American Heart Journal
Volume 156, Issue 5 , Pages 805-807, November 2008

Radial access for cardiac catheterization is not radical

  • Ian C. Gilchrist, MD, FACC

      Affiliations

    • Penn State Heart and Vascular Institute, M.S. Hershey Medical Center, Hershey, PA
    • ,
  • John K. French, MB ChB, PhD, FACC

      Affiliations

    • Department of Cardiology, Liverpool Hospital, Elizabeth St, Liverpool, New South Wales, Australia

Received 29 July 2008; accepted 3 August 2008.

Article Outline

 

Observations from a large cohort study that simple modifications in the cardiac catheterization procedure can be associated with significant changes in patient outcomes, with reduced bleeding associated with radial access, is reported in this issue of the Journal by Dr Eichhöfer et al (p. 864). This extends recent reports from large clinical trials of antithrombotic therapies in patients with non–ST- elevation acute coronary syndromes.1

For a generation of invasive cardiologists who have been raised on the dogma that femoral artery access for cardiac catheterization is de rigueur, the concept that the smaller radial artery may offer a better approach has been slow to gain acceptance. Although changing from the femoral to radial artery appears relatively straight forward, the rate of uptake of this change has occurred in a very heterogeneous manner across the international cardiology practice. There has been relatively enthusiastic adoption of transradial techniques outside of the United States but minimal conversion within the United States. A variety of barriers have slowed the widespread dissemination of transradial techniques. This is analogous to the slow adaptation into lipid-modifying regimens of niacin therapy, which was added in 1999 to the AHA/ACC guidelines for the care of coronary patients, but its widespread adoption in clinical practice has been slow because of the perceived difficulty in its use due to side effect management. A more pragmatic issue may stem from niacin's generic status and relative lack of well-funded pharmaceutical support for its dissemination compared to that of the newer statins that were concurrently coming into widespread use. Transradial procedures likewise do not require significant new catheterization equipment and may actually require lower equipment costs than those for transfemoral procedures. This results in little corporate interest in the radial procedure market.

Funding and reimbursement issues may also have created an environment of perverse disincentives to coronary procedures via radial access in some circumstances. For instance, femoral access for percutaneous coronary intervention (PCI) makes a post-PCI overnight stay highly likely and can lead to increased remuneration for the institution. Earlier reports2, 3 have suggested same day discharge after radial access PCI is safe, and the Elective PCI in Outpatient Study (EPOS) has recently confirmed the safety the of “day-case” PCI for selected patients.4 Improvements in technique, technology, and pharmacology have lead to the marked rarity of emergent-urgent coronary artery bypass graft (CABG) within 24 hours of a PCI procedure; for example, at Liverpool Hospital (Sydney, Australia), there have been no such cases in the last 18 months during approximately 1,500 PCIs (J.K.F., unpublished data). There has even been a preliminary report of safe same day discharge in certain subsets of patients with high-risk features.5

Transradial procedures do require some change in technique, and there are a variety of perceived barriers to use this techniques especially among operators who are much more familiar with using the femoral access route. It has been noted that the radial artery is smaller, but it is interesting that some of the most enthusiastic converts to the transradial approach are found in eastern Asia where patients' body mass indices are significantly lower than typical US populations.

The Allen test and its results are viewed as an opportunity to convert to a transfemoral procedure. The Allen test is an example of the concept of collateral circulation physiology and, if tested carefully with oximetry, is abnormal in about 1% of the population.6 However, missing is clinical evidence that the demonstration of a physiologic abnormality is predictive of adverse outcome in patients undergoing transradial procedures. Adverse outcomes from of transradial arterial lines in critical care units have never been associated with an abnormal Allen test,7 and the surgical literature is remarkably free of ischemic hand complications after radial harvest for CABG. There are now reports of radial harvest in those with abnormal Allen test8 and transradial catheterization without using an Allen test9 all without hand ischemia. The primary risk of an abnormal Allen test is the risk of using the femoral artery for catheterization.

There is a frequently discussed learning curve to transradial procedures that is similar to that found in most new technology. Unlike the learning period that might be experienced during closure device introduction, transradial failures are usually not of a catastrophic nature and primarily result in a shift to the contralateral radial artery or femoral artery for access with no long-term sequela. Even while the operator is progressing through the learning curve, patients are benefiting from the less invasive procedure and express their support for the physician's decision to use the radial artery especially if they have ever experienced a transfemoral procedure.

There is considerable evidence that quality of PCI performance is multifactorial and associated with procedural volume along with catheterization laboratory staff and operator-dependent factors. The successful uptake of radial access PCI is highly dependent on the catheterization laboratory nursing staff managing these patients successfully, including the use of hep-wells to facilitate central venous access10 and vigilance to avoid bleeding complications and optimize radial artery recovery.

With the present technology, most routine invasive cardiac catheterization laboratory procedures can be done with a transradial approach. This includes diagnostic angiography, left and right ventricular hemodynamics, and PCI including acute primary reperfusion. Intra-aortic balloon pumps, percutaneous ventricular assist devices, and novel first-generation interventional devices are too large to use in the radial artery, but for most of care patients received in the catheterization laboratory, the radial artery is more than adequate. Technically, the ability to image bilateral internal thoracic artery grafts via radial approaches represents a challenge, and at times patients present with absent radials or have renal fistulas that preclude their use. However, such cases make up a small part of most coronary interventional practices.

