1. Radial Access: state of the art
Y. Louvard
Massy, France

2. Transradial approach: the best way to reduce the vascular complication rate and the cost, and to improve patient comfort

4. J. Slater Am J Cardiol 2003 (suppl) 92: 18L
Impact of Access Site Hematoma With Transfusion in Patients Undergoing PCI
6613 PCI (98-00)(NHLBI): hematoma w transfusion 1.8% (97% femoral)
Independent predictors: Older age, female, thrombotic lesion, 3-VD, renal disease, emergent PCI, prior aspirin
HWT no HWT p
Procedural death (%): <0.001
death/MI (%): <0.001
HWT is a predictor of death/MI (OR = 3.49; 95% CI: )
J. Slater Am J Cardiol 2003 (suppl) 92: 18L

5. Clinical Significance of Bleeding Complications
Median Length of Hospital Stay (Day)
Extra Cost
Others
Any Vascular Site Bleeding / Vascular Complication
+ 1
Incapacitation (days-weeks)
Return to normal activity delay
Major or Minor Vascular Site Bleeding / Vascular Complication
+ 2 $ -
Major Vascular Site Bleeding / Vascular Complication (Surgical)
+ 4 $
The clinical significance of these complications for the patients, (isn’t it the most important point of view?) even for the less severe, is prolongation of hospital stay, incapacitation and delayed return to normal activity. More, the cost of vascular complications reduces the benefit/cost ratio of potent platelet inhibitors.
From Blankenship Am Heart J 1999; 138: S287-S296

6. Radial / Femoral Approach meta-analysis: Entry site complications
Agostini P personal communication

7. Transradial approach: for PCI, for Diagnosis, for Both?

8. ACCESS Study Radial Brachial Femoral p
Approach failure (%) <0.001
Procedural success (%) NS
Equipment:
Guiding cath. (n) NS
Balloons (n) NS
Stenting (%) NS
Procedural time (Min) NS
Fluoro. Time (Min
Hospital stay (days) NS
Kiemeneij JACC 1997;29:

9. Radial Artery Diameter (Ultrasound) n=120
5f f f f
This is the internal diameter of the right artery in 120 consecutive french patients. As you can see 8 french can be used in 65% of patients, 7 french in 78%, 6F in 88%. But the artery is smaller than a 6f sheath in 12%.
2,9+0,6 mm
Y. Louvard unpublished 27

10. Catheters / Devices / Technique Compatibility
Catheter Size
Devices
Techniques
Radial Compatibility 5f
Balloons < 5 mm
Stents < 4.5 mm
Ivus
Rota 1.25 mm
No Kissing Balloon
100% 6f
All Coronary balloons
All Coronary stents
Cutting Balloon
Rota < 1.75 mm
Protection device (EPI…)
Kissing Balloon
86.9% 7f
Angioguard
Rota 2 mm
Kissing Stent
76.9% 8f
Percusurge
Simpson
Rota >2 mm
64.7%
1.25 rotablator burrs and ultrasound can be used through 5f, Cutting balloon and 1.75 mm rotablator burrs through 6F, Angioguard through 7F, new Simpson atherectomy and 2mm Rotablator burrs need a 8 french catheter which can be used trough transradial approach in 65% of patients.

11. A randomized trial of 5 vs
A randomized trial of 5 vs. 6 French transradial percutaneous coronary interventions
5 Fr / 6 Fr guiding catheter, 171 pts with coronary lesions suitable for 5 Fr transradial approach
5 Fr Fr p
Procedural success (%)
Cor. cannulation failure (%)
Minor hematomas (%)
Loss of radial pulse (%)
Dahm JB CCVI 2002; 57(2):172-6

12. CARAFE (Technical Data)
Femoral Right Radial Left Radial N=
Cross over (1.4%)*
LCA catheter (n)
RCA catheter (n)
Total catheters (n) **
* p=ns : L Rad , ** p<.000 vs Femoral and L Rad
Y. Louvard CCVI 2001; 52:

