Transradial versus transfemoral approach for coronary angiography and intervention in patients above 75 years of age

Overview of the distal radial access from the radial artery occlusion perspective

Conventional radial access in endovascular surgery has certain limitations, primarily associated with the presence of local complications and radial artery occlusion. Over the past 7 years, distal radial access has exploded into all areas of endovascular procedures, from interventional cardiology to vascular surgery and interventional oncology. However, puncture of the distal radial artery has its own nuances and features: a learning curve, the use of ultrasound navigation in the initial stages of mastering the access, limitations in patients with acute conditions (acute coronary syndrome and stroke). This review aims to analyze on important aspects of the procedure of distal radial access from preparation for it to hemostasis and to explore all data about the new roles of distal radial access in avoiding but also treating radial artery occlusion, as the first thing to begin with the development and implementation of new access.

Chronological vs Biological Age in Interventional Cardiology: A Comprehensive Approach to Care for Older Adults: JACC Family Series

Aging is the gradual decline in physical and physiological functioning leading to increased susceptibility to stressors and chronic illnesses, including cardiovascular disease. With an aging global population, in which 1 in 6 individuals will be older than 60 years by 2030, interventional cardiologists are increasingly involved in providing complex care for older individuals. Although procedural aspects remain their main clinical focus, interventionalists frequently encounter age-associated risks that influence eligibility for invasive care, decision making during the intervention, procedural adverse events, and long-term management decisions. The unprecedented growth in transcatheter interventions, especially for structural heart diseases at extremes of age, have pushed age-related risks and implications for cardiovascular care to the forefront. In this JACC state-of-the-art review, the authors provide a comprehensive overview of the aging process as it relates to cardiovascular interventions, with special emphasis on the difference between chronological and biological aging. The authors also address key considerations to improve health outcomes for older patients during and after their invasive cardiovascular care. The role of "gerotherapeutics" in interventional cardiology, technological innovation in measuring biological aging, and the integration of patient-centered outcomes in the older adult population are also discussed.

Stroke risk in radial versus femoral approach in coronary intervention: an updated systematic review and meta-analysis

AIM

Peri-cardiac catheterization (CC) stroke is associated with increased morbidity and mortality. Little is known about any potential difference in stroke risk between transradial (TR) and transfemoral (TF) approaches. We explored this question through a systematic review and meta-analysis.

METHODS

MEDLINE, EMBASE, and PubMed were searched from 1980 to June 2022. Randomized trials and observational studies comparing radial versus femoral access CC or intervention that reported stroke events were included. A random-effects model was used for analysis.

RESULTS

The total population in our 41 pooled studies comprised 1 112 136 patients - average age 65 years, women averaging 27% in TR and 31% in TF approaches. Primary analysis of 18 randomized-controlled trials (RCTs) that included a total of 45 844 patients showed that there was no statistical significance in stroke outcomes between the TR approach and the TF approach [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.48-1.06, P -value = 0.013, I2 = 47.7%]. Furthermore, meta-regression analysis of RCTs including procedural duration between those two access sites showed no significance in stroke outcomes (OR 1.08, 95% CI 0.86-1.34, P -value = 0.921, I2 = 0.0%).

CONCLUSIONS

There was no significant difference in stroke outcomes between the TR approach and the TF approach.

Predicting difficult transradial approach guiding into left internal carotid artery on unruptured intracranial aneurysms

BACKGROUND

The transradial approach (TRA) is less invasive than the transfemoral approach (TFA), but the higher conversion rate represents a drawback. Among target vessels, the left internal carotid artery (ICA) is particularly difficult to deliver the guiding catheter to through TRA. The purpose of this study was thus to explore anatomical and clinical features objectively predictive of the difficulty of delivering a guiding catheter into the left ICA via TRA.

METHODS

Among 78 consecutive patients who underwent coil embolization for unruptured intracranial aneurysms through TRA in a single institution between March 1, 2021, and August 31, 2022, all 29 patients (37%) who underwent delivery of the guiding catheter into the left ICA were retrospectively analyzed. Clinical and anatomical features were analyzed to assess correlations with difficulty in guiding the catheter into the left ICA.

RESULTS

Of the 29 aneurysms requiring guidance of a catheter into the left ICA, 9 aneurysms (31%) required conversion from TRA to TFA. More acute innominate-left common carotid artery (CCA) angle (P < 0.001) and older age (P = 0.015) were associated with a higher conversion rate to TFA. Receiver operating characteristic analysis revealed that optimal cutoff values for the innominate-left CCA angle and age to distinguish between nonconversion and conversion to TFA were 16° (area under the curve [AUC], 0.93; 95% confidence interval [CI], 0.83-1.00) and 74 years (AUC, 0.79; 95% CI, 0.61-0.96), respectively.

CONCLUSION

A more acute innominate-left CCA angle and older age appear associated with difficulty delivering the guiding catheter into the left ICA for neurointervention through TRA.

Early exploration of the economic impact of transradial access (TRA) versus transfemoral access (TFA) for neurovascular procedures in Spain

INTRODUCTION

Transfemoral access (TFA) is the primary access approach for neurointerventional procedures. Transradial access (TRA) is established in cardiology due to its lower complications, yet, it is at its early stages in neuroprocedures. This study performs an early exploration of the economic impact associated with the introduction of TRA in diagnostic and therapeutic neuroprocedures from the Spanish NHS perspective.

METHODS

An economic model was developed to estimate the cost and clinical implications of using TRA compared to TFA. Costs considered access-related, complications and recovery time costs obtained from local databases and experts' inputs. Clinical inputs were sourced from the literature. A panel of eight experts from different Spanish hospitals, validated or adjusted the values based on local experience. Hypothetical cohorts of 10,000 and 1000 patients were considered for diagnostic and therapeutic neuroprocedures respectively. Deterministic sensitivity analysis was performed.

RESULTS

TRA in diagnostic procedures was associated with lower costs with savings ranging between €486 and €157 depending on the TFA recovery time considered. TRA is estimated to lead to 158 fewer access-site complications. In therapeutic procedures, TRA resulted in 76.4 fewer complications and was estimated to be cost-neutral with an incremental cost of €21.56 per patient despite recovery times were not included for this group. Variation of the parameters in the sensitivity analysis did not change the direction of the results.

