Radial AccessJust another artery?

Keith G OldroydDepartment of Cardiology

Western InfirmaryGlasgow

Brachial accessNot just another artery!

Femoral accessNot just another artery!

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

1.20%

Pre Dr X Post Dr X

Incidence of femoral artery false aneurysms

C Ilsley; personal communication

Femoral accessNot just another artery!

• 45 year old women– Moderate obesity– Elective catheterisation – RFV/RFA

• Major retroperitoneal haemorrhage– CT scan; 6 unit transfusion– Discharged on day 6

• Readmitted on day 9– RCFA false aneurysm– Doppler, CT, thrombin injections

• Discharged day 13

Radial access: just another artery?History of transradial catheterisation

• 1964– Campeau, Montreal Heart Institute– Cut-down on proximal RRA

• 1970/80’s– Percutaneous approach– Axillary > Femoral > Brachial

• 1989– Percutaneous transradial coronary

angiography/PTCA

Radial access: just another artery? Why bother?

• Pre-Colombian– Aspirin– Persantin– Warfarin– Dextran– 8-9F sheaths– 1 week in hospital– No closure devices– 10% bleeding– 5-10% SAT

• Post-Colombian– Aspirin– Clopidogrel– 6F(5F) sheaths– day case/23 hours– Closure devices– <1% bleeding– <1% SAT

Radial access: just another artery? ACCESS Study

• Randomised comparison of different access sites• Experienced operators• No difference in procedural or fluoroscopy times

Radial Brachial Femoral

PCI’s (n) 300 300 300

Coronary cannulation 93% 95.7% 99.7%

Procedural success 91.7% 90.7% 90.7%

Length of stay (days) 1.5(2.5) 1.8(3.8) 1.8(4.2)

Major access site complications 0 2.3 2.0

JACC 1997; 29: 1269-75. Amsterdam, NL

Radial access: just another artery? Carafe Study

• Randomised• Two experienced

operators• ~50% follow-on PCI with

closure devices for femoral cases

• Radial groups– Reduced pain– Earlier ambulation and

discharge– Lower costs

RRA

(n=70)

LRA

(n=70)

Fem

(n=70)

X-overs 1-LRA 0 0

Caths 1.4* 2.1 2.1

Time 12.4 14.2* 11.2

X-rays 3.8 4.2 3.1*

Quality ?LCA OK OK

Vasc. Complns

0 0 2

CCVI 2001; 52:181-7. Massy, France

Radial access: just another artery? Multiple procedures

• 812 patients• 1438 procedures• 6F – 45%• 5F – 55%

Failed procedures

(%)

2nd 3rd 5th

Men 3.5 10 30

Women 7.9 20 50

CCVI 2001;54: 204-8. Fukuoka, Japan

Radial access: just another artery?

Radial access: just another artery? Difficult radial anatomy – small vessels (1)

• Randomised trial of 5Fr vs 6Fr transradial PCI in 171 patients with a +ve Allen test

5Fr 6Fr

Procedural success 95.4% 92.9%

Failed coronary cannulation 1.1% 4.8%

Minor haematoma 1.1% 4.8%

Radial occlusion 1.1% 5.9%

CCVI 2002; 57: 172-6. Greifswa, FRG

Radial access: just another artery? Difficult radial anatomy – small vessels (2)

• 90 patients• Randomised to

hydrophilic sheath vs conventional sheath

• Automatic pullback with an electronic traction guage

CCVI 2001; 54: 289-94. Quebec Can

0

500

1000

PTF

0

2

4

6

PS

Radial access: just another artery?

Radial access: just another artery?

Radial access: just another artery?

Radial access: just another artery?

Radial access: just another artery? Difficult radial anatomy

• Preprocedural ultrasound in 115 patients• Anatomic variations in 11 (9.6%)

– Tortuosity 6 - proceed– Stenoses 2 - proceed– Hypoplasia 2 - femoral– Radioulnar loop 1 - femoral

• Success 111 (97.4%)

CCVI 2000; 49: 357-62 Tokyo, Japan

Radial access: just another artery?

Radial access: just another artery? Difficult subclavian anatomy

• Retro-oesophageal right subclavian artery

• 11 patients in 3730 attempted transradial procedures

• Increased failure rate (7%)

CCVI 2001; 54: 202-3. Massy, France

Radial access: just another artery? Difficult coronary anatomy

• LIMA– LRA is access site of choice– Specific catheters to approach from RRA

• RIMA– RRA is access site of choice

• Anomalous origin of RCA from L sinus of valsalva– Series of case reports– RRA appears to be access site of choice

• Saphenous vein grafts– Avoid during initial experience

Radial access: just another artery? Comparison with closure devices (1)

• Two groups of 109 consecutive PCI’s• Not randomised but matched for usual

demographic parameters• Experienced operators

Radial Perclose

Device not used N/A 20 (18%)

Failed haemostasis 0 9 (10%)

Procedural time 44 (22) mins 57 (22) mins*

Ambulated same day 95% 56%

CCVI 2000; 49: 157-9. Raleigh, NC, USA

Radial access: just another artery? Comparison with closure devices (2)

• 6 high volume operators in a high volume centre• Prospective non-randomised registry

Radial Prostar

PCI’s (n) 376 580

Device not used N/A 3%

Failed haemostasis 0 9.6%

Infection requiring a/b’s 0 2 patients

Transfusion 0 1 patient

CCVI 2000; 51: 417-21. Massy, Fr

Radial access: just another artery? GP IIb/IIIa inhibitors

• 150 consecutive patients treated with GPIIb/IIIa inhibitors

Radial Femoral

PCI’s (n) 83 67

Event free @ 1/12 94% 94%

Length of stay (days) 5.0 4.9

Major access site bleeding

0 5 (7.4%)

Eur Heart J 2000; 21: 662-7. Toulouse, Fr.

Radial access: just another artery? Acute myocardial infarction

• Two centre registry of 1224 patients with AMI treated by primary PCI

Radial Femoral

Closure

Femoral

No closure

PCI’s (n) 277 947

Success 95% 95%

Time No difference

Major access site bleeding

0 2% 7%

CCVI 2002; 55: 206-11. Massy, Fr

Radial access: just another artery? Non-coronary intervention

• Carotid - Case report– Castriota F et al. J Endovasc Surg 1999; 6: 385-6

• Vertebral - Case report– Fessler RD et al (Buffalo, NY) Neurosurg 2000; 46:

1527-8

• Renal - 25 patients; 27 arteries; 100% success– Galli Met al (Como, It) J Inv Cardiol 2002; 14:386-90

Radial access: just another artery? Potential effect on interventional activity

• Elective day case PCI– Reduced costs compared to groin closure– No failed haemostasis– Convert beds to reclining chairs

• In-patient PCI programme– Reduced bed utilisation– Fewer complications– Reduced LOS

Radial access: just another artery?

The only artery!

Normal arterial anatomy in forearm

Brachial tortuosity