Chinese expert consensus on transradial access in percutaneous peripheral interventions

PMD42 - A literature Review of Transradial vs. Transfemoral Lower Extremity Peripheral Artery Interventions

Transradial (TR) access for percutaneous coronary intervention (PCI) reduces bleeding compared with transfemoral (TF) access, and may reduce mortality in specific patient subsets. However, switching from TF to TR access is associated with a learning curve and it is unclear whether benefits observed in randomized trials translate into practice. We sought to characterize the trends in bleeding and mortality rates at our institution, as we changed from being a TF to predominantly TR center over a 5-year period. 10,213 consecutive patients presenting for PCI were included (mean age 65.0 ± 11.6 years, 76.1% male, 48.0% PCI for acute coronary syndrome) over 5 years at a single center with PCI volume >2,000 cases per annum. Patients were stratified by initial arterial access site (TR or TF) and outcome measures included temporal trends in TR procedural failure, 30-day bleeding complications and all-cause 1-year mortality. TR procedural failure fell to a consistently low rate within 1 year (11.8% in 2008 to 2.9% in 2009, P < 0.001). As TR volume increased, the annual 30-day bleeding rate fell (1.64% in 2008 to 0.68% in 2012, P = 0.006). TR access predicted reduced 30-day bleeding (OR 0.17 [95%CI 0.07-0.38], P < 0.001), but was not a predictor of 1-year survival (HR 0.78 [95%CI 0.58-1.05], P = 0.10). Successful transition from TF to TR PCI at our institution was rapid and associated with a reduction in 30-day bleeding. These data should encourage other centers considering the adoption of TR access.

There are limited data on predictors of long-term clinical outcomes after catheter ablation of atrial fibrillation. This secondary analysis of 750 participants enrolled in the FIRE AND ICE trial assesses the association of baseline covariates with clinical outcomes in drug-refractory paroxysmal atrial fibrillation. The study found that women had a 40% higher risk than men of recurrence of atrial arrhythmia and cardiovascular rehospitalization after catheter ablation of atrial fibrillation.

The purpose of this study was to describe a single institution's experience with transradial access (TRA) for angiographic interventions, and to compare technical success, complication rate and radiation dose of procedures performed with TRA to those performed with transfemoral access (TFA). A retrospective cohort study of patients undergoing peripheral interventions via TRA or TFA from 2015 to 2017 was performed. The cohort comprised 33 patients undergoing 44 procedures via TRA and 37 patients undergoing 44 procedures via TFA. Outcome measures were technical success, access-related complications, fluoroscopy time and radiation exposure. Differences at p < 0.05 were considered to be statistically significant. Baseline characteristics were similar between patients who had procedures via TRA versus those who had procedures via TFA, including age, sex and body mass index. Technical success was achieved in 41/44 (93.2%) of procedures performed via TRA, compared to 44/44 (100%) of procedures performed via TFA (p = 0.241). There were three access-related complications (6.8%) when TRA was performed, compared to none when TFA was performed (p = 0.241). Fluoroscopy time was longer in procedures performed with TRA compared to those performed with TFA (27.3 vs 20.4, p = 0.033). Dose area product (DAP) did not differ with access site choice (p = 0.186). TRA is a safe and feasible alternative to TFA for a range of peripheral interventions. However, TRA must be performed with prudence as it is not without complications and is technically challenging, leading to longer fluoroscopy time. • Transradial access (TRA) is feasible in a variety of peripheral interventions, achieving success in 93.2% of cases. • Access-related complications are comparable between transfemoral access (TFA) and TRA (p = 0.241), but prudence must be taken during TRA as it could be technically challenging. • Procedures performed with TRA tend to have longer fluoroscopy time compared to those performed with TFA (p = 0.033), but the DAPs are comparable (p = 0.186).

Safety and efficacy of radial versus femoral access for rotational Atherectomy: A systematic review and meta-analysis.

