Adoption Of Transradial Access Research Articles

Transradial versus transfemoral access for mechanical thrombectomy: A single institution experience.

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).

Trans-radial cerebral angiography for stereotactic radiosurgery treatment of arteriovenous malformations

The popularity of trans-radial access (TRA) for cerebral angiography is growing. Potential benefits of TRA over traditional trans-femoral access (TFA) are multitude. This study aimed to evaluate discharge outcomes and patient opinion of TRA compared to TFA in patients undergoing cerebral angiography prior to stereotactic radiosurgery (SRS) treatment for cerebral arteriovenous malformations. Consecutive patients treated at the National Centre for Stereotactic Radiosurgery (Sheffield, United Kingdom) over a 22-month period were included. All patients underwent cerebral angiography with either TRA or TFA as part of treatment planning prior to SRS. TRA patients who had previously undergone TFA in other centres were surveyed for their experience of cerebral angiography using a questionnaire. SRS staff at our centre was approached for their opinion. 492 patients were included (median age=43 years, 57.5% male, median lesions treated=1). More patients underwent angiography with TFA (75.2%) than TRA (24.8%). No difference was found in accumulated dose for angiography between the groups (p>0.05). There was 17.6% reduction in overnight stay between TRA and TRF, the proportion of patients requiring overnight admission was higher for the TFA (35.2%) than TRA (17.6%, p<0.05). 101 patients were surveyed, with a response rate of 47%. Most respondents (79%) indicated preference for TRA over TFA. Use of TRA in pre-SRS cerebral angiography is feasible and improves both patient and staff experience. The adoption of TRA could have important implications for department resources and costs by reducing the proportion of overnight admissions.

Chinese expert consensus on transradial access in percutaneous peripheral interventions

Transradial access (TRA) is a safe and comfortable approach and the preferred access for percutaneous coronary intervention. However, TRA is not widely used for peripheral interventions. Currently, there is a lack of data on patient selection, appropriate medical devices, complication prevention, and TRA adoption. Therefore, the Chinese Society of Interventional Oncology of the China Anti-Cancer Association organized nationwide experts to establish a Working Group of China Expert Consensus on TRA in percutaneous peripheral interventions in 2022, and jointly formulated this consensus to better promote the application of TRA in peripheral interventions to guide clinicians on patient selection, technical recommendations, and physician training. This consensus mainly focuses on the current situation, advantages and limitations of TRA in peripheral interventions, anatomical characteristics of the radial artery, patient selection, technical aspects, prevention and management of complications, radiation dose, and learning curve. A consensus was reached through a literature evaluation and by referring to the opinions of the expert group.

What’s New in Transradial Access

Transradial access (TRA) is a key strategy to avoid bleeding during percutaneous coronary intervention (PCI) and coronary angiography, as it reduces the risk of bleeding associated with transfemoral access (TFA). The distal radial artery (dRA) is located at the anatomical snuffbox, or radial fossa, which is a triangular depression on the lateral aspect of the dorsum of the hand. Distal transradial access (dTRA) at the anatomical snuffbox has recently gained interest as a non-femoral alternative access route for vascular procedures. Opportunities and challenges in the TRA/dTRA space include adoption of different and more complex procedures, technical innovation in access and haemostasis, and financial savings for institutions and healthcare systems. Historically, the adoption of TRA has been concentrated among interventional cardiologists, with much less adoption in the interventional radiology, vascular surgery, and neurointerventional radiology communities. This article highlights key aspects of the Think Radial webinar, an educational training session conducted by Merit Medical. The training session was conducted by three experts: Sandeep Nathan, Department of Cardiology, University of Chicago Medicine, Illinois, USA; Darren Klass, Department of Radiology, University of British Columbia, Vancouver, and Department of Radiology, Vancouver General Hospital, British Columbia, Canada; and Ajit Puri, New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical Center, Worcester, USA, all of whom have a wealth of experience in vascular access. The experts provided valuable insights into topics such as why and how to adopt a dTRA approach, the value of ultrasound for guided vascular access, and dTRA and ultrasound tips and techniques. The experts also explored the challenges in transradial intervention and management of radial access complications. Drawing on their individual specialist knowledge, the experts concluded with presentations on PCI, radial approaches in interventional radiology, and dRA access in neurointervention. The aim of this educational article is to disseminate key information on TRA provided by the experts to guide and update healthcare practitioners, particularly interventional cardiologists and interventional radiologists, working in vascular access.

