. The use of the left radial route,
ization laboratory. with puncture on the left side of the patient,
5 ~~~~\
"'
....,__-----T-
\
\---------------1
--------------------------------~
4 ~--~~
~~--
. ----------------~
3 +---------~~
----------
~ ------------------_,
2 +-----------~\~
.~=-
~ ~
---
~- . ~-
~~~-~
~~
~----~
1 +------------- - ~~ '~ &
0 ~ - - -
<50 kg 50-59 kg 60:.69'kg 0-9kg 80-89 kg 9 99 kg 100-09 kg >HO kg
Figure 13.5 Failure rate of the radial approach for diagnosis and intervention in a population of 2,400 consecutive
cases in different weight groups.
1-+- Total
24
21 •
18
\
15 \
12 \
9
\
6
0
ems <150
" \\
....
11...
]50-154.
.t.
.... ="'
155-]59
...
-.....A-
--..._ y~
l60-l64.
-
165-169
-
1 0-1 4
...
-
l 5-19
-
180-184.
~
>185
Figure 13.6 Failure rate of the radial approach for diagnosis and intervention in a population of 2,400 consecutive
cases in different height groups.
chapter 13 The Learning Curve forTransradial Access • 151
enables the operator to learn the puncture success rates, procedural durations, and x-ray
process and cardiac catheterization maneuvers exposure. This may encourage colleagues,
separately in a limited period of time (the left coworkers, paramedics, patients, and hospital
approach delivers more x-ray to the operator managers to support widespread use of this
closer to the source and is also responsible for vascular approach.
back pain for the operator). Even when the
access is left radial, most operators prefer to
work from the right side, as that is the way • REFERENCES
the catheterization laboratory is usually set
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with a "sling" that obviates the need to lean 2. Seldinger S. Catheter replacement of the needle
over the patient to reach the left radial access in percutaneous arteriography: a new technique.
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Reproduced inAJR 1084;142:5-7.
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chapter 14
Ronald P. Caputo, MD
and 1 year (OR0.68 [95% CI 0.71-0.92]; the multiple additional cost events occurring
P < 0.001). 10 A large (N = 7,020) meta-analysis after a significant vascular/bleeding complica-
of 23 randomized studies comparing TRA tion helps to illustrate the economic burden
to TFA reported a trend toward decreased (Table 14.2). The cumulative costs of bleeding
occurrence of death/myocardial infarction/ and vascular complications following PC!
stroke with TRA (2.5% vs. 3.8%; OR 0.71 have been calculated in several studies.13- 25
[95% CI 0.49-1.01; P = 0.058]. 8 The incidence Rao et al examined the GUSTO lib data and
of death/myocardial infarction was also lower found increasing length of stay (LOS) and
for TRA (n = 307) compared to TFA (n =863) hospital costs commensurate with severity of
(4.9% vs. 8.3%; P =0.05) 1 year postprocedure GUSTO lib-defined bleeding following PCI
in the PRESTO-ACS study.9 Bleeding and for an indication of non-STEMI (Table 14.3).
net clinical outcomes were also lower in the After adjusting for baseline patient differ-
TRA group (0.7% vs. 2.7%; P = 0.03 and 5.5% ences, each bleeding event and transfusion
vs. 9.9%; P = 0.03). The recently reported was determined to add $3,770 and $2,080
large randomized RIVAL study (N = 7,021) to costs, respectively. LOS was the main
compared TRA to TFA for patients with component leading to increased costY An
acute coronary syndromes treated by PCI analysis of the ACUITY trial revealed that
and demonstrated a significant decrease in a minor bleeding event increased costs by
vascular complications for the overall TRA $2,822 and a major bleeding event increased
group (1.4% vs. 3.7%; P < 0.0001). In the costs by $8,658. Furthermore, the investiga-
high-risk subgroup of ST-elevation myocardial tors determined that a hematoma, a clinically
infarction (STEMI) patients, both major significant bleed, and a pseudoaneurysm
adverse cardiac events (MACE) and bleeding translated into incremental costs of $1,399,
were lower in the TRA group (3.1% vs. 5.2%; $5,440, and $6,357 per event, respectivelyP
p < 0.0001)_11 Jacobson and colleagues at the Mayo Clinic
Although TRA may result in lower MACE examined patients treated with PCI for a
events post-percutaneous coronary inter- variety of indications between 1998 and 2003.
vention (PCI) compared to TFA, there is In this study, incremental adjusted mean
stronger evidence to support the conclusion costs were $5,882 for a bleeding event and
that TRA is associated with lower incidence $15,437 for a bleeding event associated with
of vascular access/bleeding complications. a MACE event.14 A series of 6,008 patients in
Reducing these complications provides a large the Christiana Care Health System were found
economic advantage for TRA. Examination of to have increased costs due to GUSTO-defined
post-PCI bleeding, which increased according
to severity of bleeding, adding $4,037 for
Table 14.1 Economic Advantages Related to
Transradial Arterial Access.
mild, $6,980 for moderate, and $14,006
Cost Savings with Transradial Access Table 14.2 Cumulative Cost and Economic Burden
After Singular Vascular/Bleeding Complication.
Decreased vascular and bleeding complications
Improved efficiency/ room turnover Item Cost{US $)
Enhanced same-day PCI opportunities Femoral vascular ultrasound $243.00
for severe events. When these investigators of hospital stay (1.4 ± 0.2 days vs. 2.3 ± 0.4
used thrombolysis in myocardial infarction days). 27 Examination of the economic benefit
(TIM!) bleeding definitions for this same of TRA versus TFA for diagnostic catheter-
patient group, minor bleeds translated into ization was performed by Cooper et al in a
incremental costs of $4,310, and major bleeds randomized single-center study. Significant
increased costs by $8,794.15 Kugelmass et al reduction in hospital costs for transradial
reviewed data from Medicare patients under- versus transfemoral diagnostic catheterization
going PCI (N = 335,477) and demonstrated ($2,010 vs. $2,299, respectively; P < 0.0001)
adjusted incremental costs of $4,278 for those were related to reductions in LOS (3.6 hours
experiencing a vascular complication.16 vs. 10.4 hours), pharmacy, and total costs. It
Early single-center studies attempted to is notable that a difference was demonstrated
quantify the economic benefits of transradial even though vascular closure devices were
PCI. The first, described by Kiemeneij et not used in this study, minimizing equipment
al in 1995, showed that stenting via TRA costs for the transfemoral group. 28
was associated with a 45% cost reduction Acknowledging that the definitions for
compared to stenting via TFA. Savings were major bleeding and vascular complications
driven mainly by a significantly shorter length differ somewhat between studies, these events
of hospital stay. 26 Mann et al also quantified are generally reported to occur in < 1.5% of TR
the economic benefit of TRA in a study that patients compared to 3%-7% of TFA patients.
randomized 142 patients to TRA PCI versus There is, as yet, no large published multicenter
TFA PCI demonstrating a 15% decrease in randomized data examining the cost benefit
hospital charges with the radial approach. In related to decreased bleeding and vascular
this study, total charges were significantly complications comparing TRA with TFA.
reduced with transradial access compared to The information above, however, allows for a
the femoral approach ($20,476 ± $811 vs. rough estimate of the cost savings. Assuming
$23,389 ± $1,180; P < 0.01) due both to a a reduction in vascular and bleeding compli-
lower incidence of access site complications cations provided by TRA of 4.5% and an
(0% vs. 4%; P < 0.01) and to shorter length incremental increased median cost of $4,328
158 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
for a mild/moderate bleeding event, this eliminate these complications due to the nega-
would translate into a savings of $194,760 tive financial implications at both the federal
per 1,000 treated patients or $194.76 per and state levels.