LIMITATIONS

Clinical data was obtained from literature validated by experts therefore results generalizability is limited. In therapeutic neuroprocedures, there is an experience imbalance between approaches and recovery times were not included hence the total impact is not fully captured.

CONCLUSIONS

The early economic model suggests that implementing TRA is associated with reduced costs and complications in diagnostic procedures. In therapeutic procedures, TRA lead to fewer complications and it is estimated to be cost-neutral, however its full potential still needs to be quantified.

Left vs. right radial approach for coronary catheterization: Relation to age and severe aortic stenosis

Background

Old age and the presence of aortic stenosis are associated with the unfolding of the intrathoracic aorta. This may result in increased difficulties navigating catheters from the right compared to the left radial approach.

Objective

To investigate whether increasing age or presence of severe aortic stenosis was associated with increased catheterization success rates from left (LRA) compared to right radial artery approach (RRA).

Methods

We compared coronary angiography success rates of RRA and LRA according to different age groups and in a subgroup of patients with severe aortic stenosis.

Results

A total of 21,259 coronary angiographies were evaluated. With increasing age, the first pass success rate from either radial access decreased significantly (p < 0.001). In patients aged <85 years, there was no difference between LRA and RRA. However, in patients aged ≥85 years, LRA was associated with significantly higher success rates compared to RRA (90.1 vs. 82.8%, p = 0.003). Patients aged ≥85 years received less contrast agent and had shorter fluoroscopy time when LRA was used [86.6 ± 41.1 vs. 99.6 ± 48.7 ml (p < 0.001) and 4.5 ± 4.1 min vs. 6.2 ± 5.7 min (p < 0.001), mean (±SD)]. In patients with severe aortic stenosis (n = 589) better first pass success rates were observed via LRA compared to the RRA route (91.9 vs. 85.1%, p = 0.037).

Conclusion

LRA, compared to RRA, is associated with a higher first-pass catheter success rate for coronary artery angiography in patients aged ≥85 years and those with severe aortic stenosis.

Low-molecular-weight-heparin in radial artery occlusion treatment: the LOW-RAO randomized study

Radial artery occlusion (RAO) is the commonest complication of transradial catheterization. There is no evidence-based therapy, in the frame of a randomized control study, for the treatment of RAO. The purpose of the LOW-RAO study is to question the hypothesis if low-molecular-weight heparin is effective in the treatment of RAO after transradial coronary catheterization (both angiography and percutaneous coronary intervention). It is a prospective, open label, randomized controlled trial that will randomize 60 patients with RAO, irrespective of symptoms, into two groups, one receiving anticoagulation with low-molecular-weight heparin and the other receiving no treatment. The primary end point is improvement in radial artery patency rate at 4 weeks after the procedure. Trial registration number: NCT04196309 (ClinicalTrials.gov).

Radial Access for Coronary Angiography Carries Fewer Complications Compared with Femoral Access: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIM

In patients undergoing diagnostic coronary angiography (CA) and percutaneous coronary interventions (PCI), the benefits associated with radial access compared with the femoral access approach remain controversial. The aim of this meta-analysis was to compare the short-term evidence-based clinical outcome of the two approaches.

METHODS

The PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) comparing radial versus femoral access for CA and PCI. We identified 34 RCTs with 29,352 patients who underwent CA and/or PCI and compared 14,819 patients randomized for radial access with 14,533 who underwent procedures using femoral access. The follow-up period for clinical outcome was 30 days in all studies. Data were pooled by meta-analysis using a fixed-effect or a random-effect model, as appropriate. Risk ratios (RRs) were used for efficacy and safety outcomes.

RESULTS

Compared with femoral access, the radial access was associated with significantly lower risk for all-cause mortality (RR: 0.74; 95% confidence interval (CI): 0.61 to 0.88; p = 0.001), major bleeding (RR: 0.53; 95% CI:0.43 to 0.65; p ˂ 0.00001), major adverse cardiovascular events (MACE)(RR: 0.82; 95% CI: 0.74 to 0.91; p = 0.0002), and major vascular complications (RR: 0.37; 95% CI: 0.29 to 0.48; p ˂ 0.00001). These results were consistent irrespective of the clinical presentation of ACS or STEMI.

CONCLUSIONS

Radial access in patients undergoing CA with or without PCI is associated with lower mortality, MACE, major bleeding and vascular complications, irrespective of clinical presentation, ACS or STEMI, compared with femoral access.

Outcomes of Transradial Versus Transfemoral Access of Percutaneous Coronary Intervention in STEMI: Systematic Review and Updated Meta-analysis

BACKGROUND

Transradial (TR) percutaneous coronary intervention (PCI) is a preferable PCI route. The complication difference between TR and TF approaches is controversial.

METHODS

PubMed, Embase, and the Cochrane databases were queried for PCI outcomes of TR TF in STEMI for major cardiac and cerebrovascular events (MACCE), major bleeding, and mortality. The odds ratio (OR) was calculated using the random-effect model.

RESULTS

We included 56 studies comprising of 68,733 patients (TR, n = 26,179; TF, n = 42,537). TR-PCI was associated with statistically significant lower odds of MACCE (OR = 0.66, 95% CI: 0.49-0.88, p-value = 0.005), major bleeding (OR = 0.47, 95% CI 0.32-0.68, p-value<0.001), mortality (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001) at in hospital follow-up. TR-PCI was associated with statistically significant lower MACCE (OR = 0.59, 95% CI 0.43-0.80, p-value<0.001), major bleeding (OR = 0.58, 95% CI 0.49-0.68, p-value<0.001), and mortality (OR = 0.61, 95% CI 0.44-0.86, p-value = 0.005) at 30-day follow-up. The same difference was seen at 1-year.

CONCLUSION

TR-PCI was associated with lower odds of MACCE, major bleeding, and mortality during short- and long-term follow-up.