13. Looking for the best multipurpose catheter for Right transradial coronary angiography
Multipurpose (too much rotation)
Amplatz AL2 (AL1)
Champ (dead…)
JL 3.5 (for left and right!)
Tiger II +++

14. Transradial Approach Reduces Bleeding Complications and Length of Stay in Patients With GP IIb/IIIa Inhibitors
FA RA p value N=
GPIIbIIIa – (%)
Major bleeding (n) <0.05
Major complication (n) <0.05
Minor complication (n) <0.05
Thrombocytopenia (n) <0.05
Length of stay (hrs) <0.05
*p <0.05, major bleeding (TIMI criteria), major (requiring surgical repair), and minor (pseudoaneurysm or charted hematoma) access site complications
G. Revtyak Am J Cardiol 2001; 88: 39G

15. Transradial vs. transfemoral approach in primary stent implantation for patients with acute myocardial infarction: TEMPURA trial
149 pts with AMI < 12 hr, randomized into 2 groups
TRI TFI N=
Cross over (n)
Severe bleeding complication (n)
Success of reperfusion (%)
in-hospital MACE (%)
Saito CCVI 2003; 59(1):26-33

16. OCTOPLUS: Primary endpoint, Intention to treat analysis
Femoral
Radial
p value n=
185
192
Vasc. Surgery (%)
0.5 ns
Transfusion (%)
1.6
1.0
Hb drop > 3g/DL (%)
3.8
0.063
False aneurysm compression (%)
1.1
Arm or leg ischemia (%)
Forearm compartment syndrom (%)
Large hematoma* (%)
6.5
0.031
COMPOSITE END-POINT $ (%)
0.029
Hematoma (%)
11.4
3.5
0.003
CVA (%)
0.6 Ns
$ surgery, transfusion, Hb loss>3g/100ml-Ht loss>10%, ischemia, FA, vasc. Complic. leading to discharge delay *Large hematoma: discharge delay

17. Safety of same-day-discharge radial percutaneous coronary intervention
943 Pts same-day discharge radial PCI: entry site complications or repeat angiogram and/or PCI within 24 hours and 1 month ,
811 patients responded , 38 patients died, 94 alive but refused to participate/impossible to contact
24 h month
Access complication (%)
Chest pain (%)
repeat angio (%)
Vessel occlusion (%)
(+ lost for FU pts)
Ziakas Am Heart J. 2003; 146:

18. Transradial Approach for non- Coronary Diagnosis and Intervention ?

19. Right Transradial selective vertebral and carotid angiography
Author n
Right vertebral
Right carotid
Left carotid
Left subclavian/
vertebral
Cha
103
98%
86%
Nagayoshi 83
91%
100%
56%
Iwasaki
526
99%
Nohara 60
95%

20. Transradial carotid bifurcation stenting
J. Théron, Caen, France, personal communication

21. Transradial Approach Drawbacks. : It has to be learned (
Transradial Approach Drawbacks ?: It has to be learned (!)… and teached

22. Radial approach learning curve in non selected population
52%
69%
89%
Y. Louvard, preliminary

23. Radial approach learning curve in non selected population
96%
97%
98%
Y. Louvard, preliminary

24. Transradial Approach Failure in Relation to Volume%
*Failure to enter ascending aorta
p= 0.002
Y. Louvard, unpublished

25. Predictive Factors of Radial Approach Failure
Success Failure* p n=
Age (years)
Male (%)
Hypertension (%) ns
Dyslipidemia (%) ns
Diabetes (%) ns
Smoking (%) ns
Left radial (%)
Re-radial (%) ns
N° of Same Radial (n) ns
N° Dis. Coro. Vessels (n) ns
Weight (kg)
Height (cm)
*Failure to enter ascending aorta