patient. This likely underestimates the savings The concept of value-related reimburse-
per patient, as (1) the definitions ofbleeding ment has been further expanded by the
and vascular complications used in the above Affordable Care Act that ties reimbursement
studies are strict, and therefore these events to a Value-Based Purchasing (VBP) Program.
are likely underreported, and (2) the cost for The VBP Program mandates that hospitals
severe complications is much higher. use the Hospital Inpatient Quality Reporting
(IQR) Program to determine their clinical
performance as compared to similar institu-
• ECONOMIC IMPACT OF tions. Institutions with good health care
outcomes (low complications, high compliance
POLICY CHANGES IN THE with core measures, etc), compared to their
HEALTH CARE SYSTEM peers with inferior outcomes, enjoy higher
rates of reimbursement. 32•33 Initial measures
Economic stress placed on modem health
of quality will include treatment of cardiovas-
care systems has led to several new concepts
cular disease such as acute myocardial infarc-
that are now being applied in the clinical
tion. As demonstrated in the RIVAL study,
arena that are designed to aid in overall
improved outcomes in this patient group may
reduction of health care costs. In the United
be achieved by the choice of TRA.11
States, the Deficit Reduction Act of 2005
Public reporting of health care outcomes
resulted in a policy change at the Centers for
is a relatively recent phenomenon that
Medicare & Medicaid Services (CMS) whereby
developed concordandy with the widespread
incremental payments following the occur-
availability of information access via the
rence of a hospital-acquired complication
Internet. Public reporting has been demon-
have been eliminated, thereby shifting the
strated to augment quality improvement in
economic burden of that complication solely
hospitals beyond the gains achieved by "pay
to the providing institution. Examples of
for performance" programs. 34 The greatest
these potentially preventable complications
improvements in quality tend to occur at
(PPCs) include "post operative hemorrhage
hospitals with poor outcomes.35 Negative
and hematoma with/without hemorrhage
public perception regarding poorly performing
control procedure," and "post hemorrhagic
hospitals and the consequent decline in
acute anemia with transfusion."29 Using data
market share drive these quality improvement
standardized for case mix and severity of
efforts. As PCI outcomes are reported by
illness (All Patient Refined Diagnosis Related
several states, improved outcomes realized by
Group [APR-DRG] data) from the states of
the utilization of TRA may potentially provide
Maryland and California, the additional costs
indirect economic benefit.
of these complications has been estimated
to be $6,190 (MD)/$6, 758 (CA), $11,602
(MD)/$16,481 (CA), and $4,513 (MD)/$7,604
(CA), respectively. 30 Lack of additional • ECONOMIC BENEFITS OF TRA
reimbursement for the care related to these
complications obviously compounds the
RELATED TO RECOVERY AND MOBILITY
negative economic impact to the providing Additional indirect economic benefits of TRA
institution. Negative economic effects may are related to the rapid and safe postprocedure
also occur from cost control efforts at the mobility patients enjoy compared to TFA. This
state level. Maryland has initiated a Hospital translates into several advantages, including
Acquired Conditions Initiative assigning a (1) same-day or outpatient PCI, (2) more effi-
financial penalty to hospitals that fail to meet cient patient transport, room turnover, and
targets set for PPCs.31 Therefore, significant room utilization, and (3) decreased nursing
motivation exists for hospitals to minimize or intensity.
chapter 14 Transradial Arterial Access: Economic Considerations • 159
during recovery ($185 ±$52 vs. $208 ± $70.4; catheterization procedures in the United
P < 0.001) with the transradial strategy. 45 States.51•52 Femoral vascular closure devices
can cost more than $200 per unit. The most
expensive radial artery compression device
• OTHER POTENTIAL is approximately $40 per unit.51 Conversion
from TFA with a closure device to TRA with
ECONOMIC BENEFITS a compression device can be associated with
net material cost savings of approximately
Patient Return to Productivity
$149 per case. The overall savings of course
Lost worker productivity is a large contributor will be in proportion to case volume and the
to the economic burden of coronary artery magnitude of the conversion from TFA to
disease with absenteeism, presenteeism, TRA.s3
loss of income, and disability contributing
to the estimated annual $273 billion in total
indirect costs of cardiovascular disease in the
United States.46 Household income losses for
• NEGATIVE ECONOMIC
workers with ischemic heart disease have been CONSIDERATIONS RELATED TO TRA
estimated to be $3,013 annuallyY One study Compared to TFA with manual compression,
comparing triple-vessel coronary artery bypass some minor additional expenses can accrue
to 3-vessel PCI demonstrated that faster with TRA depending on the operator's choice
recovery and improved mobility following of equipment and institutional agreements.
the less invasive strategy was associated with Arterial access kits (micropuncture), routine
reduced time out of work and fewer lost wages administration of pharmacologic agents
($7,022 vs. $14,685; P < 0.05).48 Although (heparin, nitroglycerin, calcium channel
there are no published data, a secure access site blockers), and radial artery compression
and rapid postprocedure mobility following devices are some examples. The routine use
TRA for elective procedures provide the poten- of ultrasound imaging to aid in arterial access
tial for a more rapid return to productivity has been adopted at some centers and may
compared to similar patients undergoing these be associated with a significant initial capital
procedures by the femoral approach. equipment cost.
TRA is associated with a longer learning
Universal Catheters curve compared to TFA with operators
The use of a single catheter to perform potentially requiring ~ 200 cases to maximize
ventriculography, as well as right and left coro- expertise. 54-57 During this learning period,
nary angiography, originated with the brachial case times are longer, resource utilization is
cutdown and Sones catheter. This concept higher, and patient throughput in the cath-
has been successfully applied to the radial eterization laboratory is less efficient with
approach where several shapes of universal TRA compared to TFA.54•55 However, these
catheters are now employed.49•50 Benefits of a negative effects have been demonstrated to
universal catheter include minimizing catheter be temporary with differences in fluoroscopy
exchanges and the potential for trauma to and procedure times disappearing as operators
the radial, brachial, and axillary arteries and become more proficient with TRA.57•58
reduced risk for resultant spasm and dissec-
tion. Other advantages may include shorter
procedure durations and lower material costs • sUMMARY
resulting in minor economic benefit.
Transradial arterial access for coronary
and peripheral arterial procedures provides
Lower Closure Device Costs economic advantages compared to trans-
Although TRA is utilized in < 10% of cases femoral arterial access. Significant benefit
in the United States, vascular closure devices is realized through decreased vascular and
are used in approximately 40% of femoral bleeding complications that are associated
chapter 14 Transradial Arterial Access: Economic Considerations • 161
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Universal Catheter
49. Pancholy SB. Randomized comparison of Judkins
and Tiger catheters for transradial catheterization.
Journal ofMedidne. 2008;1:101-104.
chapter 15
The authors are grateful to Mr. Yash Soni and Mr. Chidambaram Iyer for their extremely valuable support during prepa-
ration of this manuscript.
Tortuosity
Tortuosity is an important issue, particu-
larly when dealing with patients older than
70 years, long-standing diabetics, hyperten- Figure 15.5 Example of high origin of RA from
sives, and females (see Figure 15.6). 1•4•7 high BA.
168 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Figure 15.7 Panel A: Perforation of BA leading to extravasation of contrast. Panel B: The affected segment was
crossed with O.Q14-in BMW PTCA wire. Panel C: Catheter was carefully negotiated over-the-wire across the perforated
segment. Panel D: Documentation of sealed perforation.
to understand that the catheter functions as an left anterior oblique, cranial or caudal
internal hemostatic device that helps to seal the angulations). Identify the view that best
perforated segment. defines the loop. The view that is chosen
can then be used as a "road map" for
Loops and Curvatures working through it (see Figure 15.8 A-C).