Vascular access in complex high-risk but indicated percutaneous coronary interventions (CHiP) types, trends, and outcomes

Abstract Background Radial access improves the safety of PCI; however, its role in Complex, High-risk but indicated Percutaneous coronary interventions (CHiP) remains poorly studied. Objectives To examine CHiP types, clinical and procedural characteristics and clinical outcomes according to vascular access. Methods Data was obtained from the British Cardiovascular Intervention Society. We compared the baseline characteristics of 125,662 CHiP procedures performed electively between 2006 and 2017 stratified by access site. Multivariate regression analyses was used to investigate the access site specific odds for in-hospital death, bleeding, and major cardiovascular and cerebral events (MACCE). Results Overall, 61,825 CHiP procedures (49.2%) were performed via transradial access (TRA) and 63,837 (50.8%) via trans-femoral access (TFA). TRA use increased over time (14.6% in 2006 to 78.4% in 2017). The patients who had PCI through TRA were older (Median age: TRA, 71.2 vs TFA, 70.2 years). Cardiovascular risks were more prevalent in the TRA than TFA (stroke: 5.3 vs 4.3%; hypertension: 67.4 vs 64.3%; peripheral vascular disease: 7.2 vs 6.7%; smoking: 9.6 vs 8.9% respectively; p&amp;lt;0.001 for all). TRA patients had higher rates of multi-vessel PCI than TFA (two or more vessel PCI: 27.2 vs 24.2% respectively; p&amp;lt;0.001) and longer lesions (median stent length: 24mm vs 23mm). TFA group had higher rates of diabetes (26.6 vs 25.8%), previous myocardial infarction (44.2 vs 40.2%), previous PCI (38.7 vs 37.1%), heart failure (10.3 vs 9.3%), respectively (p&amp;lt;0.001 for all) suggesting operators' tendency to choose TFA in patients with greater cardiometabolic burden. TRA adoption was more prevalent in most CHiP types (elderly (54%), chronic renal failure (55.7%), poor LV function (51.4%), left main PCI (51.2%), treatment for severe vascular calcifications (53.1%)). Following adjustment for differences in clinical and procedural characteristics, TFA was independently associated with increased odds for mortality (aOR: 1.4 (1.1–1.8), p=0.004), bleeding (aOR: 2.9 (2.4–3.5), p&amp;lt;0.001), and MACCE (aOR: 1.2 (1.1–1.3), p&amp;lt;0.001). Conclusion Over the 12 years, TRA has become the predominant access site used in CHiP PCI and is associated with significantly lower mortality, major bleeding and MACCE odds than TFA. Addressing the cardiometabolic burden-treatment paradox by preferentially selecting TRA as the baseline cardiovascular burden increases may potentially improve CHiP clinical outcomes. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): An unrestricted educational grant from Abbott supports Warkaa Shamkhani's salary. However, the company had no role in the study design, manuscript preparation, or access to the manuscript's contents before submission. The authors are solely responsible for this study design and conduct and all analysis, drafting, and editing of the manuscript and its final content.

Avoiding the Radial Paradox: Neuroendovascular Femoral Access Outcomes After Radial Access Adoption.

Transradial access (TRA) for neuroendovascular procedures is increasing in prevalence. The safety benefits of TRA at a patient level may be offset at a population level by a paradoxical increase in transfemoral access (TFA) vascular access site complications (VASCs), the so-called "radial paradox." To study the effect of TRA adoption on TFA performance and outcomes in neuroendovascular procedures. Data were collected for all procedures performed over a 10-mo period after radial adoption at a single center. Over the study period, 1084 procedures were performed, including 719 (66.3%) with an intent to treat by TRA and 365 (33.7%) with an intent to treat by TFA. Thirty-two cases (4.4%) crossed over from TRA to TFA, and 2 cases (0.5%) crossed over from TFA to TRA. TFA was performed in older patients (mean [standard deviation] TFA, 63 [15] vs TRA, 56 [16] years) using larger sheath sizes (≥7 French; TFA, 56.2% vs TRA, 2.3%) ( P < .001 for both comparisons). Overall, 29 VASCs occurred (2.7%), including 27 minor (TFA, 4.6% [18/395] vs TRA, 1.3% [9/689], P = .002) and 2 major (TFA, 0.3% [1/395] vs TRA, 0.1% [1/689], P > .99) complications. Independent predictors of VASC included TFA (OR 2.8, 95% confidence interval [CI] 1.1-7.4) and use of dual antiplatelet therapy (OR 4.2, 95% CI 1.6-11.1). TFA remains an important access route, despite a predominantly radial paradigm, and is disproportionately used in patients at increased risk for VASCs. TFA proficiency may still be achieved in predominantly radial practices without an increase in femoral complications.

