Comparative Efficacy of Transradial Versus Transfemoral Approach for Coronary Angiography and Percutaneous Coronary Intervention

Rates of the Trans-radial Approach in Elective and Emergency Coronary Angiography in Iraq: A Cross-Sectional Study

Background and aims The trans-radial access is becoming the default approach in many cardiac centers worldwide. Data from the Middle East, including Iraq, on the trends and rates of the use of trans-radial access are scarce. The aim of this study is to determine the rates of trans-radial approach (TRA) versus transfemoral approach (TFA) in patients with coronary artery syndromes undergoing coronary angiography and/or percutaneous coronary intervention (PCI) in Iraq. Methods In this multicenter prospective study, we collected 885 cases of coronary artery disease undergoing coronary angiography/PCI from three main cities of the Kurdistan Region in Iraq from 2022 to 2023. Results Of the total sample, 57.2% were diagnostic coronary angiography and 42.8% were PCI, 57.1% of all cases were TFA and 42.9% were TRA, and 64.3% of PCI cases were performed through TFA. Eghty-two percent of total emergency PCI included (primary PCI) cases underwent the procedure through the TFA, and only 18% of such cases were through the TRA. The overall crossover rate between both approaches happened in 14 (3.6%) cases. Conclusions Despite its main benefits, the radial access use in the Cath lab is yet underused in our region. Further steps in training programs are indicated to popularize the use of radial access among interventional cardiologists in addition to transfemoral access.

Rationale and Design of the Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion Trial (CAPITAL-RAPTOR)

INTRODUCTION

Transradial access (TRA) has rapidly emerged as the preferred vascular access site for coronary angiography and percutaneous coronary intervention. Radial artery occlusion (RAO) remains as an important complication of TRA as it precludes future ipsilateral transradial procedures. While intraprocedural anticoagulation has been studied extensively, the definitive role of postprocedural anticoagulation has not yet been established.

METHODS AND ANALYSIS

The Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion trial is a multicentre, prospective, randomised, open-label, blinded-endpoint design study investigating the efficacy and safety of rivaroxaban to reduce the incidence of RAO. Eligible patients will undergo randomisation to receive either rivaroxaban 15 mg once daily for 7 days or to no additional postprocedural anticoagulation. Doppler ultrasound to assess radial artery patency will be performed at 30 days.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ottawa Health Science Network Research Ethics Board (approval number 20180319-01H). The study results will be disseminated via conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03630055.

Prevention of radial artery occlusion with rivaroxaban after trans-radial access coronary procedures: The RIVARAD multicentric randomized trial

Background

Radial artery occlusion (RAO) remains the most frequent complication of trans-radial access. Once the radial artery is occluded, its future use as an access site for coronary procedures, or as a conduit for coronary bypass grafting or fistula for hemodialysis, will be precluded. Therefore, we aimed to assess the value of the short-term use of Rivaroxaban to prevent RAO after a trans-radial coronary procedure.

Methods

This was a prospective, open-label, randomized study. The patients were randomly assigned (1:1) to one of two groups: those who received Rivaroxaban 10 mg for 7 days following the trans-radial coronary procedure (the Rivaroxaban Group) and those who received the standard treatment (the Control Group). The primary outcome was an occurrence of RAO evaluated by Doppler ultrasound at 30 days, and the secondary outcomes were hemorrhagic complications according to BARC classification.

Results

We included 521 patients randomized into two Groups: the Control Group (N = 262) and the Rivaroxaban Group (N = 259). The 1-month RAO was significantly reduced in the Rivaroxaban Group as compared to the Control Group [6.9% vs. 13%; p = 0.011, OR = 0.5, (95% CI, 0.27-0.91)]. We noted no cases of severe bleeding events (BARC3-5). The overall incidence of minor bleeding (BARC1) was 2.3%, with no significant difference between the two groups [Rivaroxaban Group = 2.7%, Control Group = 1.9%, p = 0.54, OR= 1.4, (95%CI 0.44-4.5)].