These are important anatomical variations to 2. Downsize the guidewire. If you encounter
understand and manage. 1.4·6•7•15 In our experi- resistance in the passage of a standard
ence, most of the time what we think is that 0.032-in or 0.035-in guidewire while
RA spasm is actually an anatomical variation working through the loop, remove the
that presents in the form of tortuosity, loop, wire because repeated attempts to nego-
or curvatures. We strongly recommend to tiate it against the resistance can lead to
keep a low threshold for performing a radial perforation, spasm, and severe local pain.
artery angiogram to define the anatomy for A flexible guidewire (ie, 0.014-in soft-tip
working through the vast majority of loops PTCA guidewire or a 0.025-in hydrophilic
and curvatures. guidewire) should be used in place of a
Tips and Tricks for Identification and standard guidewire to cross the loop.
Management of Loops and Curvatures. We The tip of a guidewire (especially of a
have already developed a protocol to work 0.014-in PTCA wire) can be shaped to the
through loops and curvatures. 15 It should angle of the loop to facilitate crossing.
reduce apprehension of a new radial operator When the guidewire crosses the loop, its
and give additional confidence to an experi- tip is parked as high as possible (ie, high
enced operator (see Table 15.1). brachial, axillary, or subclavian region).
The following are the important steps to Then the catheter can be advanced over
remember: it. Sometimes, when these guidewires
may not provide adequate support for
1. Define the task. When you encounter
the advancement of the catheters, the
resistance in the movement of a wire
strategy should be changed (mentioned
and/or a catheter, inject diluted contrast
in the later part of this discussion).
to define the anatomy. If a simple loop is
identified, you can work through it under 3. Use buddy wire(s). When a single
fluoroscopic guidance. If it is a complex 0.014-in PTCA guidewire provides
loop, take multiple views (ie, right and inadequate support for a catheter to
Figure 15.8 Panel A: Contrast injection in AP view does not reveal the anatomy properly. Panel B: RAO view reveals
the loop and a communicating artery. Panel C: LAO view adequately defines the loop.
chapter 15 Tips and Tricks forTransradial Access • 171
cross the loop, use of additionall or 2 the entire assembly slightly back (ie,
such guidewires should facilitate the the catheter along with the guidewire).
advancement of the catheter by adding This maneuver opens up the loop and
an additional support. straightens it. At this stage, advance-
ment of the catheter across the loop
4. Straighten the loop. Mostly, the catheter
becomes easy.
can easily be negotiated over the wire
across a loop without disturbing the 5. Exchanging the guidewire is helpful in
shape of the loop. When there is resis- addressing the most difficult loops. It
tance in passage of the catheter while is used if the catheter is partly inside
working through the loop, this technique the loop, but has not crossed the entire
is useful. loop, and it is difficult to advance it any
Push the catheter as far as possible farther.
into the loop, keeping the wire tip as Advance the catheter into the loop
high as possible (ie, in high brachial, as far as possible. Exchange the thin
axillary, or subclavian region). Then pull guidewire with another guidewire to
Algorithm
~
Define the task
~
Downsize the wire
~
Advance the catheter over the wire
Figure 15.11 Panel A: After crossing the loop, the catheter refuses to advance farther. Panel B: Assembly (catheter
and guidewire together) was carefully pulled back. Panel C: Demonstration of unfolding of the loop. Panel D: The loop
has been straightened.
174 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Figure 15.13 (A) Normal right subclavian and (B) axillary artery anatomy.
Figure 15.14 (A) Normal left subclavian and (B) axillary artery anatomy.
aorta (Figure 15.14). Therefore, they differ in procedure requires judicious use of guidewires
length, direction, and relationship to neigh- (0.025-in or 0.032-in hydrophilic guidewires,
boring structures in their proximal parts. standard 0.035-in guidewires, and super-stiff
The innominate-arch junction is unique to guidewires) and catheters (unusual curves, if
transradial procedures. Here the catheters and necessary) to complete the procedure.
guidewires must take an obtuse-angle turn to Following are the important relevant
enter into the ascending aorta. issues:
In cases of normal anatomy, the turn o Tortuosity in subclavian region
is smooth and does not pose challenges in
performing diagnostic or interventional o Severely dilated and distorted aortic
procedures. In cases of abnormal anatomy route (pseudo-arteria lusoria)
due to dilation or distortion of the aorta, the o Arteria lusoria
176 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
Figure 15.15 Example of mild subclavian tortuosity. Figure 15.16 Example of severe subclavian tortuosity.
• Step 1
The catheter and guidewire have a
tendency to enter the descending aorta. If
Figure 15.17 Example of pseudo-arteria lusoria.
this happens, withdraw the catheter and
the guidewire together as an assembly.
• If the catheter has tendency to enter the After asking the patient to take a deep
descending aorta, deep inspiration helps breath, gently push the 0.035-in standard
entry in the ascending aorta. guidewire. If the guidewire enters the
ascending aorta effortlessly, you can then
• While working through a left radial
push the catheter over the guidewire.
approach, the catheter traverses through
a wider angle, and at times it has a • Step 2
tendency to slip in the descending aorta.
If Step 1 is not successful, keep the guide-
Deep inspiration helps with ascending
wire in the descending aorta. Remove the
aortic entry, and wider catheter curves
Judkins right or left catheter, or the first
help coronary cannulation.
catheter you tried. Take a 5-Fr IMA diag-
nostic catheter, put it into the descending
aorta over the guidewire, and try the same
Working Through Arteria Lusoria
maneuver. In many cases, you will be
Using Right TRA successful in entering the ascending aorta.
Arteria lusoria is a congenital anomaly of the
right subclavian artery characterized topo- • Step 3
graphically as follows: The artery originates If the IMA catheter fails, then a 5-Fr
below the left subclavian artery as the fourth Simmon catheter can be used to enter the
main branch of the aortic arch and turns to ascending aorta.
Figure 15.18 Panel A: Documentation of arteria lusoria. Panel B: LCA cannulation through arteria lusoria.
Panel C: RCA cannulation through arteria lusoria.
178 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
or both, in preventing radial artery spasm during 12. Dehghani P, Mohammad A, Bajaj R, et al.
transradial artery catheterization. J Invasive Cardiol. Mechanism and predictors of failed transradial
2006;18(4) :155-15 8. approach for percutaneous coronary interventions.
4. Gilchrist I. Transradial technical tips. Catheter JACC Cardiovasc Interv. 2009; 2(11):1057-1064.
Cardiovasc Interv. 2000;49(3):253-254. 13. Grollman J Jr. The many faces ofthe anoma-
5. Kiemeneij F. Prevention and management of radial lous left aortic arch. Catheter Cardiovasc Interv.
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159-160. 14. Patel T. Right trans-radial approach: working
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procedural outcome. Heart. 2009;95(5):410-415. 15. Patel T, ShahS, Ranjan A. Patel's Atlas ofTransradial
7. Louvard Y, Lefevre T. Loops and transradial Intervention: The Basics. Chapter 7, 62-102. Seattle:
approach in coronary diagnosis and intervention. Sea Script Company; 2007.
Catheter Cardiovasc Interv. 2000;51(2):250-252. 16. Pancholy S, Coppola J, Patel T. Subcutaneous
8. Patel T, ShahS, Sanghavi K, Pancholy S. administration of nitroglycerin to facilitate radial
Management of radial and brachial artery perfora- artery cannulation. Catheter Cardiovasc Interv.
