Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Latina, Italy Radial access for coronary procedures

Why should you like radial access? BLEEDING THROMBOSIS

Why should you listen to me?

Biondi-Zoccai et al, Catheter Cardiovasc Interven 2011 Why should you listen to me?

Learning milestones Basics Basics Indications and contraindications Indications and contraindications Advantages and disadvantages Advantages and disadvantages Potential complications Potential complications

Google search for “radial access ppt”

Radial, ulnar and interosseus arteries

Femoral and radial diameters

Oxymetry Allen test

Choice of access kits

Right versus left radial artery Biondi-Zoccai et al, Int J Cardiol 2013 PROCEDURAL FAILURE PROCEDURAL TIME

Patent or mean BP-targeted hemostasis Cubero et al, Catheter Cardiovasc Interven 2009

Radial implementation Romagnoli et al, Int J Cardiol 2013

Learning milestones Basics Basics Indications and contraindications Indications and contraindications Advantages and disadvantages Advantages and disadvantages Potential complications Potential complications

Morbidly obese

Oral anticoagulants

Peripheral artery disease

Aortic dissection

Loops, spasm, abnormal origin, or tortuosity

Arteria lusoria

Upper limb atherosclerosis

Left internal mammary artery PCI

Large sheath procedures

RIMA vs radial artery vs RGEA vs SVG: functional occlusion Benedetto et al, Eur J Cardiothorac Surg 2014

Indications Morbidly obese Peripheral artery disease Aortic dissection Oral anticoagulants (eg INR>2) …

Contraindications Extremely low height Anatomic anomalies (including arteria lusoria) Ulnar occlusion Upper limb atherosclerosis Vasculitis Know disease of brachial, axillary, subclavian or innominate arteries Prior radial grafting Need for radial grafts during CABG Chronic renal failure with potential need for AV fistula LIMA PCI Large sheath procedures

Learning milestones Basics Basics Indications and contraindications Indications and contraindications Advantages and disadvantages Advantages and disadvantages Potential complications Potential complications

Patient and personnel comfort

Flexibility of radial access Biondi-Zoccai et al, J Cardiovasc Dis Diagn 2013

Reduced risk of entry site complications Agostoni et al, J Am Coll Cardiol 2004

Reduced risk of major bleeding Komocsi et al, Arch Med Sci 2014

Marso et al, American College of Cardiology 2010 Reducing risk of bleeding, even with bivalirudin

Reduced incidence of CIAKI Cortese et al, Am J Cardiol 2014

Reduced risk of MACE Komocsi et al, Arch Med Sci 2014

Reduced risk of NACE in cardiogenic shock requiring IABP Romagnoli et al, Am Heart J 2013

Reduced risk of death Komocsi et al, Arch Med Sci 2014

Meta-regression in STEMI Biondi-Zoccai et al, Int J Cardiol 2013

More skills (or ultrasound) are required for puncture Gu et al, Crit Care 2014

Door-to-balloon time Weaver et al, Catheter Cardiovasc Interven 2010

Learning curve Spaulding et al, Catheter Cardiovasc Diagnosis 1996

Radiation exposure Lange et al, Catheter Cardiovasc Interven 2006

Lower catheter support Tobita et al, J Invasive Cardiol 2013

Advantages Increased patient comfort Reduced personnel burden Same day discharge possible and safe Reduced hospital stay Reduced costs Reduced risk of entry site complications Reduced risk of bleeding Reduced risk of DVT Reduced risk of CIAKI Reduced risk of MACE Reduced risk of death

Disadvantages Ability to maintain arm position is required Less comfort for operator Anatomy highly variable Longer learning curve Increased radiation exposure, procedural duration, and contrast volume Limitation to sheath and catheter size (and no room for IABP) Less support for catheters and devices More difficult access to specific vessels (SVG, LIMA) Right heart cath possible but more difficult Dedicated materials required Repeat procedure may increase risk of complications

Learning milestones Basics Basics Indications and contraindications Indications and contraindications Advantages and disadvantages Advantages and disadvantages Potential complications Potential complications

Stroke

Hematoma

Radial perforation Sanmartin et al, Rev Esp Cardiol 2004

Radial pseudoaneurysm Cauchi et al, J Ultrasound Med 2014 Transradialworld.com

Arterio-venous fistula Sanmartin et al, Rev Esp Cardiol 2004

Compartment syndrome

Sheath entrapment/radial avulsion Arzamendi et al, Rev Esp Cardiol 2011

Radial occlusion

Takeshita et al, Am J Cardiol 2014 * *1 radial perforation and 1 massive hematoma, both conservatively managed

Hand ischemia Rhyne et al, Catheter Cardiovasc Interven 2010

Cardiovocal syndrome Romagnoli et al, Int J Cardiol 2008

Cardiovocal syndrome Romagnoli et al, Int J Cardiol 2008

Aseptic granuloma

Potential complications Forearm pain Radial spasm Radial avulsion Radial dissection Radial occlusion Hand ischemia Radial perforation Hematoma Radial pseudoaneurysm Arterio-venous fistula Compartment syndrome Nerve injury Cardiovocal syndrome Stroke Inflammatory reaction to foreign body

Take home messages

Do you know how a train stops? Atmospheric Pressure

Take home messages The benefits of radial access are so many that it is easier to remember its drawbacks (mainly increased learning curve, radiation exposure, procedural time, and access cross-over), rather than doing the opposite. Accordingly, choice of access site for coronary procedures is best approached given the premise that radial access should be the default access site, with femoral or other accesses reserved only to highly selected cases.

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