Carotid Artery Angioplasty and Stent Placement: Quality Improvement Guidelines to Ensure Stroke Risk Reduction

BackgroundAccess site complications contribute to morbidity and mortality during percutaneous coronary intervention (PCI). Transradial arterial access significantly lowers the risk of access site complications compared to transfemoral arteriotomy. We sought to develop a prediction model for access site complications in patients undergoing PCI with femoral arteriotomy, and assess whether transradial access was selectively used in patients at high risk for complications.Methods and ResultsWe analyzed 17 509 patients who underwent PCI without circulatory support from 2008 to 2011 at 5 institutions. Transradial arterial access was used in 17.8% of patients. In those who underwent transfemoral access, 177 (1.2%) patients had access site complications. Using preprocedural clinical and demographic data, a prediction model for femoral arteriotomy complications was generated. The variables retained in the model included: elevated age (P<0.001), female gender (P<0.001), elevated troponin (P<0.001), decreased renal function or dialysis (P=0.002), emergent PCI (P=0.01), prior PCI (P=0.005), diabetes (P=0.008), and peripheral artery disease (P=0.003). The model showed moderate discrimination (optimism‐adjusted c‐statistic=0.72) and was internally validated via bootstrap resampling. Patients with higher predicted risk of complications via transfemoral access were less likely to receive transradial access (P<0.001). Similar results were seen in patients presenting with and without ST‐segment myocardial infarction and when adjusting for individual physician operator.ConclusionsWe generated and validated a model for transfemoral access site complications during PCI. Paradoxically, patients most likely to develop access site complications from transfemoral access, and therefore benefit from transradial access, were the least likely to receive transradial access.

Transradial access (TRA) is a feasible method for interventional neurovascular procedures, gaining popularity after becoming the standard access route in cardiovascular interventions. While advantages of TRA include better safety, cost...

Transradial arterial access has transformed the field of coronary interventions, where it has several advantages over femoral access, such as reduced bleeding and access site complications, improved patient comfort, shorter time to ambulation after the procedure, reduced length of hospital stay, and potentially reduced mortality rates. Because of these benefits, as well as the concurrent expanding indications for various endovascular therapies, there is growing interest in adopting radial access for peripheral vascular interventions. However, radial access can present challenges, and specialized equipment for peripheral interventions through this route are under development. Nevertheless, a growing number of studies, largely comprising single-center and registry data, have broadly suggested that transradial arterial access is likely to be safe and associated with reduced bleeding and local access site complications for most peripheral interventions compared with transfemoral access. Large, prospective randomized trials are lacking, and the question of any effect on mortality rates has not been addressed. Whereas the field of transradial arterial access for peripheral vascular interventions is in development, it is clear that this approach, at least with available equipment, will not be suitable for all patients, and careful case selection is paramount. Furthermore, the remaining knowledge gaps must be addressed, and robust outcome data obtained, to allow full understanding of the factors that determine optimal patient, lesion, and equipment selection. Nevertheless, the use of transradial arterial access for peripheral vascular interventions holds great promise, particularly if the necessary technologic advances are rapid and favorable clinical trial data continue to emerge.

Transradial access has become commonly used for elective evaluation of patients with coronary artery disease, but it has some disadvantages and has had limited use in the acute coronary syndrome (ACS). Because the diameter of the ulnar artery is usually larger than that of the radial artery, we hypothesized that the ulnar artery could be used as an access for percutaneous coronary intervention (PCI). The present study compares the feasibility, safety, and outcome of transulnar artery and transradial artery access for PCI in patients with ACS. We reviewed 636 patients who had PCI for ACS from May 2006 to May 2009. The patients were randomly assigned to transulnar intervention (TUI; 317) or transradial intervention (TRI; 319). Several outcomes were similar in the TUI and TRI groups: success rate of first puncture, duration of guiding catheter engagement, puncture-to-balloon inflation time, final thrombolysis in myocardial grade 3 flow, complications at the vascular access site, and postprocedure complications. The incidence of severe arterial spasm and forearm hematoma in the TUI groups was significantly less than that in the TRI group. At 1-year follow-up, the level of blood oxygen saturation at the middle finger and Doppler ultrasonographic characteristics of the ulnar artery did not significantly change from pre-PCI values for these criteria in either group. The TUI approach has results and access complications similar to the TRI approach and is a safe and feasible alternative for ACS patients.