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9. Abhaichand R, Louvard Y, Gobeil J, et al. The Failure of transradial approach during coronary
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coronary angiography and angioplasty. Catheter Cardiovasc Interv. 2006;67(6):870-878.
Cardiovasc Interv. 2001;54(2):196-201. 18. Yiu K, Chan W, Jim M, et al. Arteria lusoria diag-
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11. Cha K, Kim M, Kim H. Prevalence and clinical
predictors of severe tortuosity of right subclavian
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chapter 16
release, which in turn causes or amplifies predicting spasm. A group from University of
arterial spasm at the injury site. Radial artery Athens Medical School reported measuring
spasm may be limited, such that catheteriza- the hyperemic blood flow response to
tion may continue, but may be associated with 5 minutes upper extremity ischemia using an
significant patient discomfort. Spasm may occlusive sphygmomanometer, and found that
also be severe, resulting in catheter entrap- an abnormal hyperemic response (an indicator
ment, a potentially very serious problem. of abnormal endothelial function) was highly
Radial artery spasm may be so severe that correlated with spasm upon radial artery
catheters or sheaths cannot be removed with sheath withdrawal;3 small arterial caliber and
force, and attempts may result in serious number of catheter exchanges also increased
vascular injury. spasm risk.
The chief principle in management of Notably, longer sheaths have been gener-
radial artery spasm is prevention through ally avoided during radial artery procedures,
administration of intra-arterial vasorelaxant over concerns that the longer sheath may
drugs, given shortly after arterial entry. provide greater resistance to removal if spasm
Without administration of vasorelaxant occurs. Although this is logical, at least one
drugs, radial artery spasm has been reported study found that use of longer 25-cm hydro-
to complicate more than one-fifth of transra- philic sheaths was linked to less spasm than
dial procedures.1 With routine intra-arterial shorter 7-cm nonhydrophilic sheaths. 4
vasorelaxant medication, spasm should not Spasm may develop gradually, with
complicate more than 5% of cases. Various catheters becoming increasingly difficult to
medication cocktails used for this purpose manipulate during the course of the case,
are reviewed elsewhere in this textbook; or can occur precipitously. Management of
although no clear front-runner drug combina- developing spasm follows three principles:
tion has been accepted as having primacy (1) additional vasorelaxant medications,
over all others, the combination of a calcium (2) sedation, and (3) time.
antagonist and a nitrate or nitrate donor drug Mild to moderate vasospasm can be
is popular owing to the ready availability of managed with additional nitrates, calcium
the drugs, their familiarity to interventional antagonists, and perhaps lidocaine. If cathe-
cardiologists, and at least some literature to ters become very difficult to manipulate, if the
support their use. 1•2 Addition of intra-arterial patient complains of significant pain during
lidocaine, which will block arterial C-fiber catheter movement, or if catheter entrapment
pain receptors, has been useful as well. Of occurs, alternative drugs should be consid-
note, some of these drugs (notably lidocaine ered. Intravenous nitroglycerin is available
and verapamil) create a strong sensation of in all labs and may be given providing blood
heat when administered to some patients. pressure is sufficient. Intra-arterial admin-
The discomfort of this can be minimized by istration of papaverine, an opium alkaloid
diluting the drug with blood or saline (blood antispasmotic compound, has occasionally
has greater buffering ability) and adminis- been pivotal in resolving spasm. 5 Intravenous
tering intra-arterial medication slowly. Early labetalol can be of theoretical benefit, having
administration of sedative drugs intrave- both alpha and beta blocking properties, but
nously is also helpful, but benzodiazepines any risk of unopposed alpha stimulation must
and morphine analogues can lower systemic be avoided. Nitroprusside should not be given,
blood pressure, making arterial puncture as its effects are chiefly on the microvascu-
harder. For this reason, many operators lature. The newer infusible dihydropyridine
choose to withhold sedating drugs until after calcium antagonist, devidipine, is untested
the arterial catheter is placed, counting on the for this application but likely will suffer from
retrograde amnestic properties of midazolam similar limitations; it has been used success-
and similar drugs to block memory of sheath fully to treat intraoperative spasm during
insertion. coronary artery bypass surgery. 6
Assessment of endothelial function along For any serious vasospasm, pain relief is
the radial artery route may be helpful in essential. The pain-spasm-pain cycle can only
chapter 16 Complications ofTransradial Access • 183
be broken when pain is abolished. Liberal treated by operators with less experience did
use of conscious sedation drugs will usually not. This observation provides a compelling
suffice, but occasionally deeper anesthesia is argument not just to use radial artery access
needed. We have observed several cases of when femoral access is problematical, but
catheter entrapment that were overcome only to use it always as your default technique.
when the patient was temporarily anesthe- Operators committed to the use of the radial
tized with propofol; once the patient was artery access route capture the benefits for
asleep, radial artery relaxation was immediate. their patients. A reassuring finding from
Although not available in many catheteriza- RIVAL: The composite of all vascular compli-
tion laboratories today, we have also found cations were lower with radial artery use, even
that the use of intra-arterial reserpine has among those operators with least experience.
succeeded in relieving spasm when other Bleeding from the radial arteriotomy site
maneuvers failed. Stellate ganglion block has is usually superficial. Although a large, deep
also been reported to be beneficial when all ecchymosis can occur, discoloring the forearm
else failed. and distressing the patient for weeks, these
Surgical removal of entrapped catheters is events don't pose significant risk. Deep tissue
exceedingly rare. bleeding into the forearm compartment is a
different matter (see "Forearm Compartment
Syndrome"). Superficial bleeding often
Access Site Vascular Complications arises when a radial hemostasis device is
Bleeding after sheath removal remains the placed improperly, either misaligned with
most obvious complication of arterial cannula- the arteriotomy or placed without sufficient
tion, whether radial, femoral, or other arterial. compressive pressure. Adjusting the device
Many reports in the literature, including should be the first step. If this fails to bring
randomized trials, attest to the reduction in bleeding under prompt control, either manual
bleeding complications when the radial artery compression should be used or a second
is selected rather than the femoral artery,7 compressive device may be applied, just
even when patients undergo catheterization in proximal to the first. Pressure should not be
the setting of full anticoagulation or intensive excessive, and the duration of pressure should
antiplatelet therapies.8•9 A small randomized not be excessive: In our laboratories, pressure
study from Greece found that transfemoral exceeding systemic blood pressure is only used
intervention in patients with international in the event of significant superficial bleeding
normalized ratio (INR) values between 1.8 that cannot be controlled otherwise, and
and 3.5 (average about 2.6) is complicated by pressure is not left for more than 90 minutes
bleeding in more than one-third of patients, in unanticoagulated patients.
whereas transradial intervention can be If uncertainty exists about whether a bleed
performed with no increase in bleeding risk. 9 is superficial or deep, measures should be
Reductions in bleeding events have been taken as outlined for forearm compartment
linked to reductions in procedural mortality in syndromes.
moderate population registries10•11 although,
interestingly, not in the large randomized
RIVAL trial,12 where rates of bleeding not Sterile Granulomas (Sterile Abscesses)
related to CABG surgery were observed to be Sterile granulomas were first reported as an
numerically less with transradial interven- apparent complication of the use of silicon-
tion but not statistically less. Several reasons coated vascular sheaths in 2003. 13 Such
might explain this finding, but a salient granulomas, in their acute phase, have the
observation is that patients treated by those appearance of bacterial abscesses, 13- 15 but are
operators with abundant experience in in fact sterile (hence they have been called
transradial procedures did enjoy significantly sterile abscesses). Although some speculate
lower bleeding rates and clinical complications that, despite their sterility, these granulomas
compared with patients treated with trans- may still have an underlying infectious
femoral intervention, whereas those patients etiology,15 most believe they represent an
184 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
inflammatory response to silicon or other hand ischemia. Nonetheless, the risk of hand
lubricant material that becomes trapped in ischemia should be borne in mind before
the dermis after sheath removal. A system- any radial artery cannulation. Publications
atic review of this problem, evaluating the from the surgical literature suggest that
federal Manufacturer and User Facility Device radial artery thrombotic occlusion following
(MAUDE) database that catalogues complica- placement of radial artery lines in critically ill
tions of medical devices, has found that only patients is associated with a high prevalence
the sheaths manufactured by Cook, Inc., were of gangrenous digits requiring amputation.