26. Radial Approach Failure Rate in Relation to Age%
Y. Louvard, unpublished

27. Radial Approach Failure Rate in Relation to Weight
Y. Louvard, unpublished

28. Predictors of Failure of Transradial Approach for Coronary Angiography and Interventions
A multivariate analysis of a large series: 6,962 TRA (94-98)
Causes of the 475 TRA failures (7%): unsuccessful puncture (69%), difficult anatomy (16%), brachial artery spasm (8%), unsuccessful canulation (5%) or miscellaneous (2%)
G.Barbeau AHA 1999

29. Evaluation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures
Automatic pullback device, efficacy of an intra-arterial vasodilating cocktail (verapamil 5 mg, nitroglycerine 200 µg) in reducing radial artery spasm
Cocktail No cocktail p value N=
Pain (%)
Pain score = 0.03
Maximal pullback force (kg) = 0.013
MPF > 1.0 kg (%) = 0.029
Kiemeneij CCVI 2003; 58: 281-4

30. Tortuous Right Subclavian Artery: Prevalence and Predictive Factors
2,341 consecutive right radial approaches
Prevalence (%)
Cross-over to Left Radial or Femoral (%)
Complications (%)
Independent predictive factors:
OR % CI p
Hypertension <0.0003
Age
BMI
Cha CCVI 2002; 56: abst 69

31. Transradial Approach Drawbacks ?: Complications

32. MAT: modified Allen’s test, plethysmography (PL) and oxymetry (Ox)
A New and Objective Method for Transradial Approach Screening: Comparaison With the Allen's Test in 1010 Patients
1010 pts, 32% female, 19% diabetics, age 62y, weight 76 kg, height 1.66 m
Right Left Right or Left
MAT < 9 seconds (%)
Positive PL* + Ox (%)
MAT exclusion (%)
PL + Ox (%)
MAT: modified Allen’s test, plethysmography (PL) and oxymetry (Ox)
Barbeau 2001, 37, 2, Suppl A, 1A-648A

33. Early ultrasonic results
270 patients
4 radial occluded (1.3%) :
- 2 with a negative flow
- 2 without flow
Pre-procedure
Post-procedure p
Diameter (mm)
3.64 ± 0.74
3.55 ± 0.77 ns
Upstream flow (cm/sec)
29.13 ± 9.51
30.8 ±
Downstream flow(cm/sec)
28.73 ± 11.84
Duration (mn)
2.92 ± 0.55
3.35 ± 0.83
J. Monsegu

34. Radial Artery/Sheath Diameter Ratio: A Predictor of Severe Radial Artery Flow Reduction
Le taux d ’occlusion (assymptomatique…) depend du ratio Artère / Desilet
Saïto CCVI 46: , 1999

35. IVUS after transradial approach
Very recently it have been suggested by IVUS of the radial artery that neointimal tissue may develop after intervention, although in this study the same patient was not controlled before and after intervention.
JACC 2003;41;

36. Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit?
67 pts underwent isolated CABG using the radial artery (RA)
preop. transradial no transradial p value
catheterization catheterization N=
Stenosis-free graft patency
Left mammary artery (%) = 0.87
Radial artery (%) = 0.017
Saphenous vein (%) = 0.42
Intimal hyperplasia of RA (%) = 0.046
Kamiya Ann Thorac Surg. 2003; 76(5):

37. False Aneurysm after PTCA
From P Garot

38. Conclusions (1)
Transradial approach is the best way to reduce the vascular complication rate of diagnostic and therapeutic coronary (vascular) catheterism: less expensive, preferred by patients and nurses…
At the price of a slight increase in procedural duration and X-Ray exposure for diagnosis only
It is specially effective in high risk populations like old patients, AMI, patients treated with powerful anticoagulant or antiplatelet drugs

39. Conclusions (2)
Transradial approach allows the use of all devices and techniques of modern coronary intervention
Peripheral vascular diagnosis and intervention is feasible with the same advantages: Subclavian, Renal, Mesenteric, Carotid?
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