Conclusions

Short-term postoperative anticoagulation with Rivaroxaban 10 mg for seven days reduces the rate of 1-month RAO.

Meta-Analysis of Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease

Data comparing outcomes of transradial (TR) versus transfemoral (TF) access for percutaneous coronary intervention (PCI) in chronic kidney disease (CKD) including patients with eGFR< 30 ml/min/1.73m² and patients with end-stage renal disease on dialysis (ESRD) are lacking. This meta-analysis compares the outcomes of TR versus TF approach for PCI in patients with CKD. PubMed, Embase, Cochrane, ClinicalTrials.gov, and Google Scholar were searched for studies including adults with CKD undergoing PCI via a TR versus TF approach from January 1, 2000, until January 15, 2021. The primary outcome was in-hospital all-cause mortality and secondary outcomes included major bleeding, stroke, myocardial infarction (MI), blood transfusion, contrast volume, and fluoroscopy time. The analysis was performed using a random-effects-model using the Mantel-Haenszel method. Five observational studies met inclusion criteria, including 1,156 and 6,156 patients in the TR and TF arms, respectively. The mean age of included patients was 70.5 years, 66% were male and 90% had ESRD. In patients with CKD, TR access for PCI was associated with lower all-cause mortality (RR = 0.48; 95% CI: 0.32 to 0.73), major bleeding (RR = 0.51; 95% CI: 0.36 to 0.73), blood transfusion (RR = 0.53, 95% CI: 0.42 to 0.68) and contrast volume (SMD -0.34 [-0.60 to -0.08]) with no difference in stroke, MI, or fluoroscopy time compared with TF access. In conclusion, in patients with CKD undergoing PCI, the TR approach was associated with a lower risk of in-hospital mortality, post-procedural bleeding, and blood transfusion compared with TF access.

Ointment therapy and prevention of cannulation-induced superficial phlebitis

The primary aim of this prospective randomized trial is to determine the effect of clobetasol ointment with nitroglycerin ointment on the prevention of phlebitis caused by cannulation. The target sample is 144 patients admitted to surgical ward, randomized to 3 groups. the data collection tools included demographic information, information about intravenous treatment and phlebitis measurement scale. In the intervention groups, after venipuncture, 1.5 cm of ointments (clobetasol and nitroglycerin) was applied n three time periods of 24, 48 and 72 hours from the time of venipuncture. In the first 24 hours after cannulation, there was no significant difference between the three groups. But at 48 and 72 hours after placement, the difference between intervention and control groups was significant (P<0.0001). It is recommended to use clobetasol ointment and nitroglycerin ointment to prevent the occurrence of phlebitis in patients who need long-term use of cannula (more than 48 hours).

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.

Transradial Versus Transfemoral Access for Percutaneous Coronary Intervention in ST-Segment-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis

[Figure: see text].

Time to discharge following diagnostic coronary procedures via transradial artery approach: A comparison of Terumo band and StatSeal hemostasis

BACKGROUND

The transradial artery (TRA) approach for cardiac catheterization is associated with fewer complications, earlier mobilization and a shorter stay at the hospital. The objective of this study was to determine whether hemostasis with a combination of a compression band (Terumo TR band™) and a hemostatic patch (StatSeal™) decreases the time to discharge from the hospital compared to the Terumo (TR) band alone in patients undergoing diagnostic coronary catheterizations through a TRA approach.

METHODS

We retrospectively looked at 445 patients who underwent diagnostic coronary angiography through the TRA approach at the Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas between July 2016 and June 2017. The difference in the time to discharge between the two groups was assessed by a Wilcoxon Rank-sum test.

RESULTS

The combination of a TR band and a StatSeal hemostatic patch was used in 70.3% (313) of the patients. Comparison of the two groups demonstrated a statistically significant reduction in time from the end of the procedure to discharge (p < 0.001), with no significant alteration in safety among those with a combination of TR band and a StatSeal hemostatic patch.

CONCLUSION

With increasing frequency of TRA procedures in the United States, we demonstrate one effective method to significantly reduce the time to radial hemostasis and reduce the time to patient discharge from the hospital.