reported to the Food and Drug Administration Moreover, surgical intervention is of limited
(FDA) as being linked to this complication.16 help, perhaps because some of the damage is
Sterile granulomas can be easily avoided mediated through thrombotic emboli to the
by "stripping" the vascular sheath of excess fingers. 22
lubricant material before insertion. Simply Although a patent palmar arch and abun-
wiping the sheath with a saline-dampened dant ipsilateral arterial collateral vessels in
gauze several times will suffice. If a granuloma the forearm preclude significant consequences
develops, it may be managed conservatively. with radial artery occlusion, this complication
Local discomfort during the acute phase is is best avoided, if for no other reason than
improved if a tense granuloma is lanced and to facilitate use of the vessel during future
drained. Although antibiotic therapy is not procedures. This risk should also be kept in
indicated for sterile abscesses, acute phase mind during patient evaluation: Patients who
granulomas may be indistinguishable from are expected to need a patent radial artery for
bacterial abscesses, so either a short course of use in planned vascular or coronary artery
antibiotic therapy aimed at common skin flora bypass surgery, as an arteriovenous shunt for
may be prescribed, or an aspiration sample hemodialysis, or for other reasons may not be
of the lesion may be sent for culture. An good candidates for this approach.
untreated sterile granuloma will complete its Use of moderate-dose heparin (4,000
acute phase within 2 weeks, and the resulting units or more) given after sheath insertion
chronic granuloma will typically resolve has been shown to lower the incidence of
completely (or nearly completely) within a this complication, 23 but the very low doses
year. Chronic granulomas may be associated of heparin (2,500 units or less), commonly
with chronic pain and tenderness at the site; used in diagnostic procedures, have not. Also,
this also usually resolves with conservative there is no apparent benefit with intra-arterial
management. rather than intravenous heparin ad.ministra-
tion.24 Bivalirudin given to patients having
intervention did not produce meaningfully
Radial Artery Narrowing and Occlusion different late occlusion rates compared with
Occlusion of the radial artery is frequendy patients given heparin alone following a
reported to occur in 5% to 15% of patients diagnostic study. 23 Antithrombin therapy is
following transradial arteriography or angio- not required to prevent thrombotic complica-
plasty,4·17-21 although a recent prospective tions during diagnostic studies, although
vascular ultrasound evaluation of 455 patients therapy should be considered if the study is
in Germany found early radial artery occlusion prolonged.
in 13.7% of patients after 5-Fr sheath use A study from China using serial ultrasound
and in 30.5% of patients after 6-Fr sheath studies found the medial-intimal thickness
use.20 Development of critical hand ischemia at the arteriotomy site increased by about
complicating transradial coronary interven- 2.5-fold within 24 hours of cannulation,
tion has never been reported20 but is entirely and was associated with 20% reduction in
possible if the integrity of the palmar arch has the mean vessel diameter and about 3% rate
not been confirmed prior to cannulation. The of vessel occlusion. However, by 30 days,
forearm is relatively rich in collateral vessels the artery showed signs of healing, and the
too, which helps minimize the risk of severe occlusion rate had fallen to less than 2%. 25
chapter 16 Complications ofTransradial Access • 185
Still, chronic evidence of vascular injury may of hand symptoms, while asymptomatic
persist, with chronically smaller radial arteries patients with occlusion served as the control
at the access site and distal to it; this may be group.
especially prevalent in patients who undergo
repeat transradial procedures.26
Occlusion likely occurs as a result of local • RARE COMPLICATIONS
arterial trauma, combined with external
pressure and regional blood stasis during the Forearm Compartment Syndrome
period of compression after sheath removal. Forearm compartment syndrome may develop
This combination may permit development when bleeding into the forearm raises the
of a significant thrombus resistant to absorp- intracompartmental pressure enough to
tion and resolution. If true, then minimizing cause ischemic injury to contained structures;
the external pressure over the arteriotomy nerves are most sensitive. [Editor's note: See
site and avoiding blood stasis is likely to be Chapter 3 on anatomy.] Bleeding from the
more effective in avoiding occlusion than any radial arteriotomy site may track deeply
other maneuver. This has led to the practice into the forearm and cause compartment
of using much less compressive pressure than syndrome, but this is quite rare. Most cases
had been customary in the past, to achieve of compartment syndrome are related to
what has been called "patent hemostasis."19 bleeding from a vascular injury within the
Patent hemostasis implies documentation arm, often from around the olecranon fossa
of radial artery patency after application of where the radial artery loops and other
a hemostatic device. Typically, this involves anatomic variant r · ri k fa perfora-
application of a compressive device after tion (Figure 16.1; ~ Video 16.1 Hydrophilic
sheath removal, applying sufficient pressure guidewires can easily get trapped in small
to achieve complete hemostasis, then gradual branches and perforate them, and cause
reduction of the applied pressure until flow profuse bleeding in the setting of vigorous
can be confirmed through the radial artery anticoagulant therapy.
segment distal to the compression device Forearm compartment syndrome should
while the ulnar artery is compressed manu- be suspected in any patient complaining of
ally. If the preoperative pulse was difficult forearm pain, with an increase in forearm
to palpate, a Doppler probe can be used to girth, diminished or absent hand pulses, and
confirm anterograde flow through the radial cool, pale hand or fingers. If doubt exists,
artery (this eliminates the need to compress place 2 fingers into the palm of the patient's
the ulnar artery also, because a change in the hand and ask the patient to squeeze: Increased
flow signal direction can be easily appreci- compartment pressure makes contraction of
ated). Use of the patent hemostasis technique muscles intensely painful. If a patient is able
has been reported to reduce acute and to grip your fingers firmly without pain, he or
chronic radial artery occlusion significantly.19 she does not have compartment syndrome.
[Editor's note: See Chapter 6 on closure and Loss of sensation and pain on passive motion
hemostasis.] of the fingers are also consistent with the
Patients identified as having postproce- diagnosis of compartment syndrome.
dure radial artery occlusion before hospital Permanent neurologic injury can develop
dismissal may be considered for outpatient with high pressures sustained for more than
anticoagulant therapy. At least one study 4 hours and can lead to Volkmann contracture
has shown that a 4-week course of heparin of the hand.27 Although this is undoubtedly
therapy led to restored patency of the vessel the most serious vascular complication
in nearly 90% of afflicted patients, while fewer associated with transradial procedures, it
than 20% of those not receiving heparin had is exceedingly uncommon. A review of all
patent radial arteries at 1 monthP It should published literature on this topic between
be noted, however, that patients in this study 1992 and 2007 found only 5 reports in the
were selected to receive heparin on the basis literature on this topic. A 2008 institutional
186 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
review from one of the largest transradial the systolic pressure, maintaining that
practices in North America found 2 cases in pressure for 10 to 15 minutes, then releasing
more than 51,000 transradial procedures, pressure to allow hand perfusion and venous
yielding an incidence rate of 0.004%. 28 Small outflow for about 2 to 5 minutes. Some opera-
women may be at increased risk, and high tors advocate for use of external pressure that
doses of anticoagulants may contribute to the is slightly less than the systolic pressure. 28
risk, 28 but the rarity of the event makes these Between 2 and 4 cycles of external forearm
observations suspect. pressure is typically enough to stop forearm
If forearm hemorrhage is suspected, hemorrhage, but continued bleeding may
certain steps are mandatory to minimize occur. Forearm fasciotomy may be required
risk of permanent injury. All anticoagulants to prevent neurologic injury, even if bleeding
must be stopped; heparin should be reversed has stopped. For these reasons, it is critical
with protamine. Controlling pressure should that an appropriate surgeon be called to assess
be applied to the forearm to tamponade the the patient immediately. All radial operators
bleeding area by applying circumferential should be aware of the best surgeon for this
forearm pressure equal to, or greater than, task: In many hospitals this would be a job for
systemic blood pressure. Although standard a vascular surgeon, but in some hospitals this
sphygmomanometer cuffs are fine for this may be the purview of a hand, an orthopedic,
purpose, the inflatable pouches used for or even a general surgeon.