Radial arteries do get damaged on occasions during coronary procedures,11 and this is an area that further research and development is needed. Repeat procedures even within the same day are possible, but the close proximity between the arterial wall and catheters appears to enhance the risk for endothelial damage. Asymptomatic chronic arterial damage and occlusion may make the artery a poor conduit in the future for conduit use in CABG or fistula use in renal dialysis. Alteration in hemostasis techniques, improvements in equipment, and pharmacology may be able to provide at least a partial solution to this challenge.

The adverse prognostic effect of bleeding in patients with acute coronary syndromes has been increasingly highlighted in recent years. Indeed, data from Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial have shown that the adverse prognostic effect of bleeding in patients with acute coronary syndromes is at least as significant as that of reinfarction.12 The mortality risk attributable to bleeding may be more than the adverse prognostic effect of recurrent myocardial infarction.13, 14 Much of the focus regarding the risk of bleeding has been focused on the antithrombotic and antiplatelet regiments, although some of the risk of bleeding may be related to whether, or not, blood transfusion is used for treatment.15 New antithrombotic regimens using agents such as bivalirudin in studies designed around composite end points that include reductions in bleeding have shown promising results that have been successfully put into practice. Unfortunately, most of these trials have occurring in the setting of transfemoral catheterization. Whether the reduction in bleeding associated with angiography and PCI via the femoral route with these newer therapies translates to the same relative benefit if the radial route is used needs clarification.

In patients with non–ST-elevation acute coronary syndromes, a group inherently at risk for iatrogenic bleeding, the influence of the route of arterial access has received surprisingly little attention. The Superior Yield of the New strategy of Enoxaparin, Revascularization, and GlYcoprotein inhibitors (SYNERGY) trial investigators1 have reported a close association between the arterial route access, the bleeding risk, and outcomes. These investigators found that the risk of major bleeding with a radial route was 0.9%. The risk was similar from the femoral route if a 4/5F sheath was used from the femoral route, but the risk approximately doubled with in each increase in sheath size from 5F to 6F and 6F to 7F. With a 7F sheath, which many “femoral route” operators favor for, PCI had major bleeding rates of 3.3%, approximately 4-fold higher than the rate associated with the radial access route.

Among patients undergoing PCI for various clinical indications, the use of the radial route was associated with a halving of transfusion rates, which was in turn associated with mortality in another Canadian Registry.16 The use of the radial access route and the bleeding reduction associated with that route also occurs in 2 patients groups in whom operators have particular concerns about bleeding risk—women and the elderly, albeit at an approximate 10% to 15% frequency of requiring a second access route.17, 18

The report of Eichhöfer et al includes almost 1000 patients with ST-elevation myocardial infarction, and approximately 200 patients were propensity matched. The radial artery approach was used approximately half as frequently as the institutional average of 24% for this indication even when shock patients were excluded. As the radial access route for PCI has lower rates of bleeding when rescue PCI is performed for “failed pharmacological reperfusion,”19 it would have been interesting to know the bleeding rates with respect to the access route in the “high-risk” ST-segment elevation myocardial infarction (STEMI) cohort. Furthermore, whether rates of bleeding in the recently published Harmonizing Outcomes with RevascularIZatiON and Stents (HORIZONS)-AMI trial were reduced with bivalirudin therapy applied, when the radial route was used for primary PCI is of interest as limited preliminary nonrandomized data from the ACUITY trial has not indicated reduced bleeding with bivalirudin when a radial approach has been used.

Compared with the significant efforts made to optimize pharmacologic regimens, some of which have modest effects on patient outcomes, little attention has been focused on the potential benefits of altering invasive procedures that might markedly improve outcomes. For example, during the most recent Society for Cardiovascular Angiography and Interventions-American College of Cardiology i2 (SCAI-ACCi2) meeting in Chicago 2008, there was only a single invited talk related to transradial approaches and that did not list a speaker in the final program. Likewise, the large Transcatheter Cardiovascular Therapeutics (TCT) meetings held annually in Washington and the annual American Heart Association meetings similarly have offered little dissemination of transradial technology. Given the reduction in complications and length of stay demonstrated by Eichhöfer et al, further evidence is now available to encourage changes in practice techniques that may have profound benefits to our patients.

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References 

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PII: S0002-8703(08)00663-7

doi:10.1016/j.ahj.2008.08.005

Refers to article:

  • Decreased complication rates using the transradial compared to the transfemoral approach in percutaneous coronary intervention in the era of routine stenting and glycoprotein platelet IIb/IIIa inhibitor use: A large single-center experience

    Jonas Eichhöfer, Eric Horlick, Joan Ivanov, Peter H. Seidelin, John R. Ross, Douglas Ing, Paul Daly, Karen Mackie, Brenda Ridley, Leonard Schwartz, Alan Barolet, Vladimír Džavík
    American Heart Journal November 2008 (Vol. 156, Issue 5, Pages 864-870)

American Heart Journal
Volume 156, Issue 5 , Pages 805-807, November 2008

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