Cardiac Catheterizations in Patients With Prior Coronary Bypass Surgery: Impact of Access Strategy on Short-Term Safety and Long-Term Efficacy Outcomes

Little data are available on access strategy outcomes for cardiac catheterizations in patients with prior coronary artery bypass graft surgery (CABG). We investigated the effect of transradial access (TRA) and transfemoral access (TFA) on short-term major vascular complications (MVC) and long-term major adverse cardiovascular events (MACE). In this single-center, retrospective cohort study, 1084 patients met our inclusion criteria (TRA = 469; TFA = 615). The cumulative incidence for the primary safety endpoint MVC at 30 days (a composite of major bleeding, retroperitoneal hematoma, dissection, pseudoaneurysm, and arteriovenous fistula) was lower with TRA (0.7% vs 3.0%, P < .01) and this difference remained significant after propensity score adjustment (odds ratio: 0.24; 95% CI, 0.07-0.83; P = .024). The cumulative incidence for the primary efficacy endpoint MACE at 36 months (a composite of all-cause mortality, myocardial infarction, stroke, and urgent target vessel revascularization) was 28.6% with TRA and 27.6% with TFA, respectively. Kaplan-Meier curves showed no difference for the primary efficacy endpoint (P = .65). Contrast use (mL) was significantly lower with TRA (130 [100-180] vs 150 [100-213], P < .01). In conclusion, in patients with prior CABG, TRA was associated with significantly fewer short-term MVC and contrast use, but not with a difference in long-term MACE, compared with TFA.

Transradial approach and its variations for neurointerventional procedures: Literature review

Background:

The transfemoral approach (TFA) has been the standard in neuroradiology over the years. However, the transradial approach (TRA) and its variants offer several benefits over the TFA.

Methods:

Review of the literature about TRA and its variations. We present our results for different neurointerventional procedures at our institution between January 2018 and December 2019.

Results:

We wrote an educational review describing anatomical and technical aspects, advantages, and complications of this approach. In the past year we increased the percentage of neurointerventional procedures performed through radial or ulnar arteries.

Conclusion:

There are clearly proven benefits of employing a wrist approach in patients for neurointerventional procedures and its utilization should especially be considered on a daily basis.

The Neuro Radialist

Trans-radial approach (TRA) has been used in cardiac and peripheral interventional radiology practices for decades, because of safety and patient comfort. There is interest in TRA in the cerebrovascular field, with potential to replicate benefits over trans-femoral approach. TRA is technically more challenging and has a learning curve, which hinders its use as the first-line approach; however, as more neuro-interventionalists embrace TRA, techniques are being optimized simultaneously for supra-aortic vessel catheterization. This article describes advantages, patient selection, conventional and distal radial access, and detailed techniques of trans-radial catheterization for diagnostic angiography, as well as cerebrovascular interventions and its current limitations.

Transition to Radial Approach for Neurovascular Procedures is Safe and Convenient: Characterization of a Learning Experience

BACKGROUND

The transradial access for endovascular procedures has become a popular access point of preference for both patients and for many neuro-endovascular practitioners.

OBJECTIVE

To describe a single-center experience on the transition to a radial-first approach for neurovascular procedures, focused on diagnostic angiographies, and to compare the differences in terms of length of procedure within the first 5 mo of its execution.

METHODS

We performed a retrospective review of a prospective maintained cerebrovascular registry at an academic institution within the United States, to identify the expected adoption curve required to transition to a transradial route first approach focused mainly on diagnostic procedures. The 5 mo of experience were divided into 4 quartiles evenly distributed in time. The primary outcome was the total length of procedure. Secondary outcomes were access failure, radiation dose, the usefulness of ultrasound assistance and complications.

RESULTS

A total of 121 transradial procedures were performed: 113 diagnostic angiographies (93%) and 8 therapeutic interventions (7%). We identified 6 access failures (5%) and 1 complication (1%). The mean length for diagnostic angiographies was 24 ± 10 min, and for therapeutic procedures was 58 ± 19 min. A multivariate regression analysis demonstrated a significant decrease in the total length of procedures after the first quartile.

CONCLUSION

The transradial route shows to be a safe and convenient approach. The total length of procedure starts decreasing as providers gain experience and become more confident with this route, as seen in our 5-mo experience.

An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome: A Scientific Statement From the American Heart Association

Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome-related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a "radial-first" strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.

Comparison of Transradial and Transfemoral Approaches for Coronary Angiography and Percutaneous Intervention in Patients with Coronary Bypass Grafts

OBJECTIVE

We sought to compare the transradial and transfemoral approaches for coronary angiography and percutaneous intervention in patients with coronary artery bypass grafts in terms of volume of radiographic contrast administered during cardiac catheterization, fluoroscopy time, and total procedure time.

BACKGROUND

The transradial access has been increasingly used as an alternative to transfemoral. Several studies demonstrated that such access is associated with lower rates of vascular and bleeding complications. Although coronary artery bypass graft patients comprise a significant portion of the coronary artery disease population, this subpopulation was often excluded or underrepresented in transradial access studies.

METHODS

Single center, retrospective cohort study. In the study period, all patients who had previously undergone coronary artery bypass graft surgery and had received cardiac catheterization at our institution were included in the study population.

RESULTS

A total of 2153 patients were included in the study. From these, 1937 were performed by femoral artery and 216 by transradial approach. Compared to the transfemoral approach, transradial access was associated with lower contrast use (136.3 ± 74.4 ml vs. 122.8 ± 59.1 ml, p = 0.035) and longer fluoroscopy time (13.9 ± 25.6 min vs. 15.9 ± 14.3 min, p < 0.001).

CONCLUSION

Diagnostic and interventional catheterization through the transradial approach in patients with previous coronary artery bypass graft surgery was associated with less contrast amount used and longer fluoroscopy time compared to the transfemoral approach. The transradial approach was also associated with lower crossover rates and less vascular complications.

[Radial approach in the elderly]

Due to the steady increase in life expectancy, the number of patients over 80 years of age proposed for coronary angioplasty is increasing significantly. The elderly patient is a patient at high cardiovascular risk and high risk of bleeding; whose severity of prognosis depends of comorbidities. The radial approach presents particularities and technical difficulties that have to be known in this part of the population, but reduce vascular and hemorrhagic complications, as well as mortality. Because of greater safety, the radial approach is therefore the first choice for the elderly.