pressuring bags of saline are also suitable and
typically available in catheterization labora-
tory environments (Figure 16.2). Protocols Delay in Delivery of Large-Caliber Devices
for applying pressure vary, but 2 consistent Among the rare complications that should
characteristics are (1) use of pressure suffi- be considered with transradial intervention
cient to stanch arterial bleeding in the forearm is the possibility that reliance on the radial
and (2) intermittent release of this pressure access route may limit emergency treatment
to perfuse the hand. A sensible practice is to options, particularly during high-risk proce-
apply forearm pressure matching or exceeding dures and circumstances. Although nearly all
chapter 16 Complications ofTransradial Access • 187
Figure 16.2 Management of forearm bleeding complications. (A) Inflatable pouch used to pressurize bags of saline
(blue arrow) may be used to apply a broad band of pressure to a forearm with hematoma or perforation, and can be
used while hemostatic bands are in place over the arteriotomy site. Note bleeding beneath the original hemostatic
band (yellow arrow). Second hemostatic band (green arrow) placed proximal to original band often improves
hemostatic control at arteriotomy. (B) Successful management of forearm hematoma with two hemostatic bands and
a forearm pressure bag applied. Note that the integrated pressure gauge shows approximately 150 mm Hg pressure in
the bag, exceeding systemic blood pressure temporarily.
Figure 16.3 Perforation of radial artery and subsequent development of radial artery pseudoaneurysm. Catheter
advancement through a tortuous radial artery (A) resulted in vascular injury and forearm bleeding (B). Despite
successful management acutely, the patient returned 5 days later with pain and swelling of the forearm. Repeat study
identified radial artery pseudoaneurysm development at the site of vascular injury (C). Source: Williams PD, Eccleshall
5, Heart. 2009;95(1 3):1 084.
Figure 16.4 Ultrasound image of forearm of 59-year-old man 3 weeks after transradial intervention. (A) Image is
consistent with radial artery pseudoaneurysm. (B) Ultrasound image of forearm of 61-year-old man one year after
transradial intervention. Doppler images demonstrate presence of arteriovenous fistula. Source: Spence MS, Byrne J,
Hargeli L, Mildenberger R, Kinloch D. Rare access site complications following transradial coronary intervention. Can
J Cardiol. 2009;25(6):e206.
be readily diminished with simple measures rare but notable complication is Ortner's
easily incorporated into routine practice. More syndrome: damage to the recurrent laryngeal
serious vascular complications include the nerve caused by excessive deformation of
development of a forearm hematoma with a highly tortuous right innominate artery,
compartment syndrome, which stands as avoidable by recognizing the anatomy most
the most important to recognize quickly and likely to place a patient at risk of this compli-
manage correctly because it can lead quickly cation and using an alternative access route.
to permanent neurologic injury. Surgical As with other aspects of medical practice,
decompression of the forearm compartment awareness of complication possibilities,
is the mainstay of therapy for this problem. knowledge of appropriate preventive and
Radial artery pseudoaneurysms and arterio- corrective actions, and recognition of actual
venous fistulae are rare but can cause forearm adverse events are the keys to a transradial
perfusion problems and discomfort and often interventional practice characterized by a
require surgical intervention for repair. A very minimum of complications. It's also worth
190 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
remembering that although transradial access study (Mortality benefit Of Reduced Transfusion
has much to recommend it, there is no room after percutaneous coronary intervention via the
Arm or Leg). Heart. 2008;94:1019-1025.
for zealots in a transradial practice: failure 11. Rao SV, Ou FS, Wang TY, et al. Trends in the
to transition to another access route when prevalence and outcomes of radial and femoral
circumstances place a patient at increased approaches to percutaneous coronary intervention:
risk of complications related to radial artery a report from the National Cardiovascular Data
use is not defensible. Conversion from radial Registry. JACC Cardiovasc Interv. 2008;1:379-386.
12. Jolly SS, Yusuf S, Carins J, et al. Radial versus
to femoral access because of complication femoral access for coronary angiography and inter-
risk should be very uncommon, but is not an vention in patients with acute coronary syndromes
admission of technical ability; indeed, it is a (RIVAL: a randomized, parallel group, muticentre
measure of good medical judgment. trial). Lancet. Epub April4 2011.
13. Kozak M, Adams DR, Ioffreda MD, et al. Sterile
inflammation associated with transradial catheter-
ization and hydrophilic sheaths. Cathet Cardiovasc
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2. Kiemeneij F, Vajifdar BU, Eccleshall SC, Laarman abscess formation as a complication of hydro-
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Intraoperative administration of clevidipine 19. Pancholy S, Coppola J, Patel T, Rake-Thomas
to prevent vasospasm after radial and internal M. Prevention of radial artery occlusion-patent
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2009; 157:132-140. artery catheterization: impact of sheath size on
8. Siudak Z, Zawislak B, Dziewierz A, et al. vascular complications. JACC Cardiovasc Interv.
Transradial approach in patients with ST-elevation 2012;5(1):44-46.
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493- 499. 23. Plante S, Cantor WJ, Goldman L, et al. Comparison
10. Chase AJ, Fretz EB, Warburton WP, et al. of bivalirudin versus heparin on radial artery
Association of the arterial access site at angioplasty occlusion after transradial catheterization. Catheter
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24. Pancholy SB. Comparison of the effect of intra- 33. Tsao JW, Neymark E, Gooding GA. Radial
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J Cardiol. 2009;104(8):1083-1085. 2000;28(8):414-416.
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Wang Z. Impact of transradial coronary procedures Dzavik V. Pseudoaneurysm after transradial cardiac
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• viDEO LEGENDS
874-875. IVideo 1&.1 Run 1~ Excessive tortuosity of upper
30. JaffeR, Hong T, SharieffW, Chisholm RJ, et al. extremity arteries below the olecranon fossa (videoclip
Comparison of radial versus femoral approach for label: Nadel Run 1).1Run 2:1Excessive tortuosity of
percutaneous coronary interventions in octogenar- upper extremity arteries above the olecranon fossa. Note
ians. Cathet Cardiovasc Interv. 2007;69(6):815-820. pseudostenosis of forearm arteries as a result of forced
31. Vuurmans T, Byrne J, Fretz, E, et al. Chronic kidney straightening of tortuous vessels. Radial approach aban-
injury in patients after cardiac catheterisation or doned to avoid injury (videoclip label: Nadel Run 2).
percutaneous coronary intervention: a comparison I
Run 3:trortuous radial artery with forced straighten-
of radial and femoral approaches (from the British ing, perforated while attempting to advance diagnostic
Columbia Cardiac and Renal registries). Heart. catheter. Perforation managed with external pressure
2010;96 (19): 1538-1542. (videoclip label: AJ radial art perf).