Abstract P541: Avoiding the Radial Paradox: Radial Adoption is Not Associated With Worse Femoral Outcomes in Neuroendovascular Cases

Background and Purpose: Transradial access (TRA) for neuroendovascular procedures is increasing in prevalence, although numerous procedures are still performed using transfemoral access (TFA). Some cardiology studies have suggested the safety benefits of TRA at a patient level may be offset at a population level by a paradoxical increase in TFA vascular access site complications (VASCs) associated with radial adoption, the so-called “radial paradox.” We studied the effect of TRA adoption on TFA performance and VASC rates in neuroendovascular procedures. Methods: Data were collected for all neuroendovascular procedures performed over a 10-month period by trainees after implementation of a radial-first paradigm at a single center. Results: Over the study period, 1,084 procedures were performed, including 689 (63.6%) via TRA and 395 (36.4%) via TFA. In comparison to TRA, TFA cases were performed in older patients (TFA 63 ±15 vs. TRA 56 ±16), were predominantly male (TFA 52.9% vs. TRA 38.6%), used larger sheath sizes (≥7 French, TFA 56.6% vs. TRA 2.3%), were more often emergent (TFA 37.7% vs. TRA 1.1%), and used tPA administration (TFA 15.3% vs. TRA 0%) (p&lt;.001 for all comparisons). Overall, 29 VASCs occurred (2.7%), including 27 minor (TFA 4.6% [18/395] vs. TRA 1.3% [9/689], p=.002) and 2 major (TFA 0.3% [1/395] vs. TRA 0.1% [1/689], p&gt;.99) complications. After multivariate analysis, independent predictors of any VASC included TFA (OR 2.8, 95% CI 1.1-7.4) and use of dual antiplatelets (OR 4.2, 95% CI 1.6—11.1). Conclusions: TFA remains an essential route for neuroendovascular procedures, accounting for 36.4% of cases under a radial-first paradigm. TFA is disproportionately performed in patients undergoing procedures with an increased-risk for VASCs, though the minor and major VASC rates are comparable to historical controls. TFA proficiency may still be achieved in radial-first training without an increase in femoral complications.

Meta-Analysis of Transradial vs Transfemoral Access for Percutaneous Coronary Intervention in Patients With ST Elevation Myocardial Infarction

Transradial access (TRA) has emerged as an alternative to transfemoral access (TFA) for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) patients. However, the rate of TRA adoption has been much slower in the acute coronary syndrome (ACS) patient population. This meta-analysis was conducted to assess clinical outcomes of TRA compared with TFA in STEMI patients undergoing PCI. A manual search of PubMed, EMBASE, Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov, and recent major scientific conference sessions from inception to October 15th, 2019 was performed. Primary outcomes in our analysis were all-cause mortality and trial-defined major bleeding. Secondary outcomes included vascular complications, myocardial infarction, stroke, procedure, and fluoroscopy time. 17 randomized controlled trials (RCTs) (N = 12,018) met inclusion criteria. TRA was associated with lower all-cause mortality (risk ratio [RR]: 0.71, 95% confidence interval [CI]: 0.57 to 0.88), major bleeding (RR: 0.59, 95%CI: 0.45 to 0.77), and vascular complications (RR: 0.42, 95%CI: 0.32 to 0.56) compared with TFA. There was no difference in the incidence of myocardial infarction (MI), stroke, or procedure duration between the 2 groups. The difference in all-cause mortality between TRA and TFA was statistically nonsignificant when major bleeding was held constant. In conclusion, TRA was associated with lower risk of all-cause mortality, major bleeding, and vascular complications compared with TFA in STEMI patients undergoing PCI.