Patient Radiation Exposure in Transradial versus Transfemoral Yttrium-90 Radioembolization: A Retrospective Propensity Score-Matched Analysis

PURPOSE

To compare differences in patient radiation exposure (PRE) during transarterial yttrium-90 (⁹⁰Y) radioembolization (TARE) between transradial access (TRA) and transfemoral access (TFA).

MATERIALS AND METHODS

A total of 810 consecutive first-time TARE procedures in patients from 2013 to 2017 were retrospectively reviewed. A propensity score-matching (PSM) analysis matched TRA and TFA groups on the basis of patient age, sex, weight, height, cancer type, ⁹⁰Y microsphere type, and number of previous procedures from the same and opposite approaches. Matched groups were then compared by PRE measures fluoroscopy time (FT), dose-area product (DAP), and cumulative air kerma (AK). Effect size for each PRE measure was calculated.

RESULTS

Before PSM, TRA and TFA groups differed significantly in mean age, weight, and number of previous procedures from the same and opposite approach (all P < .05). After PSM, each group consisted of 302 procedures (overall, n = 604) and no longer differed in any procedure performed before surgery measure. TRA did not differ from the matched TFA group regarding median FT (9.50 vs 9.40 minutes, P = .095), median DAP (67,066 vs 67,219 mGy·cm²; P = .19), or median AK (323.63 vs 248.46 mGy; P = .16). Effect sizes were 0.068, 0.054, and 0.110 for FT, DAP, and AK, respectively.

CONCLUSIONS

No statistical differences were found for PRE measures between the matched TRA and TFA approach groups. Furthermore, practical effect sizes were considered to be small for AK and less than small for FT and DAP, and therefore, any differences in PRE between the radial and femoral approaches for TARE are minor and unlikely to be noticeable in everyday clinical practice.

Transradial versus transfemoral approach for diagnostic coronary angiography and percutaneous coronary intervention in people with coronary artery disease

BACKGROUND

Cardiovascular disease (CVD) is the major cause of mortality worldwide. Coronary artery disease (CAD) contributes to half of mortalities caused by CVD. The mainstay of management of CAD is medical therapy and revascularisation. Revascularisation can be achieved via coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Peripheral arteries, such as the femoral or radial artery, provide the access to the coronary arteries to perform diagnostic or therapeutic (or both) procedures.

OBJECTIVES

To assess the benefits and harms of the transradial compared to the transfemoral approach in people with CAD undergoing diagnostic coronary angiography (CA) or PCI (or both).

SEARCH METHODS

We searched the following databases for randomised controlled trials on 10 October 2017: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science Core Collection. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform in August 2017. There were no language restrictions. Reference lists were also checked and we contacted authors of included studies for further information.

SELECTION CRITERIA

We included randomised controlled trials that compared transradial and transfemoral approaches in adults (18 years of age or older) undergoing diagnostic CA or PCI (or both) for CAD.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. At least two authors independently screened trials, extracted data, and assessed the risk of bias in the included studies. We contacted trial authors for missing information. We used risk ratio (RR) for dichotomous outcomes and mean difference (MD) or standardised mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). All analyses were checked by another author.

MAIN RESULTS

We identified 31 studies (44 reports) including 27,071 participants and two ongoing studies. The risk of bias in the studies was low or unclear for several domains. Compared to the transfemoral approach, the transradial approach reduced short-term net adverse clinical events (NACE) (i.e. assessed during hospitalisation and up to 30 days of follow-up) (RR 0.76, 95% CI 0.61 to 0.94; 17,133 participants; 4 studies; moderate quality evidence), cardiac death (RR 0.69, 95% CI 0.54 to 0.88; 11,170 participants; 11 studies; moderate quality evidence). However, short-term myocardial infarction was similar between both groups (RR 0.91, 95% CI 0.81 to 1.02; 19,430 participants; 11 studies; high quality evidence). The transradial approach had a lower procedural success rate (RR 0.97, 95% CI 0.96 to 0.98; 25,920 participants; 28 studies; moderate quality evidence), but was associated with a lower risk of all-cause mortality (RR 0.77, 95% CI 0.62 to 0.95; 18,955 participants; 10 studies; high quality evidence), bleeding (RR 0.54, 95% CI 0.40 to 0.74; 23,043 participants; 20 studies; low quality evidence), and access site complications (RR 0.36, 95% CI 0.22 to 0.59; 16,112 participants; 24 studies; low quality evidence).

AUTHORS' CONCLUSIONS

Transradial approach for diagnostic CA or PCI (or both) in CAD may reduce short-term NACE, cardiac death, all-cause mortality, bleeding, and access site complications. There is insufficient evidence regarding the long-term clinical outcomes (i.e. beyond 30 days of follow-up).

Transradial cerebral angiography: techniques and outcomes

Background

Despite several retrospective studies analyzing the safety and efficacy of transradial access (TRA) versus transfemoral access (TFA) for cerebral angiography, this transition for neurointerventional procedures has been gradual. Nonetheless, based on our positive initial institutional experience with TRA for mechanical thrombectomy in acute ischemic stroke patients, we have started transitioning more of our cerebral angiography cases to TRA. Here we present our single institution experience.

Methods

We performed a retrospective review of patients receiving TRA cerebral angiography at our institution between January 2016 and February 2017. We present our experience transitioning from TFA to TRA, including our criteria for patient selection, technical nuances, patient experience, complications, and operator learning curve.

Results

We included 148 angiograms performed in 141 people by one of four operators. No major complications were observed, and the technical success of the procedures was consistent with those of TFA. Marked improvement in operator efficiency was achieved in a short number of cases during this transition when looking at operator proficiency as a function of angiograms performed and days of exposure to TRA (4.3 vs 3.6 min/vessel, P<0.05).

Conclusions

Safety and efficiency can be preserved while transitioning to TRA. While further investigation is necessary to support transition to TRA, these findings should call for a re-evaluation of the role of TRA in catheter cerebral angiography.