32. Spence MS, Byrne J, Hargeli L, Mildenberger R,
Kinloch D. Rare access site complications following
transradial coronary intervention. Can J Cardiol.
2009;25(6):e206.
chapter 17
technique, and those few remaining inter- Table 17.1 Requirements for Transitioni ng to
ventional cardiologists with experience in the Transradial Catheterization.
Sones technique will find the radial technique 1. Accept shortcomings of femoral access.
is easier to master.] In addition, relatively few
2. Recognize benefits of radial access.
teaching laboratories prior to the past few
3. Educate physician operators.
years performed transradial procedures in
sufficient volume to comprehensively train 4. Educate cath lab staff.
fellows. As a result, most operators and hospi- 5. Observe established radial operation.
tals have had to initiate transradial programs 6. Choose and obtain proper equipment.
without the benefit of in-house expertise. 7. Choose initial cases prudently.
In general, transitioning to radial access
8. Avoid high-risk cases initially.
requires a significant commitment. The
9. Start slow.
purpose of this chapter is to review the
practical issues involved and to provide some 10. Select a project leader.
suggestions for shortening the inherent 11. Collect feedback from patients (especially those
learning curve. Indeed, one of the major who have had prior femoral access) and staff.
purposes of this textbook is to shorten the 12. Stay the course.
learning curve for the new operator. In addi- This list is adapted from Pinak Shah, Transradiallntervention
tion, some practical suggestions are provided Program, Society of Cardiac Angiography and Interventions,
for smoothing the transition. Table 17.1 is a January 15, 201 1. http://www.cardiovascularbusiness.com/index
.php?option=com_articles&view=article&id=25868:scai-a-12-step-
summary of the salient issues to be consid- program-for-femora 1-aholies
ered and serves as an outline for this chapter.
jumping on the bandwagon when the staff • Understand and choose patient-specific
evinced enthusiasm and the trend was clearly periprocedure polypharmacy.
apparent. The fifth and last convert switched
• Have a plan of action for challenges
over through peer pressure: Patients being
posed by arm, subclavian, aortic, and
referred specifically for radial access required
coronary anatomy.
readjustment of clinic schedules and other
responsibilities to cover radial cases when that Consider having a proctor on site for the
individual was in the cath lab. first few days of radial procedures, and make
certain that 1 or 2 operators who will lead the
2. Recognize the Benefits of Radial transition perform as many cases as possible
with the proctor present.
The data for lower complication rates with
radial access,3·6•8 greater patient comfort,
and simpler postprocedure management, 4. Educate Cath Lab and Hospital Staff
including early ambulation and simpler and Just as there will be recalcitrant physician
cheaper closure methodologies, are reasonably operators, cardiac cath lab staff may exhibit
supported by the literature. 9 The argument reluctance to switch from the "tried and true"
that combining vascular closure devices femoral approach, in particular because labs
with a femoral approach is the equivalent of that perform radial catheterization uncom-
performing the procedure via the radial route monly are likely to associate radial access
has not been compelling. 10 The cost benefits with prolonged access times, high failure rate
plus shorter length of stay for radials along and crossover, extended procedure duration,
with a mandate for same-day discharge of PCis and often a "messy" process in general, with
will draw the support of cath lab managers patient pain, blood and fluids on the floor, and
and hospital administrators. Patient prefer- in general anything but the smooth and quick
ence lends a significant impetus and spreads procedures associated with longtime femoral
fairly rapidly in the community, and lack of a access operations. The substantial increase in
strong radial operation eventually becomes a failure and complications for the occasional
commercial disadvantage for many hospitals. operator have been well documented in the
brachialliterature;13 many of the reasons for
3. Educate Physidan Operators failure are identical to those seen with the
occasional brachial as well as the occasional
As with most procedures, physician education
radial approach. Staff need to be exposed
requires reviewing the evidence base as well
to the same evidence base that physician
as some "how to"literature. 11 An increasing
operators rely on to understand the rationale
number of courses are offered as well. Some
for transitioning to radials, and a lead nurse
particularly important elements to consider
or technician should be sought to champion
include the following:
and oversee the transition. Having a dedicated
• Develop a sophisticated knowledge of radial team of technicians and nurses in the
the subtleties and limitations of the early phases of the transition may be helpful
Allen's test. as well.
• Use an oximeter/plethysmography
device along with the Barbeau classifica- 5. Take a Field Trip
tion12 rather than a simple "positive/
Instead of "reinventing the wheel," it makes
negative" grade for the Allen's test.
substantial sense to take physician operators
• Develop a comprehensive understanding and cath lab staff to visit a successful transra-
of the factors that cause, as well as diallaboratory. There are considerable bits of
the means to treat, spasm, intractable know-how involved in successful transradial
pain, hand ischemia, and perforation/ catheterization that may not be found easily
compartment syndrome. in the literature or on the Internet. This
196 • Transradial Access: Techniques for Diagnostic Angiography and Percutaneous Intervention
applies to mundane but important aspects nonhydrophilic wires to traverse the arm,
such as preprocedure radial artery assessment, short versus longer sheaths, short micropunc-
prepping and draping the patient, preparing ture versus longer-sheathed N insertion-type
the left radial, equipment selection, pre- and needles, arm boards versus no arm boards,
postprocedure management, management of sheathed versus sheathless catheters, ali-in-
the x-ray gantry, and working with the peri- one versus dedicated right and left coronary
procedural polypharmacy distinct to the radial diagnostic and guiding catheters, and so on. 14
approach. Currently there are no accreditation The same applies for type and amount of
standards and no training program standards anticoagulation. 15 A particularly vexing issue
in transradial catheterization. A number for cath lab staff is that individual opera-
of academic courses coordinated by high- tors tend to choose different "cocktails" and
volume radialists provide an excellent initial equipment, much more so than with routine
exposure to the transradial approach. Beyond femoral cases. In our laboratory, we finally
the lectures, these courses provide a unique had a meeting of operators and came up with
opportunity to ask questions and network a compromise that was acceptable to all radial
with individuals who have been practicing catheterizers.
transradial catheterization.
After attending a course and visiting a
high-volume radial center, the next step in 7. Pick Your First Cases Carefully
the development of a transradial program is It is essential to start with a manageable group
to plan a meeting of all interested parties. of patients who have a high chance of success
Practice partners and interventionalists will and low risk of complications. As a rule, it
be interested in physician staffing needs. is initially best to avoid elderly, thin, short
Catheterization laboratory staff will be vital or very tall, and diabetic patients. Similarly,
in the preparation and troubleshooting of patients who are known to require PCI,
the new radial program. Cardiology fellows coronary artery bypass graft (CABG) patients,
and physician assistants will need to be or procedures that will require larger than
trained on preprocedural radial evaluation of 5-Fr sheaths are less desirable for novices,
patients. Nurses and technicians will need although after the early learning curve all of
to be trained on radial site preparation, arm these patients will be not only appropriate
board placement, and catheter selection. The but in most cases desirable candidates for a
recovery room staff will need to be made transradial approach.
aware of monitoring for radial complications Initially, both the planned radial site and
and management of vascular closure methods. a backup femoral site should be prepared for
For patients who are admitted to the floors catheterization. This will allow for minimal
or intensive care units, nurses will need to be disruption in the event the radial access is
in-serviced. Hospital administration should be unsuccessful. Some seasoned centers will tran-
involved in some of these meetings to provide sition to only preparing the radial site once an
the infrastructural support. adequate learning curve has been achieved.