Should Ultrasound Guidance Be Routinely Used for Femoral Artery Access?

ABSTRACTUltrasound-guided femoral artery access should always be utilized as it has been shown to significantly reduce vascular complications, number of arterial access attempts, accidental venipunctures, and time to access. Despite the increased adoption of transradial access, the conventional femoral artery cannulation remains the primary route for performing peripheral angiography and cardiac catheterization in the setting of high-risk interventional procedures requiring mechanical hemodynamic support. Similarly, with the expansion of structural heart interventions such as transcatheter aortic valve replacement and mitral valve interventions, femoral access has been increased especially for large-bore sheaths.

Highlights From the Circulation Family of Journals.

Highlights From the Circulation Family of Journals.

The Current State of Transradial Access: A Perspective on Transradial Outcomes, Learning Curves, and Same-Day Discharge

The adoption of transradial access in the United States and internationally has been growing over the past few years. In the population of patients presenting with acute coronary syndromes, particularly ST-elevation myocardial infarction, transradial access has the benefit of fewer vascular and bleeding complications and lower mortality rates over transfemoral access. We will examine the current evidence supporting transradial access for several patient populations, including those patients presenting with acute coronary syndromes. We will review the literature regarding the learning curve for transradial access with new operators, as well as experienced transfemoral operators new to transradial access. Finally, we will investigate the role of transradial access in same-day discharge for stable patients undergoing percutaneous coronary intervention.

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

To review indications, techniques, and equipment of transradial access (TRA) in peripheral interventions and to compare complications, main outcomes, and costs between TRA and transfemoral access (TFA) in patients undergoing lower extremity peripheral artery procedures. We systematically searched PubMed for studies published in English between 2008 and 2018 comparing TRA and TFA among patients undergoing endovascular peripheral artery interventions. The data suggest that TRA may be a safe treatment approach in patients who are not suitable for TFA, including obese patients, patients with heavily calcified femoral arteries, or with history of femoral surgery. Endovascular peripheral interventions performed via TRA had high procedural success rates, low rates of access-site and bleeding complications, and simplified post-procedure care, but increased radiation exposure and longer procedure time compared to TFA. There is only one single center study that compared the costs of the two accesses. Peripheral angioplasty via TRA was associated with higher cost for devices compared with TFA with vascular closure device. However, based on the coronary studies where TRA is more frequently used, TRA could be cost-effective due to decreased bleeding complications and shorter hospital stays. Adoption of TRA in the peripheral interventions is still limited. The main barrier to the adoption of TRA is the lack of dedicated equipment with adequate length and small enough outer diameter. Atherectomy devices, for example, are limited by both shaft length and outer diameter. The only atherectomy device that could be used from TRA is the peripheral orbital atherectomy system. TRA can be used in situations where TFA is unsuitable. TRA leads to shorter post-procedural monitoring, earlier ambulation, reduced length of hospital stay and less discomfort compared to TFA. Comparative studies are needed to determine the cost-effectiveness of the radial approach for peripheral interventions, as demonstrated in the coronary procedures.

Training the next generation of invasive cardiologists: Feasibility of implementing a trans-radial access program at an academic hospital.

Slow adoption of trans-radial access (TRA) for left heart catheterization (LHC) in the U.S. may be related to concerns about procedural complexity and a steep learning curve. However, TRA acceptance among novice operators remains poorly characterized. We initiated a 1-year TRA learning period among lower-risk outpatients, followed by a "radial-first" policy for all LHC patients beginning year 2. By year 3, all fellows prospectively collected diagnostic LHC data as part of a quality improvement study. TRA procedural characteristics were compared with patients undergoing trans-femoral access for the 3months prior to the TRA program, and trends over time were evaluated. Between 7/2009 and 6/2012, we identified 960 patients undergoing LHC via TRA by 23 rotating cardiology fellows supervised by 5 interventional cardiologists. When evaluated against the 160 trans-femoral comparator patients, TRA patients had lower procedural success through the initial access site (88% vs. 99%, p<0.001) and longer fluoroscopy times (9.5 [5.8-15.9] vs. 6.5 [3.1-12.7] min, p<0.001), with similar contrast volumes and fewer catheters used. Despite tackling more complex patients during years 2-3, there were improvements in fluoroscopy times, catheter utilization, contrast volumes, and procedural success rates over time (all p<0.001). The dedicated adoption of TRA by an academic catheterization laboratory demonstrated improvements in efficiency and resource utilization over a relatively short period of time. Additional exposure to TRA during training may help facilitate acceptance of this approach among the next generation of invasive cardiologists. When initiating a trans-radial access program for cardiac catheterization at an academic training hospital, procedural success rates were lower and fluoroscopy times were higher than traditional trans-femoral access. Nonetheless, other procedural variables were similar between the 2 approaches, and improvements over time were consistent with the learning curves reported among experienced cardiologists in prior studies. Exposure to trans-radial access during training may help facilitate acceptance of this approach among the next generation of invasive cardiologists.

