Radial access interventions pros,cons and evidense
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This document discusses the history and current evidence regarding transradial catheterization. Some key points: - Transradial catheterization began in the 1920s but became more widely used starting in the late 1980s and 1990s. - Studies have shown that radial access reduces access site bleeding complications compared to femoral access, especially in high-risk patients. It also improves patient comfort and allows for shorter hospital stays. - Radial access should be the preferred approach over femoral for experienced operators, according to ESC revascularization guidelines. While there is a steep learning curve, radial access can be used for all procedures including bifurcation PCI. - Disadvantages include a longer procedural time initially and risks of radial
Radial access interventions pros,cons and evidense
- 1. Transradial Catheterization Pros, Cons and current evidence Ahmed Kamel,MD,FEBC National Heart institute Fellow of Arhus university hospital,Denmark Member of the EAPCI
- 2. Historical Background • Approaching the heart from upper limb is not new , it started in 1929 by Dr. Werner Frossman who performed the first human cardiac cath via brachial vein. • In 1948, the first radial aortic canulation was described by Dr. Rander S.
- 3. Historical Background Cont • Dr. Frank Mason Sones performed the first coronary catheterization through brachial artery by arterial cutdown technique in 1958 . • By the late 60 s Dr. Melvin Paul Judkins invented the preshaped catheters and used the Seldinger technique transfemoral, that was discovered by Sven Seldinger in 1953
- 4. Historical Background cont • In 1977 the first coronary angioplasty was Performed by Andreas Gruentzig. • 1989 100 transradial angiography cases reported by Lucien Campeau. • In 1993 the first radial intervention was done by Ferdinand Kiemeneij and Laarman .
- 5. References 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
- 6. WHY RADIAL ???????? Why should I have to go radial if I can do all my procedures through femoral access?
- 7. Simply because sometimes you will have no choice
- 9. • What if I have an average built patient with a (straight) non tortous iliac and femoral arteries, Do I have to go radial? YES because you will get many advantages
- 10. Advantages of radial access • Clinical advantages • 1-Less access site bleeding and other complications as the radial artery is small and superficial, it is easily compressible ,bleeding complications associated with radial arterial access are extremely rare. • Non clinical advantages • 2-Patient comfort. • 3-Less hospital stay which will save a big sum of money.
- 12. • Femoral access procedures carry a significant risk of access-site bleeding complications. Hematomas, pseudoaneurysms and Retroperitoneal hemorrhage which is a potentially life-threatening complication of femoral arterial catheterization. • Patient groups who derive an increased benefit from transradial cardiac catheterization include elderly persons, those with acute coronary syndromes,and those receiving IIb/IIIa inhibitors
- 13. Low bleeding risk • Many trials have compared between radial and femoral access in STEMI in particular (STEMI RADIAL, RIFLE STEACS) or ACS in general (RIVAL,MATRIX) • They all showed superiority of radial access PCI regarding bleeding complications.
- 14. NSTE-ACS and STEMI (n=7021) Radial Access (n=3507) Femoral Access (n=3514) Primary Outcome: Death, MI, stroke or non-CABG-related Major Bleeding at 30 days Randomization RIVAL Study Design Key Inclusion: • Intact dual circulation of hand required • Interventionalist experienced with both (minimum 50 radial procedures in last year) Jolly SS et al. Lancet 2011. Blinded Adjudication of Outcomes
- 15. Primary and Secondary Outcomes Radial (n=3507) % Femoral (n=3514) % HR 95% CI P Primary Outcome Death, MI, Stroke, Non-CABG Major Bleed 3.7 4.0 0.92 0.72-1.17 0.50 Secondary Outcomes Death, MI, Stroke 3.2 3.2 0.98 0.77-1.28 0.90 Non-CABG Major Bleeding 0.7 0.9 0.73 0.43-1.23 0.23
- 16. Other Outcomes Radial (n=3507) % Femoral (n=3514) % HR 95% CI P Major Vascular Access Site Complications 1.4 3.7 0.37 0.27-0.52 <0.0001 Other Definitions of Major Bleeding TIMI Non-CABG Major Bleeding 0.5 0.5 1.00 0.53-1.89 1.00 ACUITY Non-CABG Major Bleeding* 1.9 4.5 0.43 0.32-0.57 <0.0001 * Post Hoc analysis