Many skilled operators facilitate a more
rapid learning curve by working in conjunc-
6. Choose the Right Equipment tion with a partner in a dual-operator
Individual aspects of equipment selection scenario. In academic centers, after this initial
have already been covered in this book. It is learning period, a cardiology fellow can be
important to appreciate that the evidence the first or second operator once the primary
base for an optimal radial approach remains operator has developed adequate comfort
in evolution, and many recommendations with the procedure. As proficiency increases in
are empiric rather than evidence based. the radial technique, it is reasonable to begin
Thus there is fervent support for both transitioning to more complex cases, including
sides of several debates: hydrophilic versus emergent PCis.
chapter 17 How to Start a Transradial Program at Your Hospital • 197
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Figure 17.1 Transition from transfemoral (TF) preferred to transradial (TR) preferred in one high-volume laboratory.
The red line demonstrates the percentage of cases that required crossover to femoral, peaking at 13.6% in the early
learning curve, and again at 15.9% as volume and operator involvement increased and case selection liberalized.
Source: Reproduced with permission. From TurnerS, Sacrinty M, Manogue M, et al. Transitioning to the radial artery as
the preferred access site for cardiac catheterization: an academic medical center experience. Catheter Cardiovasc lnterv.
201 1. doi:1 0.1 002/ccd.23387.
peripheral access procedures. As newer tech- 5. Turi ZG, Wong SC. Perspective: femoral access is
nologies specifically designed for the transra- preferred or don't throw the femoral out with the
bathwater. JAm Coli Cardiol. 2013 (In Press).
dial approach come to market, radialists will 6. Jolly SS, Yusuf S, Cairns J, et al. Radial versus
have an even greater range of procedures that femoral access for coronary angiography and inter-
they can perform. Careful introduction of the vention in patients with acute coronary syndromes
radial technique should make the transition (RIVAL): a randomised, parallel group, multicentre
relatively seamless. trial. Lancet. 2011;377(9775):1409-1420.
7. Brasselet C, Blanpain T, Tassan-Mangina S, et al.
Comparison of operator radiation exposure with
optimized radiation protection devices during coro-
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Cathet Cardiovasc Diagn. 1993;30:173-178. site complications. Catheter Cardiovasc Interv.
3. Rao SV, Ou FS, Wang TY, et al. Trends in the 2012;79(4):589-594.
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4. Proudfit WL, Shirey EK, Sones FM Jr. Selective 10. Mann T, Cowper PA, Peterson ED, et al. Transradial
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•
IX
ChapterS
Brachial Loop
IVideo 5.2 1The loop in the brachial artery
above the elbow is overcome with an angled
Glidewire gradually advanced through the
loop. It is advisable to overcome the loop with
201
202 • Appendix
203
204 • Index
non-access site-related, 10, llf central venous catheterization. See right heart
non-CABG, 10, lOt catheterization
predicting, 102 clevidipine, 182
transradial access and, 13-14, 80-81 CMS. See Centers for Medicare & Medicaid Services
Bleeding Academic Research Consortium (BARC), compartments
bleeding definition, 100, lOOt anatomy, 35
blood transfusions, harm from, 13 syndrome, 35-36, 185-186, 186f, 187f, 19lv
brachial artery upper extremity, 34-36
anatomy, 166, 166f Cook Silhouette double dilator, 68
loop, 52, 54v Cordis Fajadet L4 guide, 68, 69
system, 21-22, 22f Cordis Hockey Stick, 68
buddy wires, 70, 71f Coronary Angiography Through the Radial or Femoral
bypass graft interventions, catheters for, 69-70, 69f, Approach (CARAFE) study, 17, 146
70f coronary arteries, cannulation of, 178, 177f
coronary artery bypass graft (CABG), non-CABG
bleeding, 10, lOt
coronary Palmaz-Schatz stent implantation, outpatient,
83-84
CABG. See coronary artery bypass graft cost benefits analysis, 17-18
calcium channel blockers, 52, 97, 133, 135 See also economic benefits
Campeau, L.,l, 30, 80, 141,193 Coumand, A., 131
Can Rapid risk Stratification of Unstable Angina CRUSADE (Can Rapid risk stratification of Unstable
Patients Suppress Adverse Outcomes with Early angina patients Suppress ADverse outcomes with
Implementation of the ACC/AHA Guidelines Early implementation of the ACC/AHA guidelines)
(CRUSADE), Bleeding Score, 99t, 101, 102, 103f Bleeding Score, 99t, 101, 102, 103f
CARAFE (Coronary Angiography Through the Radial or c7E3, 85
Femoral Approach) study, 17, 146 CURE trial, 13
cardiovocal (Ortner) syndrome, 188 CURRENT-OASIS 7 trial, 9t, 105
carotid arteries, stenting of, 124-125, 124f, 125f
catheters and catheter techniques
Amplatz catheter, 64, 65f, 68, 69-70
for bypass graft interventions, 69-70, 69f, 70f
diagnostic coronary angiography, 63-67, 65f, 66f deep seating, 70
Eaucath catheter, 67, 75 Deficit Reduction Act (2005), 158
BBU catheter, 68, 97-98 descending aorta to ascending aorta, 53-54, 54v
general, 62, 62f, 63f diagnostic coronary angiography, 63-67, 65f, 66f
Glide catheter, 67-68 door-to-balloon (D2B) times, 16, 61, 108, 109f
Jacky catheter, 65, 66f Doppler ultrasonography, 43-45, 44f
J-tipped wire, 26, 27£, 62, 62f, 63£, 65 drugs
Judkins catheters, 64, 68, 97, 125-126, 126f See also type of
Kimny guide catheter, 64, 65f, 68, 70, 7lf anticoagulants, 56, 97
for LAD interventions, 68 antispasm cocktail, 135
larger-caliber guides, 76, 77f intra-arterial, 52, 97, 182, 183
for left circumflex interventions, 68-69 sedating, 182, 183
left radial approach, 64 vasorelaxant, 182
patient selection and, 61-62 D2B. See door-to-balloon times
for PCI, 67-73, 67f, 69f, 70f, 71f, 72£
pseudodilators, 67-68
for right coronary interventions, 68
right radial approach, 64
sheathless insertion of, 67-68, 67f, 75-78, 76f, Early Discharge After Transradial Stenting of Coronary
77f, 78f Arteries (EASY), 85-86, 159
size,67 EASY (Early Discharge After Transradial Stenting of
smaller-caliber guides, 77, 77f Coronary Arteries), 85-86, 159
Sones technique, 65-66 Eaucath catheter, 67, 75
TIG catheter, 62, 63f, 65 EBU catheters, 68, 97-98
universal catheters, 64-67, 160 ECMO. See extra-corporeal membrane oxygenation
XB catheter, 68, 98 economic benefits
Centers for Medicare & Medicaid Services (CMS), 96, health care policy changes and, 158
158 recovery and mobility and, 158-160
central aorta from right radial, accessing, 52-53 reduced complications and, 155- 158, 156t, 157t
Index • 205
vascular anatomy
anthropometric measurements in vascular system, women
122f acute coronary syndromes and, 114
assessment of hand, 30-34 guide catheters and, 73
brachial artery system, 21-22, 22f wrist branches, 25
dimension considerations, 28, 30, 31f
palmar arches, 31-34, 32f, 33f, 34f
radial and ulnar branches, 22-24, 23£, 24f
radial artery branches, 24-25
radial artery system, 22-24, 23f XB catheters, 68, 98
recurrent radial artery, 24-25, 23f, 24f x-ray exposure, 145
upper extremity compartments, 34-36
vascular anomalies, 25-28
vascular closure devices (VCDs), 104, 160
vascular complications
defined, 8
incidence of, 8, 10
management of, 183
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