Conversion factors of effective and equivalent organ doses with the air kerma area product in patients undergoing coronary angiography and percutaneous coronary interventions

To derive effective dose (E), organ dose (H_T) and conversion factors with the air kerma area product (KAP) in coronary angiography (CA) and percutaneous coronary intervention (PCI) by the radial route, using the ICRP 103 tissue weighting factors. The study included 34 patients referred for CA and 31 for PCI. E and H_T were derived from in-the-field KAP measurements using Montecarlo methods. Median KAP of 23.2 and 56.8Gycm² and E of 6.9 and 20.0mSv were found for CA and PCI, respectively. Mean KAP and E were significantly higher in males than in females (52.4±40.0 vs 32.3±16.6Gycm²; p=0.02) and (16.8±13.6 vs 10.7±5.8mSv; p=0.04). KAP (r=0.39; p=0.001) and E (r=0.34; p=0.005) showed a significant correlation with the patient's weight. Conversion factors between KAP and E (E/KAP) were 0.30±0.04mSvGy^-1cm^-2 for CA and 0.33±0.05mSvGy^-1cm^-2 for PCI. No significant differences in the E/KAP between males and females were found (0.31±0.05 vs 0.33±0.05; p=0.08). Again, no significant correlation was found between E/KAP and patient's weight (r=0.23; p=0.07). The correlation between E and KAP was excellent for CA (r=0.99) and PCI (r=0.96). The correlation between H_T and KAP ranged from r=0.87 to r=1 and from r=0.71 to r=0.98 for CA and PCI, respectively. A single factor, the total KAP, could be used for a specific acquisition protocol to reliably estimate E and H_T without the need of a patient's specific analysis. Conversion factors might be installation, X-ray beam quality or protocol dependent.

Transradial access: lessons learned from cardiology

Innovations in interventional cardiology historically predate those in neuro-intervention. As such, studying trends in interventional cardiology can be useful in exploring avenues to optimise neuro-interventional techniques. One such cardiology innovation has been the steady conversion of arterial puncture sites from transfemoral access (TFA) to transradial access (TRA), a paradigm shift supported by safety benefits for patients. While neuro-intervention has unique anatomical challenges, the access itself is identical. As such, examining the extensive cardiology literature on the radial approach has the potential to offer valuable lessons for the neuro-interventionalist audience who may be unfamiliar with this body of work. Therefore, we present here a report, particularly for neuro-interventionalists, regarding the best practices for TRA by reviewing the relevant cardiology literature. We focused our review on the data most relevant to our audience, namely that surrounding the access itself. By reviewing the cardiology literature on metrics such as safety profiles, cost and patient satisfaction differences between TFA and TRA, as well as examining the technical nuances of the procedure and post-procedural care, we hope to give physicians treating complex cerebrovascular disease a broader data-driven understanding of TRA.

Safety and Efficacy of Percutaneous Coronary Intervention via Transradial Versus Transfemoral Approach in Bypass Grafts

We compared the efficacy and safety of the transradial approach percutaneous coronary intervention (TRA-PCI) and transfemoral approach percutaneous coronary intervention (TFA-PCI) for bypass grafts lesions. Patients (n = 184) were retrospectively enrolled. Less contrast was used during the procedure in the TRA group than in the TFA group, 201.5 (45.5) mL versus 221.5 (49.1) mL, P = .004, although fluoroscopy time was longer in the TRA group, 22.5 (6.3) minutes versus 20.3 (6.1) minutes; P = .017. The incidence of net adverse clinical events (NACEs) was lower in the TRA group than in the TFA group (3.1% vs 8.8%, respectively, P = .111). The incidence of Bleeding Academic Research Consortium type 3 and 5 bleeding (0% vs 5.5%, respectively, P = .022) was significantly lower in the TRA group than in the TFA group. For 1-year outcomes, there was no difference in the incidence of major adverse cardiovascular events (7.5% vs 9.9%, respectively, P = .569). In conclusion, TRA-PCI was associated with a lower rate of in-hospital NACEs mainly attributed to lower rates of major bleeding. The TRA-PCI showed comparable feasibility and efficacy in bypass grafts as compared with TFA-PCI when carried out by experienced operators.

Efficacy and indications of transradial and transfemoral approaches for peripheral artery stent implantation

The transradial approach (TRA) has become an attractive alternative to the transfemoral approach (TFA) in percutaneous coronary intervention. To date, however, these two approaches have not been systematically compared in various percutaneous peripheral artery interventions (PPAIs). In the present study 258 patients with peripheral artery disease that underwent PPAI via the TRA (n=75) or the TFA (n=183) were analyzed. Clinical factors and outcomes in these two groups were compared. The puncture time was significantly longer (P<0.05) and the prevalence of artery vasospasm significantly higher (P<0.05) in patients who underwent PPAI via the TRA rather than via the TFA. However, the complication rate was significantly lower (P<0.05) and the artery compression time (P<0.05) and time bedridden (P<0.05) were significantly shorter via the TRA than via the TFA. These results suggest that PPAI via the TRA was associated with a lower complication rate, and shorter artery compression time and bedridden time than PPAI via the TFA. The TRA may be preferable for bilateral vertebral artery stenosis, whereas the TFA may be preferable for interventional treatment of carotid and subclavian artery stenosis. Therefore, the catheter length, artery support and push force should be comprehensively considered before choosing the TRA or TFA in the interventional treatment of renal artery stenosis.

Contrast use in relation to the arterial access site for percutaneous coronary intervention: A comprehensive meta-analysis of randomized trials

AIM

To compare the amount of contrast used during percutaneous coronary intervention (PCI) via trans-radial access (TRA) vs trans-femoral access (TFA).

METHODS

Scientific databases and websites were searched for:randomizedcontrolledtrials (RCTs). Data were extracted by two independent reviewers and was summarized as the weighted mean difference (WMD) of contrast used with a 95%CI using a random-effects model.

RESULTS

The meta-analysis included 13 RCTs with a total of 3165 patients. There was no difference between the two strategies in the amount of contrast used (WMD = - 0.65 mL, 95%CI: -10.94-9.46 mL; P = 0.901).

CONCLUSION

This meta-analysis shows that in patients undergoing PCI, the amount of contrast volume used was not different between TRA and TFA.