Radial versus femoral approach for same-day inter-facility transfer for percutaneous coronary intervention

BACKGROUND

The use of radial approach for coronary angiography, followed by same-day inter-facility transfer for percutaneous coronary intervention (PCI) has not yet been evaluated.

OBJECTIVES

We sought to assess the safety and feasibility of using the transradial as compared to the transfemoral approach in patients undergoing diagnostic angiogram with same-day transfer to a PCI facility.

METHODS

Patients that underwent diagnostic coronary angiography between January 2011 and June 2017 in a referring facility, and were transferred for same-day PCI were included. Patients' demographics, as well as procedural data and in-hospital outcome, were collected.

RESULTS

Three hundred fifty-two participants were included. Of these, 36 (10.2%) patients received transradial access. Patients in the transradial group were older (68 ± 10 vs 62 ± 12 years, P = 0.007), and received a significantly higher total dose of heparin including both, diagnostic and PCI procedures (5935 ± 1865 vs 10029 ± 2771 units, P < 0.001). None of the transradial patients experienced bleeding or access-related complications. In the transfemoral group, 9 (3%) vascular-access complications were recorded. Contrast volume was lower for transradial patients (177 ± 47 vs 216 ± 75 mL, P < 0.001). A higher proportion of outpatients were discharged from the PCI-center the same day after transradial procedures (53% vs 1.3%, P < 0.001).

CONCLUSIONS

Transradial access for inter-facility transfer for PCI after diagnostic angiogram appears safe and feasible, without increasing the risk for ischemic hand complications. Transradial access was associated with fewer bleeding and vascular access-site complications, and with a higher likelihood for a same-day discharge home in outpatients.

Urinary metabolites in patients undergoing coronary catheterization via the radial versus femoral artery approach

The transradial approach (TRA) for coronary angiography and percutaneous coronary intervention is associated with lower rates of vascular complications and acute kidney injury when compared to the transfemoral approach (TFA). Urine metabolites and proteins may be useful in identifying the dynamic changes at the vascular endothelial cell level. We attempted to explore the changes in the measurable signals of endothelial and nephron injury within 60 to 90 minutes after catheterization among those with the TRA and TFA approaches. Consecutive patients of a single interventionist who underwent coronary angiography between June 2015 and May 2016 were included. Of the 60 patients included in the analysis, the baseline characteristics were similar between those with a TRA (n = 30) and TFA (n = 30) approach. The values of the biomarkers were natural log transformed for the analysis. We found that the mean values of heat shock protein 27, taurine, and sulfuric acid did not significantly change after the procedure. However, the median value of thioredoxin decreased (P = 0.002) and that of talose increased (P = 0.01) after the procedure. None of the patients in our cohort experienced vascular complications or acute kidney injury. No differences in the values of urinary metabolites (pre, post, and delta) were found between TRA and TFA except for postprocedural thioredoxin. In conclusion, this exploratory study showed no difference in the patterns of acute vascular/renal injury metabolic markers before and after catheterization irrespective of the arterial access site.

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.

Penoscrotal haematoma after cardiac catheterisation

Scrotal haematoma is an extremely rare complication after cardiac catheterisation (CC) with only few cases reported in literature. We report a 56-year-old patient who developed large scrotal haematoma after CC via transfemoral approach requiring blood transfusion due to haemodynamic instability. After an uneventful elective procedure, he was discharged with a collagen plug-based vascular closure device (Angio-Seal). He developed sudden onset, excruciating groin pain with scrotal swelling and shock. Bleeding was stopped with manual compression over the femoral artery and 2 units of packed red blood cells were transfused. CT angiogram revealed scrotal haematoma without active bleeding. Testicular blood supply remained intact. Scrotal swelling improved with conservative management and patient got discharged 3 days later in a stable condition. The review of literature suggests that penoscrotal haematoma is unusual after CC but may result from arterial injury or bleeding into the fascial planes. Majority of patients require observation but surgery is indicated in selected cases for vascular complications.