Refer to the page 457-468 Transradial coronary angiogram was initially attempted with 8-10 F catheter in 1948,1) and transradial stent implantation was successfully performed in 1993.2) Transradial access (TRA) became widely used, and the proportion of radial approach during percutaneous coronary intervention (PCI) increased from 1.18% in 2007 to 16.07% in 2012.3) The transfemoral approach (TFA) has been widely used because of the huge arterial accessibility, with added advantages of reduced procedure time, catheter selection without major restrictions on the thickness, and faster learning of procedure as compared with the TRA. However, TFA was significantly associated with vascular complications, such as increasing transfusion rate, retroperitoneal hemorrhage, morbidities, and mortality.4),5) Several studies which compared TRA with TFA demonstrated that transradial coronary angiography and angioplasty are safe, feasible, and effective with similar results, if not superior, to those of the TFA.6),7),8) In contrast to the TFA, the rate of major vascular complications was negligible using the TRA.9) Meta-analysis comparing TRA with TFA showed a major reduction in complications associated with bleeding when compared with TFA, and a major reduction in transfusion rates as well as improved outcome of death or myocardial infarction.10),11) However, TRA had some complications which include radial artery perforation, evulsion, pseudoaneurysm formation, non-occlusive radial artery injury, radial artery occlusion, and higher procedural duration and radiation exposure.12) Many countries and races have reported a trend towards TRA, but there is only limited information regarding these trends in the Korean population. Youn et al.13) have reported a large prospective registry showing the current practice of coronary angiogram (CAG) and PCI using radial access in Korea. Also, in this issue of the Korean Circulation Journal, they have summarized the current practice of CAG and PCI using radial access. As per the Korean Transradial Intervention Prospective Registry, this study13) showed that TRA was 82.4% in the initial access site for PCI, which was a surprising number when compared with only 16.1% for TRA PCI in the United States in 2012.3) Although the adoption of TRA has rapidly increased, some centers still prefer TFA especially during primary PCI, because not all centers and operators in Korea are specialized for radial procedures. Considering this, the value of 82.4% could be interpreted to reflect an over-estimated value rather than the actual percentage in Korea, since 20 participating centers in this registry have been performing TRA for many years and have a high volume of TRA PCI. It is the limitation of this study that the TRA data conducted only by high volume centers may not be completely extrapolated to all PCI centers in Korea. The rate of access site crossover, bleeding, and major vascular complications in overall subjects, was similar with other major studies.7),8),14) TRA needed a learning curve for the proficiency and training for specific skills. The fact that the rate of access site crossover increased to 8.1% of the subjects undergoing PCI and decreased to 4.8% of the subjects undergoing primary PCI, reflected that TRA needed experience and confidence for TRA PCI. When TRA failed, crossover to TFA required additional cost, patient inconvenience, longer procedural time, and reperfusion delays. The radial-to-femoral crossover rate of TRA in primary PCI, from the study of radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL), was 7%.8) A reasonable recommendation is that interventional cardiologists should not start performing transradial primary PCI until their procedure success rates are comparable between their elective radial and femoral PCI procedures, and their radial-to-femoral crossover rate is ≤7%. Considering this, a crossover rate of 4.8% in this study was an outstanding result compared to the RIVAL study. Moreover, in this study,13) the rate of bleeding after primary PCI was lower than that of the RIVAL study, and the rate of major vascular complications was also very low. Considering the low complication rates, primary PCI was safely and reasonably performed via TRA in 20 participating centers in Korea. Furthermore, for patients with acute coronary syndrome in the Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox (MATRIX) study, TRA PCI not only reduced bleeding, but also reduced mortality.7) However, we need to keep in mind that experienced interventional cardiologists who performed at least 75 TRA PCI within the past year, and who performed more than 50% of their PCI via radial artery, participated in the MATRIX trial.7) It is clear from the available evidence that radial access CAG and PCI not only improve clinical outcomes and reduce cost, but also have no adverse effects on arm or hand functions. These data will provide evidence for achieving consensus on radial access CAG and PCI in the Korean population, and will encourage radial access to be the default strategy for PCI.