Meta-analysis comparing radial versus femoral approach in patients 75 years and older undergoing percutaneous coronary procedures

Introduction

Elderly patients (≥75 years) undergoing coronary angioplasty are increasing. Meta-analyses have shown the benefits of radial access which might reduce hospital stay by decreasing access site complications with associated secondary benefits, however, the population over the age of 75 years were not a large part of the cohort and may behave differently due to increased atherosclerotic burden and age-related vascular changes. In addition, complications unique to this age group such as delirium and deconditioning might occur which could have a bearing on the outcome.

Methods

We searched Pubmed, SCOPUS, Medline, Dynamed, Cochrane. The search terms used were femoral and radial, femoral versus radial, radial or femoral access site, radial or femoral comparison. There were no restrictions.

Results

There was a significant decrease (85%)in the incidence of access site complications in the radial group. The time to achieve ambulation was lower by 14.25 h (8.86–19.56 h). However, the incidence of crossover (in effect failure to perform catheterization by radial access) from radial to femoral was significantly higher. Radial access was associated with longer procedural times (2.75 min) and increased contrast dose however, there was no statistical difference in the fluoroscopy time between the two.

Conclusions

Radial access has similar benefits in elderly patients as those under the age of 75 and may be beneficial in patients at risk of delirium or deconditioning. However, crossover rates, contrast dose and procedure time were higher. It is conceivable that as experience is gained, these rates will diminish.

Transradial Approach for Hepatic Radioembolization: Initial Results and Technique

OBJECTIVE

The transradial approach (TRA) has been shown to reduce the morbidity and mortality associated with arterial coronary interventions. Selective internal radiation therapy (SIRT) performed via the TRA can enhance patient comfort, compared with the traditional transfemoral approach (TFA), by allowing immediate ambulation and precluding potential complications associated with the TFA, such as closure device injury or retroperitoneal hematoma. We report our initial experience with and technique for using the TRA for SIRT.

MATERIALS AND METHODS

Between May 1, 2012, and April 30, 2015, a total of 574 procedures, including planning angiograms (n = 329) and infusions of ⁹⁰Y (n = 245), were performed for 318 patients (mean age, 64.5 years). Of the 245 patients who received ⁹⁰Y infusions, 52 had SIRT performed with the use of a permanent single-use implant of ⁹⁰Y resin microspheres and 193 had SIRT performed with the use of millions of small glass microspheres containing radioactive ⁹⁰Y. Procedural details, technical success, the radial artery (RA) occlusion rate noted at 30 days (as assessed via pulse examination), and the major and minor adverse events noted at 30 days were evaluated.

RESULTS

Technical success was achieved in 561 of 574 cases (97.7%). The reasons for crossover to use of the TFA included an RA loop (n = 2), RA occlusion (n = 9), and type D response as determined by use of a Barbeau test (n = 2). Patients had undergone between zero and six previous TRA procedures. The mortality rate at 30 days was 0%. Superficial bruising occurred in 13 of 574 cases (2.3%). A grade 2 hematoma that required a second nonocclusive hemostasis cuff occurred in one case. Transient forearm numbness or pain occurred in two of 574 cases. One patient had a transient convulsive event occur after receiving intraarterial infusion of verapamil. RA occlusion occurred in nine of 574 cases (1.6%).

CONCLUSION

Use of the TRA for SIRT is safe, feasible, and well tolerated and is associated with high rates of technical success and rare complications.

Expert Opinion: Transradial Coronary Artery Procedures: Tips for Success

Historically, the majority of coronary procedures have been performed via the femoral artery. However, since the inception of the transradial approach, a number of studies have confirmed that this technique is associated with a significant reduction in vascular complications, equivalent procedure times and radiation exposure to femoral procedures, the ability to perform complex coronary interventions, early ambulation and patient preference. Over the last decade, this has led to an exponential rise in the use of the transradial access site, with several potential technical challenges becoming increasingly recognised. However, with greater experience and technological advancement these potential obstacles may be overcome. The following review highlights the potential challenges and suggests several tips to assist transradial operators with recognising and overcoming these challenges.

Influence of access site choice for cardiac catheterization on risk of adverse neurological events: A systematic review and meta-analysis

BACKGROUND

Stroke is a rare but potentially catastrophic complication of cardiac catheterization. Although some procedural aspects are known to influence stroke risk, the impact of radial versus femoral access site use is unclear. Early observational studies and limited randomized trial data suggested more frequent embolic events with radial access. Subsequently, larger pooled analyses have shown no clear differences in stroke risk but were limited by low event rates. Recent publication of relevant new data prompted our reevaluation of this concern. Therefore, we conducted a systematic review and meta-analysis to evaluate stroke complicating cardiac catheterization with use of transradial versus transfemoral access.

METHODS AND RESULTS

A search of MEDLINE and EMBASE was undertaken using OVID SP with appropriate search terms. RevMan 5.3.5 was used to conduct a random-effects meta-analysis using the inverse variance method for pooling risk ratios (RRs) or the Mantel-Haenszel method for pooling dichotomous data. Pooled data from >24,000 patients in randomized controlled trials and >475,000 patients from observational studies were used. The risk ratio (RR) for (any) stroke, using randomized controlled trial data, was not significant (RR 0.87, 95% CI 0.58-1.29). Using observational data, a significant difference favoring radial access was seen (RR 0.71, 95% CI 0.52-0.98).

CONCLUSIONS

Radial access site utilization for cardiac catheterization is not associated with an increased risk of stroke events. These data provide reassurance and should remove another potential barrier to conversion to a "default" radial practice among those who are currently predominantly femoral operators.

Percutaneous Coronary Intervention Is More Beneficial Than Optimal Medical Therapy in Elderly Patients with Angina Pectoris

PURPOSE

Data comparing the clinical benefits of medical treatment with those of percutaneous coronary intervention (PCI) in an elderly population with angina pectoris are limited. Therefore, we evaluated the efficacy of elective PCI versus optimal medical treatment (OMT) in elderly patients (between 75 and 84 years old) with angina pectoris.

MATERIALS AND METHODS

One hundred seventy-seven patients with significant coronary artery stenosis were randomly assigned to either the PCI group (n=90) or the OMT group (n=87). The primary outcome was a composite of major adverse events in the 1-year follow-up period that included cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and stroke.

