Group 67b

Victoria Chin, Venosheni Ravichandran,

Yamunaah Bala, Sangeeirthana
Rao,Kanchana

 Dr Marco Tubaro (Italy), ACCA member and coauthor, said:

The radial approach strongly reduces the bleeding
complication at the site of the procedure. The
reduction in bleeding translates into a reduction in
events and even into a reduction in mortality,
particularly in patients with ST-elevation myocardial
infarction (STEMI).
http://www.escardio.org/The-ESC/Press-Office/Pressreleases/Last-5-years/Radial-access-should-be-firstchoice-for-PCI-says-ESC

 Transradial approach (TRA) in percutaneous

coronary interventions (PCI) today becomes
widely accepted and practiced procedure
worldwide. TRA for PCI is safe and fast growing
alternative to transfemoral approach (TFA) in
many clinical settings and it is the desirable
vascular access for most highly experienced
operators. The radial artery is a preferred
approach because perfusion of the hand can
remain uncompromised even in case of radial
artery occlusion (RAO) due to double arterial
vasculature including ulnar artery and a palmar
vascular arch

History
Transradial catheterization first described by
Radner in 1948.
In 1989, Campeau et al revisited Radners idea &
reported on percutaneous entry into distal radial
artery for selective coronary angiography in 100
pts.
In 1992, Kiemeneij et al used Campeaus work as
the basis for developing TRI.
1. Radner S. Thoracal aortography by catheterization from the radial artery; preliminary report of a new
technique. Acta radiol. 1948;29:178-80.
2. Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn.
1989;16:3-7.
3. Kiemeneij F, Laarman GJ, de Melker E. Transradial coronary artery angioplasty. Am Heart J.
1995;129:1-7.

Risk of vascular complications associated

with femoral and radial access
Retrospective review of 5,234 cath and PCI
Vascular complications by BMI: lower rate of vascular complications using
TR vs. TF approach for obese and non obese patients

6.0%
5.0%

P= 0.048
P= 0.040

5.3%

4.0%
4.00%

3.0%
2.0%

2.1%

1.0%
0.0%

0.7%

Non-obese
Femoral

Obese
Radial

Cox, N. Am J Cardiol 2004; 94 1174-1177

Radial versus femoral

access for coronary
angiography or PCI:
A systematic review and
meta-analysis of
randomized trials (total
of 4458 patients)

Jolly SS et al.
Am Heart J
2009;157:132-40

Radial vs. femoral access for coronary angiography or PCI:

A systematic review and meta-analysis of randomized
trials

Jolly SS et al. Am Heart J 2009;157:132-40

RIVAL Study Design

NSTE-ACS and STEMI
(n=7021)
Key Inclusion:
Intact dual circulation of hand required
Interventionalist experienced with both
(minimum 50 radial procedures in last year)

Randomization
Radial Access Femoral Access
(n=3507)
(n=3514)
Blinded Adjudication of
Outcomes
Primary Outcome:
Death, MI, stroke
or non-CABG-related Major Bleeding at 30 days
Jolly SS et al. Lancet 2011.

RIVAL study
7021 patients with
ACS undergoing PCI

Primary endpoint - NACE

No difference in
MACE death, MI,
stroke
Trend for less major
bleeding with radial
access, depending
on the bleeding
definition

Non CABG major bleeding

Less vascular
complications with
radial access
Special benefit for
radial in STEMI pts

Jolly et al, Lancet 2011

RIFLE-STEACS study (Radial Versus Femoral Randomized Investigation in ST-

Elevation Acute Coronary Syndrome)

1001 pts with ST elevation ACS randomized TRI vs

TFI at high volume centers
NACE at 30 days (cardiac death, stroke, MI, TVR,
bleeding): 13.6% TRI VS. 21% TFI (P=0.003)
Cardiac mortality : 5.2% TRI vs. 9.2% TFI (P=0.02)
Bleeding: 7.8% TRI vs. 12.2% TFI (p=0.026)
Shorter hospital stay with TRI
Romagnoli et al JACC, 2012

Technical Tips for

Successful Transradial Cannulation

Use a 21 G x 2.5 cm thin wall needle to

cannulate the radial artery
Advance a 0.025 inch guidewire through the
needle
After the introducer is inserted, give cocktail
of Verapamil 2 mg diluted in saline, or 100-200
mcg of nitroglycerine, with by 50 units/kg
heparin bolus

Quesada et al, Transradial Coronary Interventions,

Interventional Cardiology Secrets, 2003, pp. 203-210

The Anatomy

The Anatomy

Allens Test -

Can be performed Oximetry

test

Peripheral vascular diseases. Edgar van Nuys Allen, MD and others with associates in the Mayo
Clinic and Mayo Foundation; 2nd edition, Philadelphia, Saunders, 1955.

Allens Test - Can be performed Oximetry

test

We

recommend that, in the presence of an abnormal AT, the

RA should not be used for cardiac catheterization unless the
risk of using the femoral approach is excessive. Greenwood
et al. JACC Vol. 46, No. 11, 2005, 2005:20137

Optimal Candidates for TR Access

Most of the population who have dual

circulation to the hand

Obese individuals who are at increased

risk of complications from TF access

Individuals with severe PVD or AAA

Diagnostic procedures (e.g. prior to

cardiac surgery)

Today TR is the default approach in many centers

Radial Access: proximal to styloid process

Not really the wrist!

Sedation and Verapamil / Nitro Virtually

Eliminate the Spasm Problem

Before

After

Radial Loop and Radial Recurrent Artery

The Learning Curve: Transradial Pitfalls

Getting access
Radial Artery Spasm
Prevention and management
Anatomical Variations
Tortousity, vascular anomalies
Transversing the subclavian Rt vs. Lt
Respiration maneuvers
Need for TF conversion
Catheter shape selection for cannulation
Catheter control and backup support
Patent Haemostasis after pulling out the sheath

Sheathless Catheters

Transradial Access Site Complications

Radial artery occlusion (5%, higher rates

when routine doppler is used, mostly asympt.)
Forearm hematoma and/or pain
Radial artery pseudoaneuyrsm
Radial or brachial or artery perforation
Uncontrolled bleeding with resultant
compartment syndrome
Pain during catheter insertion
Need for femoral conversion (5-10%)

Radial Artery Occlusion Factors

Artery size: higher incidence with smaller artery
Larger catheter (>6 French)
Lack of heparinization or heparin dose
Artery spasm: pretreatment with verapamil /
nitro
Hemostasis device: minimize over-compression

Ruo S, EHJ 2012

Radial Access - Disadvantages

Associated with a significant operator learning curve
Has limited compatibility with very large equipment
Elderly patients may have increased tortuousity of the
radial and subclavian arteries which makes the
procedure
more challenging

May have limited guiding catheter support in most

challenging PCI scenarios (tortousity, heavy calcifications,
complex bifurcations)

Associated with upper limb arterial complications (rare)

Higher radiation exposure to the operator

Radial Access - The Advantages

Decrease the incidence of major vascular
complications
Decrease the incidence of bleeding complications
Appears to decrease MACE in patients with ACS
Better control over vascular access and hemostasis
for obese and overall patients
Decreased time to ambulation
Improved patient movement and comfort
Allows early discharge policy
May decrease cost