Expert Opinion: Transradial Coronary Artery Procedures: Tips for Success

Correlation of a guidewire maximum insertion length with tortuous radial artery and the success rate during transradial coronary angiography

Background

Percutaneous coronary intervention (PCI) is a safe and effective therapy for patients with obstructive coronary artery disease (CAD). We aimed to assess the correlation between the success rate of angiography and the maximum insertion length and resistance of a soft-tipped guidewire.

Methods

Five hundred twenty-one patients were treated by successful radial artery puncture. According to whether the guidewire resistance, the patients were divided to three groups. 17 patients were maximum insertion length of guidewire ≤ 30 cm when resistance was encountered (group 1). 17 patients were maximum insertion length of guidewire between 30 and 45 cm when resistance was encountered (group 2). 487 patients were no resistance encountered (group 3).

Results

The coronary angiography success rates of group 1, 2, and 3 were 52.94%, 47.05%, 98.97%, respectively. Typically, angiography can be completed in patients with Ω-shaped, S-shape or Z-shaped tortuosity.

Conclusions

The maximum insertion length of straight guidewire and resistance can be used to determine radial artery status. The radial artery tortuosity or spasm significantly affects the success rate of coronary angiography.

Transradial Neuroendovascular Procedures in Adolescents: Initial Single-Center Experience

BACKGROUND AND PURPOSE

The feasibility and safety of transradial angiography is not established outside the adult literature. The objective of this study was to assess the feasibility and safety of transradial access for neuroangiography in adolescents.

MATERIALS AND METHODS

A retrospective case-control study was performed, comparing transradial neuroendovascular procedures in adolescents (age range, 10-18 years) with an age- and procedure-matched cohort of transfemoral neuroendovascular procedures. Clinical and procedural details, including type of procedure, conversion rate, fluoroscopy time, radiation dose, complications, and readmissions, were reported by descriptive statistics or measures of central tendency and compared using a t test or nonparametric equivalent. A P value < .05 was considered statistically significant.

RESULTS

Twenty adolescents (mean age, 14.6 [SD, 1.7] years, M/F ratio = 9:11) who underwent transradial neuroangiography were compared against 20 adolescents (mean age, 14.4 [SD, 2.1 ] years, M/F ratio = 12:8) who underwent transfemoral neuroangiography. We found no significant difference in procedural success (0% conversion rate), fluoroscopy times (33.7 [SD, 40.2] minutes versus 23.3 [SD, 26.2] minutes, P = .34) and radiation dose (150.9 [SD, 133.7] Gy×cm² and 122.9 [SD, 79.7] Gy×cm,² P = .43) There were 2 self-limiting postprocedural complications in the transradial group. There were no major hemorrhages, need for further interventions, or readmissions in either group.

CONCLUSIONS

The benefits of transradial angiography described for adults can likely be safely extended to adolescents. These are important data before transitioning to smaller children and should be prospectively evaluated in a larger cohort.

Vascular Complications of Transradial Access for Cardiac Catheterization

Transradial access has been increasingly adopted for cardiac catheterization. It is crucial for operators to recognize potential vascular complications associated with radial artery access. Prevention, early detection, and prompt treatment of vascular complications are essential to prevent serious morbidities. This review aims to raise awareness of transradial access vascular complications. Radial artery spasm is treated with intra-arterial verapamil and/or nitroglycerine. Hemorrhagic complications, such as perforation, hematoma, arteriovenous fistula, and pseudoaneurysm, are treated with prolonged compression. Patent hemostasis and adequate anticoagulation are used to prevent radial artery occlusion. Hand ischemia is a rare complication not associated with abnormal results of the Allen or Barbeau test, and can be treated with intra-arterial verapamil, IV heparin, and IV diltiazem. Finally, an attentive monitoring protocol for the timely detection of vascular complications should be implemented in daily practice.

Radial artery access site complications during cardiac procedures, clinical implications and potential solutions: The role of nitric oxide

Percutaneous coronary intervention for the treatment of coronary artery disease is most commonly performed in the UK through the radial artery, as this is safer than the femoral approach. However, despite improvements in technology and techniques, complications can occur. The most common complication, arterial spasm, can cause intense pain and, in some cases, procedural failure. The incidence of spasm is dependent on several variables, including operator experience, artery size, and equipment used. An anti-spasmolytic cocktail can be applied to reduce spasm, which usually includes an exogenous nitric oxide (NO) donor (glyceryl trinitrate). NO is an endogenous local vasodilator and therefore is a potential target for anti-spasm intervention. However, systemic administration can result in unwanted side-effects, such as hypotension. A method that adopts local delivery of NO might be advantageous. This review article describes the mechanisms involved in radial artery spasm, discusses the advantages and disadvantages of current strategies to reduce spasm, and highlight the potential of NO-loaded nanoporous materials for use in this setting.

A comparative study of Terumo radial Band® and PreludeSYNC hemostasis compression device after transradial coronary catheterization

OBJECTIVE

Novel hemostasis strategies, including PreludeSYNC DISTAL, Merit Medical Systems, Inc. South Jordan, UT, USA (PSD) radial compression device for distal radial artery (DRA) access, have been described for radial access protocols. This study aimed to compare the safety profile of PSD and Terumo radial (TR) Band®.