RESULTS

Major adverse events occurred in 5 patients (5.6%) of the PCI group and in 17 patents (19.5%) of the OMT group (p=0.015). There were no significant differences between the PCI group and the OMT group in cardiac death [hazard ratio (HR) for the PCI group 0.454; 95% confidence interval (CI) 0.041-5.019, p=0.520], myocardial infarction (HR 0.399; 95% CI 0.039-4.050, p=0.437), or stroke (HR 0.919; 95% CI 0.057-14.709, p=0.952). However, the PCI group showed a significant preventive effect of the composite of major adverse events (HR 0.288; 95% CI 0.106-0.785, p=0.015) and against the need for coronary revascularization (HR 0.157; 95% CI 0.035-0.703, p=0.016).

CONCLUSION

Elective PCI reduced major adverse events and was found to be an effective treatment modality in elderly patients with angina pectoris and significant coronary artery stenosis, compared to OMT.

Radiation exposure in relation to the arterial access site used for diagnostic coronary angiography and percutaneous coronary intervention: a systematic review and meta-analysis

BACKGROUND

Transradial access for cardiac catheterisation results in lower bleeding and vascular complications than the traditional transfemoral access route. However, the increased radiation exposure potentially associated with transradial access is a possible drawback of this method. Whether transradial access is associated with a clinically significant increase in radiation exposure that outweighs its benefits is unclear. Our aim was therefore to compare radiation exposure between transradial access and transfemoral access for diagnostic coronary angiograms and percutaneous coronary interventions (PCI).

METHODS

We did a systematic review and meta-analysis of the scientific literature by searching the PubMed, Embase, and Cochrane Library databases with relevant terms, and cross-referencing relevant articles for randomised controlled trials (RCTs) that compared radiation parameters in relation to access site, published from Jan 1, 1989, to June 3, 2014. Three investigators independently sorted the potentially relevant studies, and two others extracted data. We focused on the primary radiation outcomes of fluoroscopy time and kerma-area product, and used meta-regression to assess the changes over time. Secondary outcomes were operator radiation exposure and procedural time. We used both fixed-effects and random-effects models with inverse variance weighting for the main analyses, and we did confirmatory analyses for observational studies.

FINDINGS

Of 1252 records identified, we obtained data from 24 published RCTs for 19 328 patients. Our primary analyses showed that transradial access was associated with a small but significant increase in fluoroscopy time for diagnostic coronary angiograms (weighted mean difference [WMD], fixed effect: 1·04 min, 95% CI 0·84-1·24; p<0·0001) and PCI (1·15 min, 95% CI 0·96-1·33; p<0·0001), compared with transfemoral access. Transradial access was also associated with higher kerma-area product for diagnostic coronary angiograms (WMD, fixed effect: 1·72 Gy·cm(2), 95% CI -0·10 to 3·55; p=0·06), and significantly higher kerma-area product for PCI (0·55 Gy·cm(2), 95% CI 0·08-1·02; p=0·02). Mean operator radiation doses for PCI with basic protection were 107 μSv (SD 110) with transradial access and 74 μSv (68) with transfemoral access; with supplementary protection, the doses decreased to 21 μSv (17) with transradial access and 46 μSv (9) with transfemoral. Meta-regression analysis showed that the overall difference in fluoroscopy time between the two procedures has decreased significantly by 75% over the past 20 years from 2 min in 1996 to about 30 s in 2014 (p<0·0001). In observational studies, differences and effect sizes remained consistent with RCTs.

INTERPRETATION

Transradial access was associated with a small but significant increase in radiation exposure in both diagnostic and interventional procedures compared with transfemoral access. Since differences in radiation exposure narrow over time, the clinical significance of this small increase is uncertain and is unlikely to outweigh the clinical benefits of transradial access.

FUNDING

None.

Radial versus femoral access for elderly patients with acute coronary syndrome undergoing coronary angiography and intervention: insights from the RIVAL trial

BACKGROUND

Radial access for percutaneous coronary intervention is associated with lower rates of access site complications and bleeding. However, elderly patients have more complex vascular anatomy and radial access may be more challenging in this population. There remains uncertainty regarding the role of radial access in elderly patients undergoing cardiac catheterization.

METHODS AND RESULTS

The RIVAL trial randomized patients with acute coronary syndromes undergoing cardiac catheterization to radial versus femoral access. In this analysis, the rates of access site complications and access site cross-over were compared across different age groups. Among the 7,021 patients, 1035 (15%) were ≥75 years of age. Across all age categories, radial access was consistently associated with higher rates of access site cross over and lower rates of major access site complications, with no significant interaction between age and access site. Radial access was associated with lower rates of major vascular access site complications in patients ≥75 years of age (3.6% vs 6.6%; P = .03) and in patients <75 years of age (1.0% vs 3.2%; P < .001; P value for interaction = .2). The rates of access site crossover were higher with radial access among patients ≥75 (12.5% vs 2.6%; P < .001) and <75 (6.7% vs 1.9%; P < .001; P value for interaction = .9). There were no significant differences in the primary composite outcome (death, myocardial infarction, stroke or non coronary artery bypass graft major bleeding) or its individual components in either age group. In patients ≥75 years of age undergoing primary percutaneous coronary intervention, there was no significant difference in procedure time (120 vs 115 minutes; P = .3).

CONCLUSIONS

Consistent with the overall RIVAL trial population, elderly patients undergoing cardiac catheterization have lower rates of major bleeding or access site complications and higher rates of access site crossover with radial access compared to femoral access.

Sheathless guide catheter in transradial percutaneous coronary intervention for ST-segment elevation myocardial infarction

OBJECTIVES

The aim of this study was to assess the safety and efficacy of sheathless guide catheters in transradial percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

BACKGROUND

Transradial PCI for STEMI offers significant clinical benefits, including a reduced incidence of vascular complications. As the size of the radial artery is small, the radial artery is frequently damaged in this procedure using large-bore catheters. A sheathless guide catheter offers a solution to this problem as it does not require an introducer sheath. However, the efficacy and safety of sheathless guide catheters remain to be fully determined in emergent transradial PCI for STEMI.

