radial access coronary interventions

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.

11. Clinical advantages

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

30. Non Clinical advantages

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.

42. What about bifurcation?

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