34 Do Centres that Usually Perform Percutaneous Coronary Intervention Trans-Radially have Inferior Outcomes when Operating Trans-Femorally?

Background Over the last decade trans-radial access (TRA) has become more common than trans-femoral access (TFA) for Percutaneous Coronary Intervention (PCI) in the UK. Despite studies highlighting the benefits of this transition, there are concerns that the resulting drop in TFA activity has led to operators and centres losing TFA proficiency, compromising the safety and efficacy of procedures where TFA is necessary. Aims To evaluate the impact of each centre’s recent experience of the TFA approach on procedural outcomes in TFA-only procedures. Methods This retrospective cohort study used procedures recorded in the British Cardiovascular Intervention Society (BCIS) PCI audit from 2007 to 2013 in England and Wales. Centres were split into one of three groups depending on the proportion of total procedures undertaken via TFA in 2013, with patient and procedural characteristics for TFA-only procedures observed within these groups over time. By considering each centre’s access site choices in the 12 months prior to procedure date, simply-derived measures were used to capture the ‘recent TFA experience’ of the operating centre for each procedure. The association of these measures on 30-day mortality, after risk-adjustment, were then studied using multiple logistic regression. Results A total of 235,474 procedures were available for analysis. Unadjusted TFA-only mortality in centres who were early-adopters of TRA increased more rapidly than for centres who maintained high TFA activity, and this was driven by higher baseline risk. After case-mix adjustment, recent TFA experience was found to have no effect on 30-day mortality (OR=0.99 per 0.1 increase in recent TFA proportion; CI=0.96 to 1.01; p = 0.220), with similar results when restricting to procedures with low clinical-complexity (OR=0.98 per 0.1 increase in recent femoral proportion; CI=0.95 to 1.01; p = 0.245). Conclusions Poorer TFA outcomes for predominantly high TRA centres are driven by the propensity of these centres to utilise TFA in the highest risk patients. Once differences in case mix are adjusted for, TFA outcomes are similar between high and low radial proportion centres, with no evidence to suggest that increasing unfamiliarity with the TFA technique is detrimental. The outcome gains achieved by the national adoption of TRA is not attenuated by a loss of TFA proficiency, and centres should be encouraged to continue to adopt TRA as the default access site for PCI wherever possible.

The wise radialist's guide to optimal transfemoral access: Selection, performance, and troubleshooting

Transradial access (TRA) has reduced vascular access-site complication (VASC) and bleeding rates in patients undergoing coronary angiography and intervention. A "radial-first" approach should be adopted and indications of TRA extended in order to maximize its beneficial effect. However, in certain clinical scenarios, transfemoral access (TFA) is a preferable or a mandatory route to successfully perform the procedure. Since the widespread adoption of TRA, a paradoxical increase in VASC rates has been observed in patients undergoing TFA, which might be attributed to a combination of increased risk profile of both the procedures and the patients, and a loss of skills in securing TFA by those who are now default radial operators. In the present article we provide recommendations on how to optimize patient selection for TRA and TFA, how to manage access site crossover, and how to perform state-of-the-art femoral artery puncture. © 2016 Wiley Periodicals, Inc.

Changes in Arterial Access Site and Association With Mortality in the United Kingdom: Observations From a National Percutaneous Coronary Intervention Database.