METHODS

Data on consecutive STEMI patients undergoing primary PCI at the Sendai Kousei Hospital between September 2010 and May 2013 were analyzed. The primary endpoint was the rate of acute procedural success without access site crossover. Secondary endpoints included door-to-balloon time, fluoroscopy time, volume of contrast, and radial artery stenosis or occlusion rate.

RESULTS

We conducted transradial PCI for 478 patients with STEMI using a sheathless guide catheter. Acute procedural success was achieved in 466 patients (97.5%). The median door-to-balloon time was 45 min (range, 15-317 min). The median fluoroscopy time was 16.4 min (range, 10-90 min). The median volume of contrast was 134 mL (range, 31-431 mL). Radial stenosis or occlusion developed in 14 (3.8%) of the 370 evaluable patients.

CONCLUSIONS

This study showed that use of a sheathless guide catheter taking a transradial approach was effective and safe in primary PCI for STEMI. © 2015 Wiley Periodicals, Inc.

Percutaneous coronary intervention in the elderly

Our population dynamics are changing. The number of octogenarians and older people in the general population is increasing and therefore the number of older patients presenting with acute coronary syndrome or stable angina is increasing. This group has a larger burden of coronary disease and also a greater number of concomitant comorbidities when compared to younger patients. Many of the studies assessing percutaneous coronary intervention (PCI) to date have actively excluded octogenarians. However, a number of studies, both retrospective and prospective, are now being undertaken to reflect the, "real" population. Despite being a higher risk group for both elective and emergency PCIs, octogenarians have the greatest to gain in terms of prognosis, symptomatic relief, and arguably more importantly, quality of life. Important future development will include assessment of patient frailty, encouraging early presentation, addressing gender differences on treatment strategies, identification of culprit lesion(s) and vascular access to minimise vascular complications. We are now appreciating that the new frontier is perhaps recognising and risk stratifying those elderly patients who have the most to gain from PCI. This review article summarises the most relevant trials and studies.

Transradial Primary Percutaneous Coronary Intervention

Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). Many bleeding events are related to the access site. Transradial access (TRA) PPCI is associated with significant reduction in bleeding and vascular complications and reduced cardiac mortality compared with the transfemoral approach (TFA). High-risk patients might particularly benefit from TRA. Radial skills providing procedural times and success rates comparable with those of the TFA are strongly recommended before using this technique in the STEMI PPCI setting.

An overview of PCI in the very elderly

Cardiovascular disease, and in particular ischemic heart disease (IHD), is a major cause of morbidity and mortality in the very elderly (> 80 years) worldwide. These patients represent a rapidly growing cohort presenting for percutaneous coronary intervention (PCI), now constituting more than one in five patients treated with PCI in real-world practice. Furthermore, they often have greater ischemic burden than their younger counterparts, suggesting that they have greater scope of benefit from coronary revascularization therapy. Despite this, the very elderly are frequently under-represented in clinical revascularization trials and historically there has been a degree of physician reluctance in referring them for PCI procedures, with perceptions of disappointing outcomes, low success and high complication rates. Several issues have contributed to this, including the tendency for older patients with IHD to present late, with atypical symptoms or non-diagnostic ECGs, and reservations regarding their procedural risk-to-benefit ratio, due to shorter life expectancy, presence of comorbidities and increased bleeding risk from antiplatelet and anticoagulation medications. However, advances in PCI technology and techniques over the past decade have led to better outcomes and lower risk of complications and the existing body of evidence now indicates that the very elderly actually derive more relative benefit from PCI than younger populations. Importantly, this applies to all PCI settings: elective, urgent and emergency. This review discusses the role of PCI in the very elderly presenting with chronic stable IHD, non ST-elevation acute coronary syndrome, and ST-elevation myocardial infarction. It also addresses the clinical challenges met when considering PCI in this cohort and the ongoing need for research and development to further improve outcomes in these challenging patients.

What's Age Got to do with it? A Review of Contemporary Revascularization in the Elderly

Currently a quarter of all patients treated with percutanous coronary intervention (PCI) are aged >75 years, with this proportion steadily growing. This subset of patients have a number of unique characteristics, such as a greater number of cardiovascular risk factors and frequently a larger burden of coronary artery disease, when compared to younger patients, therefore potentially deriving increased benefit from revascularization. Nonetheless this population are also more likely to experience procedural complications, secondary to age-related physiological alterations, increased frailty and increased prevalence of other co-morbidities. This article reviews the various aspects and data available to clinicians pertaining to and guiding revascularization in the elderly, including the use of adjuvant pharmacotherapy, specific considerations when considering age-related physiology, and revascularization in acute coronary syndromes.

Impact of the use of transradial versus transfemoral approach as secondary access in transcatheter aortic valve implantation procedures

No data exist on the impact of vascular complications related to the secondary access site in transcatheter aortic valve implantation (TAVI). The objectives of this nonrandomized study were to determine the rate of vascular complications related to the secondary access site in TAVI procedures and to evaluate the clinical impact of using the radial versus femoral approach as a secondary access in such procedures. A total of 462 consecutive patients (mean age 79 ± 9 years, 50% men) who underwent TAVI were included. The femoral approach (FA) was used as the secondary access (for the insertion of a 5F pigtail catheter) in 335 patients and the radial approach (RA) in 127 patients. Thirty-day events were prospectively collected. There were no baseline differences between groups, except for a higher prevalence of women and peripheral disease in the FA group (p <0.05 for both). A total of 74 vascular access site complications occurred in 70 patients (15%), and 23% of them (29% in the FA group) were related to the secondary access. The use of FA as secondary access was associated with a higher rate of vascular complications (5.0% vs 0% in the RA group, p = 0.005, adjusted p = 0.014). All major vascular complications related to the secondary access occurred in the FA group (3% vs 0% in the RA group, p = 0.040, adjusted p = 0.049), and this translated into a higher rate of major and/or life-threatening bleeding events related to the secondary access in the FA group (3% vs 0% in the RA group, p = 0.040, adjusted p = 0.049). In conclusion, about 1/4 of vascular access site complications in TAVI are related to the secondary access. The use of the RA as a secondary access was associated with a major reduction in vascular complications. These results highlight the impact of secondary access vascular complications in TAVI procedures and support the use of the RA as the preferred secondary access.