There has been debate in the literature regarding the adoption of a "radial-first" approach for mechanical thrombectomy (MT) in acute ischemic stroke (AIS). Conflicting reports suggest that transradial access (TRA) may allow for shorter times to reperfusion while others conclude that long-term functional outcomes may favor transfemoral access (TFA). Here, we report a single-institution experience with the adoption of TRA as the primary route for acute stroke intervention. We retrospectively reviewed a single-institution database of patients undergoing MT for AIS from March 2020 to April 2023. This time period was selected to capture the change in clinical practice at our institution from TFA to TRA. Primary and secondary outcomes included technical success, procedural complications, and long-term functional outcomes. Patients were stratified into two cohorts from initial access. Cohorts were compared utilizing inferential statistics. A total of 192 consecutive cases were identified, with 80 in the TFA cohort and 112 in the TRA cohort. There was no difference in outcomes with respect to time from puncture to recanalization, rates of successful recanalization (TICI ≥ 2b), number of passes, rates of symptomatic intracranial hemorrhage (sICH), modified Rankin scale (mRS) at discharge and 90 days, and 90-day mortality (p ≥ 0.05, all). The TRA had a higher rate of access conversion (p < 0.001), while the TFA cohort had a higher rate of access site complications (p < 0.05).

Percutaneous revascularization of superficial femoral artery (SFA) is increasingly carried out to treat patients with peripheral vascular disease and either intermittent claudication or critical limb ischemia. Transradial vascular access is increasingly adopted for invasive procedures due to reduced access-site complications and improved patient's comfort, compared with transfemoral. However, compared with coronary interventions, the adoption of transradial access in peripheral procedures is limited. Concerning SFA interventions, transradial access is usually prevented by the distance between the vascular access and the target lesion, which extends over the length of the currently available devices. Thanks to technical improvements, resulting in specifically dedicated low-profile equipment with adequate shaft length availability, transradial access is now feasible for the treatment of selected SFA lesions. We report the first two cases of SFA stenting performed by transradial access with a new specifically developed self-expanding nitinol stent with extended delivery system length. This report suggests that, with proper technique and specifically dedicated equipment, transradial SFA stenting is feasible. Treatment of SFA disease by transradial route, allowing for immediate post-procedure walking and simultaneous bilateral interventions, may represent an alternative for effective treatment of selected patients with SFA lesions.

Background: Anticoagulation strategies used in peripheral percutaneous intervention (PPI) are based primarily on percutaneous coronary intervention. In these studies, relatively higher doses of heparin were used, usually in combination with a GP IIb/IIIa agent. There are no studies comparing PPIs done with low-dose heparin alone versus bivalirudin in PPI. We compared the efficacy and safety (i.e. bleeding complications) of low-dose heparin versus bivalirudin in PPI. Methods: We assessed prospectively 160 consecutive patients who underwent PPI from January through April 2008 during their index hospitalization for bleeding and thrombotic complications. Inclusion criteria included patients age &gt;18 undergoing PPI for subclavian, renal or lower extremity arterial stenosis. Exclusion criteria included acute limb ischemia, use of fibrinolytic agents or GP IIb/IIIa antagonists, recent MI or CVA, and contraindication to heparin or bivalirudin. Out of 160 patients, 79 patients were dosed with heparin at 50 u/kg (goal ACT of 180 –225) and 81 patients were dosed with bivalirudin at 0.75 mcg/kg bolus followed by 1.75-mcg/kg infusion. Bivalirudin infusions were discontinued at the end of the procedure. Procedural success was defined as less than 30% post procedure residual stenosis. Major bleeding was defined as intracranial or retroperitoneal hemorrhage, or fall in Hgb ≥3 g/dl. All other bleeding was considered a minor bleed. In addition, anticoagulation cost analysis was conducted. Results: Procedural success in 100% and 96.2% patients (p=NS) (no patient suffered acute vessel occlusion or any intraprocedural thrombotic complications), major bleeding occurred in 0% and 3.7% patients (p=NS), minor bleeding occurred in 5.1% and 11% patients (p=NS), who received heparin and bivalirudin, respectively. There was no statistical difference in time to sheath removal, time-to-ambulation, and length of hospital stay. The average charge to patients for heparin was $66, whereas the charge for bivalirudin was $2727. Conclusion: Low-dose heparin is equally as safe and effective as bivalirudin in PPI. PPI with heparin is considerably more cost-effective than PPI with bivalirudin. Larger randomized studies are required to further evaluate this issue.

Procedural Feasibility and Peri-procedural Outcomes of Peripheral Endovascular Therapy via Transradial versus Transfemoral Access: A Systematic Review and Meta-Analysis