The transradial access (TRA) site has become the default access site for percutaneous coronary intervention in the United Kingdom, with randomized trials and national registry data showing reductions in mortality associated with TRA use. This study evaluates regional changes in access site practice in England and Wales over time, examines whether changes in access site practice have been uniform nationally and across different patient subgroups, and provides national estimates for the potential number of lives saved or lost associated with regional differences in access site practice. Using the British Cardiovascular Intervention Society database, we investigated outcomes for growth of TRA in different regions in England and Wales in 448 853 patients who underwent percutaneous coronary intervention from 2005 to 2012. Multiple logistic regression was used to quantify the effect of TRA on 30-day mortality and quantify lives saved and lost by differences in TRA adoption. TRA use increased from 14.0% to 58.6% in 417 038 PCI patients with large variations in different parts of the country. TRA was independently associated with a decreased risk of 30-day mortality (odds ratio=0.70; 95% confidence interval=0.66-0.74), with significant but small differences observed across different regions. The number of estimated lives saved was 450 (95% confidence interval=275-650), and we estimate that an additional 264 (95% confidence interval=153-399) lives would have been saved if TRA adoption were uniform nationally. TRA has become the dominant percutaneous coronary intervention approach in the United Kingdom, with a wide variation in different parts of the country. Changes in practice have contributed to mortality reductions, and inequalities have resulted in missed opportunities for further improvements.

Institutional Switch from Transfemoral to Transradial Vascular Access for Percutaneous Coronary Intervention was Associated with a Reduction in Bleeding Events: A Singlecenter Experience of >10,000 Consecutive Cases.

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.

Current Practices in Korea: Coronary Angiography and Intervention Using Radial Access.

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.

Two years follow up of outcomes from transradial vs. transfemoral primary percutaneous coronary intervention for ST elevation myocardial infarction

Objective: We have compared the impact of access strategy change on early and two-year outcomes after primary percutaneous coronary intervention using trans-radial access (TRA) versus intervention by trans-femoral access (TFA). Background: Adoption of TRA was recently proposed as potentially beneficial strategy to improve outcomes of PPCI for STEMI patients. Methods: We have studied 1808 consecutive patients which underwent TFA (n=646) and TRA (n= 1162) intervention for STEMI at our institution between 2007 and 2010. This was all-comers study regardless patient acute clinical presentation of STEMI. We have compared the cardiac mortality and the MACE rates (composite of death, stroke, re MI and TVR) after two years of follow up. Results: The majority of deaths occurred as early events in the first 30 days from STEMI. The major difference in early mortality rates was in favor of TRA strategy (5.2% or 60deths) comparing TFA strategy (10.5% or 68 deaths) (OR 0.46; 95% CI [0.32-0.66], p< 0.001). TRA was also associated with significant 30 days MACE rate reduction (7.3% vs. 12.5%, HR 0.55; 95% CI [0.39-0.76], p< 0.001). Following the first year of follow up additional 1.7% and 1.0% of deaths occurred in both groups respectively. At two years follow up there were 93 deaths (8.0%) mortality rate in TRA group comparing to 90 deaths (13.9%) in TFA group (OR 0.60; 95% CI [0.47-0.89], p=0.001). The difference obtained in the first 30 days between the two accesses strategies have sustained with similar trends for mortality rates in the following two years. Two year MACE rates were in favor of TRA strategy (14.6% Vs 22.1%; OR 0.56; 95% CI [0.43-0.78], p< 0.001). Cumulative survival curves were created to illustrate findings. Conclusions: Our study confirmed that transradial access strategy for primary coronary intervention is associated with significant early and two years MACE rate reduction comparing to default transfemoral access strategy for primary coronary interventions in STEMI patients. TRA was associated with sustained mortality benefit after two years.

The Role of the Transradial Approach for Complex Coronary Interventions in Patients with Acute Coronary Syndrome.

Despite advances in antithrombotic and antiplatelet therapy, bleeding complications remain an important cause of morbidity and mortality in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). A significant proportion of such bleedings are related to the access site, and adoption of transradial access (TRA) may reduce these complications. In patients with ST-segment elevation myocardial infarction (STEMI), TRA reduced cardiac mortality in comparison with the femoral approach (TFA). High-risk patients such as women, obese patients and elderly subjects who are at increased risk for vascular complications and bleeding, might particularly benefit from the TRA. However, specific radial expertise providing procedural time and a success rate comparable to those with the TFA are strongly recommended before using this technique in the emergency setting.