- 17. Other Outcomes Radial (n=3507) Femoral (n=3514) P Access site Cross-over (%) 7.6 2.0 <0.0001 PCI Procedure duration (min) 35 34 0.62 Fluoroscopy time (min) 9.3 8.0 <0.0001 Persistent pain at access site >2 weeks (%) 2.6 3.1 0.22 Patient prefers assigned access site for next procedure (%) 90 49 <0.0001 • Symptomatic radial occlusion requiring medical attention 0.2% in radial group
- 18. Conclusion • No significant difference between radial and femoral access in primary outcome of death, MI, stroke or non-CABG major bleeding • Rates of primary outcome appeared to be lower with radial compared to femoral access in high volume radial centres and STEMI • Radial had fewer major vascular complications with similar PCI success
- 29. • Radial access should be preferred over femoral access if performed by an experienced radial operator. Class IIa A
- 31. Patient comfort
- 32. Short hospital stay just two hours after CAG and 8 hours post PCI
- 33. Can I do all procedure through radial ? • All procedures can be done through the radial access to decrease potential access site complications with femoral access. • Emergency procedures with great benefit in patients with high bleeding risk as old patients with low body mass index and those with ACS who may receive GP IIb/IIIa antagonists during the PCI procedure to decrease the risk of bleeding. • Bifurcation PCI with provisional stenting or intended two stent strategy can be done through radial acess with 6 F sheath.
- 34. Primary PCI • This was an 80 years old lady known hypertensive ,diabetic with low body mass index who presented by Acute inferior STEMI and was loaded by ticagrelor.
- 41. Bifurcation PCI • This is a 48 years old man with recurrent exertion chest pain who was loaded by Clopidogrel . • He requested to have his cath through radial access and had a same day hospital discharge.
- 45. Disadvantages of Radial access 1.Steep learning curve. 2.Increased procedural time and increased radiation exposure. 3. Radial artery occlusion. 4. Hand ischemia. 5. Radial spasm.
- 46. 1.Steep learning curve • The transradial approach is more technically challenging, an operator may need from 50 to 100 radial procedure to build up an average experience.
- 47. There are three steps in radial technique: • 1.Arterial puncture and sheeth insertion. • 2.guiding the catheter through radial ,brachial and subclavian till the ascending aorta. • 3.Selective coronary engagement. • Obstacles faced in any of these steps may lead to procedure failure and cross over to other access as femoral and ulnar arteries.
- 48. 2.Increased procedural time and increased radiation exposure • Several studies have shown longer procedural time and fluoroscopy time for transradial coronary angiography compared with transfemoral catheterization ,however proceure time may decrease after sometime with large volume expert operators . • Brueck et al, JACC Cardiovasc Interv 2009;2:1047-54 • Neill et al, Am J Cardiol 2010;106:936-40
- 49. 3.Radial artery occlusion • This is a Potential complication with transradial catheterization thay may : limit future radial access • limit the use of the radial artery for dialysis fistulas or as grafts for CABG. • Pancholy and Patel, Catheter Cardiovasc Interv. May 16 2011 • ** Cubero et al, Catheter Cardiovasc Interv. 2009;73:467-72
- 50. 4.Hand Ischemia • Extremely rare. • Of the estimated 650,000 transradial procedures performed annually around the world,only one incident of hand ischemia has been reported, which was successfully revascularized percutaneously. • Rhyne et al, Catheter Cardiovasc Interv 2010;76:383-6
- 51. 5.Radial artery spasm • This is more common than other complications and can be avoided by proper local anesthesia it may occur just after arterial puncture and may prevent sheath insertion or may occur during long procedures due to prolonged manipulations and catheter exchange . • Can be managed by injection of NG at the radial sheath sometimes patient sedation is needd.
- 52. Take home message 1.Mastering radial technique is very important for all interventional cardiologists and you can go radial in all procedures ,emergency ,elective (CTO,Bifurcation) 2. Sometimes you will have no choice so you should always be ready. 3.If you have to choose between radial and femoral just remember that radial will decrease your complications ,it is more convenient to your patients and it saves much money.
- 53. • 4.Many studies proved that radial access is superior to femoral regarding bleeding complications ,and it is recommended in ESC revascularization guidelines 2014 as class IIa A . • 5. Mastering radial procedures needs a steep learning curve but remember that No Pain,No Gain
- 54. Thank you