1. Giuseppe Biondi-Zoccai, MD Sapienza University of Rome, Latina, Italy giuseppe.biondizoccai@uniroma1.itgbiondizoccai@gmail.com Radial access for coronary procedures

2. Why should you like radial access? BLEEDING THROMBOSIS

3. Why should you listen to me?

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

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

6. Google search for “radial access ppt”

8. Radial, ulnar and interosseus arteries

9. Femoral and radial diameters

10. Oxymetry Allen test

12. Choice of access kits

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

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

15. Radial implementation Romagnoli et al, Int J Cardiol 2013

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

17. Morbidly obese

18. Oral anticoagulants

19. Peripheral artery disease

20. Aortic dissection

21. Loops, spasm, abnormal origin, or tortuosity

22. Arteria lusoria

23. Upper limb atherosclerosis

24. Left internal mammary artery PCI

25. Large sheath procedures

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

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

28. 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

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

30. Patient and personnel comfort

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

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

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

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

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

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

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

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

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

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

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

42. Learning curve Spaulding et al, Catheter Cardiovasc Diagnosis 1996

43. Radiation exposure Lange et al, Catheter Cardiovasc Interven 2006

44. Lower catheter support Tobita et al, J Invasive Cardiol 2013

45. 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

46. 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

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

48. Stroke

49. Hematoma

50. Radial perforation Sanmartin et al, Rev Esp Cardiol 2004

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

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

53. Compartment syndrome

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

55. Radial occlusion

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

57. Hand ischemia Rhyne et al, Catheter Cardiovasc Interven 2010

58. Cardiovocal syndrome Romagnoli et al, Int J Cardiol 2008

59. Cardiovocal syndrome Romagnoli et al, Int J Cardiol 2008

60. Aseptic granuloma

61. 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

62. Take home messages

63. Do you know how a train stops? Atmospheric Pressure

64. 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.

65. One of the many reasons I like France

67. Many thanks for your attention! For any query: giuseppe.biondizoccai@uniroma1.it gbiondizoccai@gmail.com For these and similar slides: http://www.metcardio.org/slides.html