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SCAI paper outlines best practices for transradial access
The Society for Cardiovascular Angiography and Interventions has published a paper defining best practice recommendations for transradial angiography and intervention in response to a significant increase in the use of the transradial approach in the United States in recent years.
The recommendations were published in Catheterization and Cardiovascular Interventions.
Sunil V. Rao, MD, FSCAI, associate professor of medicine at Duke University and lead author of the consensus statement, discussed the broad strokes of the document in a recent press release.
Sunil V. Rao
“While there are a number of benefits to transradial over transfemoral approaches, there are risks associated with any procedure,” Rao said. “By emphasizing proper training and highlighting best practices, we aim to ensure that patients receive the advantages of this approach, while minimizing any potential complications.”
The recommendations call for monitoring for radial artery occlusion. Patency should be assessed before discharge and at the first visit after procedure, according to the paper. Anticoagulation should be administered as intra-arterial or IV unfractionated heparin at a dose of at least 50 U/kg or 5,000 units in patients with no contraindications to the drug. IV bivalirudin (Angiomax, The Medicines Company) is recommended for patients with heparin-induced thrombocytopenia. Transradial procedures should be performed using a low profile system and with the patent hemostasis technique.
The recommendations also provide guidelines for reducing radiation exposure in operators and patients. Clinicians are encouraged to position the patient’s arm next to the patient’s torso and use extension tubing to increase distance from the radiation source. The recommendations also suggest that the left radial approach should be considered in patients with tortuous vascular anatomy because it has been associated with less fluoroscopy time. Clinicians are encouraged to document procedures with “fluoro save” when possible, and, in general, perform a high proportion of transradial procedures in their practice.
Regarding transitioning to transradial primary PCI, the authors wrote that a minimum of 100 elective primary cases and a femoral crossover rate of 4% are recommended before operators and sites make the transition. The document contains a strong recommendation for transradial primary PCI in patients who were previously treated with CABG with a pedicle left internal mammary artery graft; in patients who are aged at least 75 years; and in patients 5’5” or shorter.
Bailout to contralateral radial or femoral procedure is recommended in the following instances: “if the time to obtain radial access is >3 minutes, or the time from introducer sheath placement in the radial artery to engaging the infarct-related artery with the guide catheter is >10 min (including the time to inject the non-infarct artery), or the total time from radial artery introducer sheath placement to dilating the infarct lesion is >20 minutes,” according to the authors.
Clinicians are encouraged to monitor door-to-balloon times and prepare femoral access sites in patients with STEMI, particularly when the operator is early in experience with the transradial approach or when adjunctive devices are required.
The recommendations also outline areas that may require further investigation, including the role of preprocedure testing for dual circulation of the hand; the optimal strategy for anti-thrombosis; and the elements of a successful transradial training program.
Disclosure: The researchers report a number of financial relationships with companies, including Abiomed, Acumed, AstraZeneca, Boston Scientific, Daiichi Sankyo, Eli Lily, St. Jude Medical and The Medicines Company. See the paper for a full list of relevant financial disclosures.
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