METHODS

This prospective interventional study was conducted on patients who underwent coronary interventions via either the DRA or forearm radial artery (FRA). Patients with an arterial diameter of <2 mm, requiring dialysis, with unstable acute coronary syndrome, failed radial cannulation, and sheath insertion were excluded. PSD and TR Band® were used for hemostasis after DRA and FRA access, respectively. The time to hemostasis and complications, including minor/major hematoma, radial artery occlusion (RAO), and neurological symptoms (after 20 days) were recorded. The mean and standard deviation were calculated for age and hemostasis duration. Frequency and percentages were calculated for categorical variables. Independent t-test and Chi-squared test were performed to determine the significance of the differences between the two groups. A p-value of <0.05 was significant.

RESULTS

Of 139 participants, TR Band® and PSD were used in 76 and 63 patients, respectively. The mean age of the participants was 58.70±10.00 years, and the majority of the patients were men (67.60%). The hemostasis time of both devices was similar (p>0.490). Compared with PSD, TR Band® had more complications (52.63% vs. 23.81%; p=0.020), particularly RAO [odds ratio (OR), 3.17; p=0.018] and neurological problems (OR, 5.33; p=0.005).

CONCLUSIONS

Although, PSD seems safer in patients with coronary interventions, the device should further be explored in crossover trials for the two access types to determine the overall safety profile.

Barriers to use of radial access for percutaneous coronary intervention

OBJECTIVES

The aim of this study was to identify barriers to transradial access percutaneous coronary intervention (PCI).

BACKGROUND

Transradial access yields fewer vascular complications, earlier ambulation, and more patient comfort. However, the adoption to practice is slow, and transfemoral access is still commonly used.

METHODS

We identified all PCIs done by one operator in a radial-first trainee-driven practice. The individual charts were reviewed for all PCIs using femoral access. Reasons for not using radial access were identified. Descriptive statistics were used to report reasons for not using transradial access. Analyses were performed on a per-procedure basis.

RESULTS

Of 1,948 PCIs, 1,790 (92%) were via radial access and 158 (8%) via femoral access. Femoral access was used to bail out unsuccessful radial access in 21 PCIs (13% of all femoral PCIs, 1% of all PCIs). Radial access was unsuccessful due to failure to cannulate radial artery, radial artery spasm, and radial loop in majority of radial access failure PCIs (n = 13). Femoral access was used as a primary strategy in 137 PCIs (87% of all femoral PCIs, 7% of all PCIs), mostly due to undetectable radial artery pulse (both left and right) (n = 40).

CONCLUSIONS

Radial access can be used for PCI safely and effectively. Inadequate radial pulse is the main barrier. Adjunctive strategies such as ulnar access and use of ultrasound may further increase the success rate of arterial access from the upper extremities.

Coronary Angiography in Patients with Arteria Lusoria via Right Radial Access: A Case Series and Literature Review

Transradial is becoming the access of choice for coronary angiography (CAG). Arteria lusoria (AL) poses a challenge for right transradial access because it can cause difficulty in accessing the ascending aorta. Of 18,686 patients who underwent CAG in Geisinger Medical Center from 2012 to 2018, 6 had a diagnosis of AL. Four underwent attempted right radial access, in 3 cases before AL was identified. All were successful, and one patient had successful right transradial percutaneous coronary intervention. CAG and PCI can be successfully performed using right radial access in patients with AL.

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.

Effects of Catheterization on Artery Function and Health: When Should Patients Start Exercising Following Their Coronary Intervention?

Coronary artery disease (CAD) is a leading cause of death worldwide, and percutaneous transluminal coronary angiography (PTCA) and/or percutaneous coronary intervention (PCI; angioplasty) are commonly used to diagnose and/or treat the obstructed coronaries. Exercise-based rehabilitation is recommended for all CAD patients; however, most guidelines do not specify when exercise training should commence following PTCA and/or PCI. Catheterization can result in arterial dysfunction and acute injury, and given the fact that exercise, particularly at higher intensities, is associated with elevated inflammatory and oxidative stress, endothelial dysfunction and a pro-thrombotic milieu, performing exercise post-PTCA/PCI may transiently elevate the risk of cardiac events. This review aims to summarize extant literature relating to the impacts of coronary interventions on arterial function, including the time-course of recovery and the potential deleterious and/or beneficial impacts of acute versus long-term exercise. The current literature suggests that arterial dysfunction induced by catheterization recovers 4-12 weeks following catheterization. This review proposes that a period of relative arterial vulnerability may exist and exercise during this period may contribute to elevated event susceptibility. We therefore suggest that CAD patients start an exercise training programme between 2 and 4 weeks post-PCI, recognizing that the literature suggest there is a 'grey area' for functional recovery between 2 and 12 weeks post-catheterization. The timing of exercise onset should take into consideration the individual characteristics of patients (age, severity of disease, comorbidities) and the intensity, frequency and duration of the exercise prescription.