Rapid cycle change to predominantly radial access coronary angiography and percutaneous coronary intervention

Controversies in the Management of ST-Segment Elevation Myocardial Infarction: Transradial Versus Transfemoral Approach

This article discusses the controversies surrounding the use of transradial versus transfemoral approaches in the management of patients with ST-segment elevation myocardial infarction, beginning with a review of the benefits of transradial percutaneous coronary intervention (PCI) in this population. The unanswered questions about the mechanism underlying the mortality benefit of transradial PCI are discussed, concluding with recommendations for safe and effective strategies for adoption of the transradial approach to optimize outcomes in these high-risk patients.

Variation in Arterial Access for Invasive Coronary Procedures in New Zealand: A National Analysis (ANZACS-QI 5)

BACKGROUND

Radial arterial access (RA) and femoral arterial access (FA) rates for invasive coronary angiography (ICA) vary widely internationally. The European Society of Cardiology (ESC) suggests default RA is feasible. We aim to investigate the variation in RA rates across all New Zealand public hospitals.

METHODS AND RESULTS

Patient characteristics, procedural details, and inpatient outcome data were collected in the All New Zealand Acute Coronary Syndrome - Quality Improvement (ANZACS-QI) registry on consecutive patients undergoing ICA over five months. Of the 5894 ICAs 81% were via RA. Hospitals averaged 25 - 176 procedures/month (46.5% - 96.4% via RA). Operators averaged 17 procedures/month. Those performing more than 20 ICAs/month had RA rates between 61% - 99%. Of the 75 operators, 69% met the ESC recommendation. After multivariable adjustment higher operator (RR 1.12, CI 1.09 - 1.30) and hospital (RR 1.21, CI 1.15 - 1.28) volume were independent predictors of RA. Those with prior CABG (RR 0.51, CI 0.45 - 0.57), STEMI <12h (RR 0.91, CI 0.87 - 0.96), and female sex (RR 0.96, CI 0.94 - 0.99) were less likely to receive RA.

CONCLUSIONS

New Zealand has a high RA rate for ICAs. Rates vary substantially between both operators and centres. Radial arterial was highest amongst the highest volume operators and centres.

The Transradial Learning Curve and Volume-Outcome Relationship

This article discusses how learning curves correlate with learning in transradial catheterization. Although learning curves exist in the conversion to transradial approaches, current percutaneous coronary intervention (PCI) procedures are so safe that only surrogate end points such as contrast usage and x-ray exposure show learning effects. Using these surrogates, a learning curve of 30 to 50 patients seems typical to transition cardiologists from transfemoral to transradial PCI. This transition occurs with the immediate benefit of reduced vascular complications and bleeding and without loss of overall procedural success. These measures of safety during learning exist despite difference of procedural volumes.

Transradial vascular access: a growing trend

The transradial route for coronary angiography is a growing trend in the United States. Nurse practitioners (NPs) are an essential part of the preprocedural assessment and management of patients. This article will outline the benefits and risks of transradial access as well as methods for NPs to assess arterial hand circulation.

Radiation Dose Reduction during Radial Cardiac Catheterization: Evaluation of a Dedicated Radial Angiography Absorption Shielding Drape

Objectives. Radiation scatter protection shield drapes have been designed with the goal of decreasing radiation dose to the operators during transfemoral catheterization. We sought to investigate the impact on operator radiation exposure of various shielding drapes specifically designed for the radial approach. Background. Radial access for cardiac catheterization has increased due to improved patient comfort and decreased bleeding complications. There are concerns for increased radiation exposure to patients and operators. Methods. Radiation doses to a simulated operator were measured with a RadCal Dosimeter in the cardiac catheterization laboratory. The mock patient was a 97.5 kg fission product phantom. Three lead-free drape designs were studied. The drapes were placed just proximal to the right wrist and extended medially to phantom's trunk. Simulated diagnostic coronary angiography included 6 minutes of fluoroscopy time and 32 seconds of cineangiography time at 4 standard angulated views (8 s each), both 15 frames/s. ANOVA with Bonferroni correction was used for statistical analysis. Results. All drape designs led to substantial reductions in operator radiation exposure compared to control (P < 0.0001). The greatest decrease in radiation exposure (72%) was with the L-shaped design. Conclusions. Dedicated radial shielding drapes decrease radiation exposure to the operator by up to 72% during simulated cardiac catheterization.