Transradial access to percuatanous coronary intervention shows significant advantages over the femoral approach when used by experienced clinicians.Load more
A growing body of evidence suggests that a transradial intervention rather than a transfemoral approach to PCI is associated with greater reductions in bleeding complications than those achieved with pharmacological strategies alone.
Whilst the transfemoral approach to cardiac catheterization has dominated the huge growth of invasive cardiology to date, transradial access appeared early in the development of cardiac catheterization techniques as early as 1948.
Despite early enthusiasm for the approach, equipment limitations resulted in a shift to larger vessels for most catheter-based procedures, and the radial artery was consigned as a site for monitoring arterial pressure.
In the late 1970s, percutaneous coronary angioplasty was introduced using predominantly 9-F guiding catheters. Building on reports of successful transradial angiography from Canada in 1989, four years later, Kiemeneij and Laarman first reported on the transradial approach for coronary stenting.
Given observed reductions in periprocedural bleeding and reported improvements in patient comfort, a few enthusiastic early adopters surfaced, although transradial intervention generally remained a niche technique. The greater technical complexity of the procedure compared to the transfemoral procedure and the associated significant learning curve hindered its uptake.
As experience with transradial intervention grew, the lack of severe access-site complications when compared with the transfemoral approach to coronary angiography and coronary intervention was repeatedly demonstrated in small observational studies.
Cost-effectiveness was also demonstrated and small single-centre or limited multicenter randomised comparisons to femoral and brachial approaches showed the superiority of transradial intervention with respect to vascular access site complications, patient preference and speed of post-procedural recovery.
There are important veins or nerves near to the radial artery in the wrist, which decreases the likelihood of arteriovenous fistulas or nerve lesions; the superficial trajectory of the artery and its proximity to the bone allow simple hemostasis by means of simple compression, bypassing the need for closure devices and decreasing the chance of hematoma and pseudoaneurysm.
Several studies have reported that the patients can ambulate almost immediately following the procedure, which increases the patient´s comfort and level of satisfaction, and at the same time decreases the length of hospital stay and the cost.
Nevertheless, the procedure could only be performed with safety in patients with a normal Allen test, and technically, the procedure is more complex than the transfemoral procedure due to the greater difficulty in cannulating the artery, variations in the arteries of the upper limb, possibility of spasm, and the manipulation of the catheters that is necessary to cannulate the coronary arteries.
These difficulties result in a slight increase in the length of time needed for the procedure and time needed for fluoroscopy. There is also a significant learning curve involved, even for specialists with a a lot of experience in transfemoral procedures.
However, ESC Guidelines published last year give the highly recommend the radial approach over the femoral one for coronary angiography and percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS). The ACS without persistent ST-segment elevation (NSTE-ACS) guidelines are published online on the ESC Website and in European Heart Journal.Load Less
Key Transradial Articles From Around The Web
Angiolillo DJ. Lancet 2018;392:801–2.
Gargiulo G, Carrara G, Frigoli E, et al. J Am Coll Cardiol 2018;71:1231–42.
Impact of Sex on Comparative Outcomes of Radial Versus Femoral Access in Patients With Acute Coronary Syndromes Undergoing Invasive ManagementGargiulo G, Ariotti S, Vranckx P, et al. JACC Cardiovasc Interv 2018;11:36–50.
The Current State of Transradial Access: A Perspective on Transradial Outcomes, Learning Curves, and Same-Day DischargeRymer JA, Rao SV. Cardiovasc Innov Appl 2018;3:149–62.
Key Transradial presentations from around the web
Transradial artery access (TRA) for diagnostic CA or percutaneous coronary intervention (PCI) is associated with lower bleeding and vascular complications than transfemoral artery access (TFA). The European Society of Cardiology guidelines and American Heart Association support TRA first strategy and evidence also supports, an improvement in healthcare quality, and reduced cost. While TFA predominates peripheral interventions, increases in dedicated equipment and the technical expertise may result in it as a preferred access in this patient group as well.
The Radcliffe Transradial Intervention educational programme is supported by:
University Hospital North Staffordshire, Stoke-on-Trent, UK
The purpose of this review is to look at alternative access sites to radial access, as this is not always available.Parikh A, Jia KQ, Lall SK, et al. Curr Treat Options Cardiovasc Med 2020;22:1.
Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee
These recommendations were developed based on the collection of access literature, including neurointerventional and other interventional specialties.Starke RM, Snelling B, Al-Mufti F, et al. J Neurointerv Surg 2019; epub ahead of press.
This article is the first study looking into successive use of the same artery for repeat procedures in neurointerventional procedures.Chen SH, Brunet M, Sur S, et al. J Neurointerv Surg 2020;12:431–4
Best Practices for the Prevention of Radial Artery Occlusion After Transradial Diagnostic Angiography and Intervention: An International Consensus Paper
This literature reviews the primary recent advances in the field of radial artery occlusion (RAO) prevention and provides expert recommendations to prevent RAO.Bernat I, Aminian A, Pancholy S, et al. JACC Cardiovasc Interv 2019;12:2235–46.
Rymer JA, Rao SV. Cardiovasc Innov Appl 2018;3:149–62.
Schulte-Hermes M, Klein-Wiele O, Vorpahl M, Seyfarth M. J Invasive Cardiol 2018;30:355-9.
Kwok CS, Rao SV, Gilchrist IC, et al. Am J Cardiol 2019;123:33–43.
Mamas MA, Tosh J, Hulme W, et al. Circ Cardiovasc Quality Outcomes 2018;11:e004482.
Kok MM, Weernink MGM, von Birgelen C, et al. Catheter Cardiovasc Interv 2018;91:17–24.
Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS DatasetRashid M, Lawson C, Potts J, et al. JACC Cardiovasc Interv 2018;11:1021–33.
Transradial versus transfemoral ancillary approach in complex structural, coronary, and peripheral interventions. Results from the multicenter ancillary registry: A study of the Italian Radial ClubCortese B, Rigattieri S, Aranzulla TA, et al. Catheter Cardiovasc Interv 2018;81:97–102.