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Reassessment of the Era After the Radial Revolution
Approximately 5 years ago, there was a “call to arms” by interventionalists who argued that transradial access should be the default strategy for vascular access. In many countries, especially in Europe and Asia, transradial access is the most commonly used vascular access strategy, with popularity gaining in the United States. This is largely due to higher patient satisfaction, less vascular access-site complications and several trials that demonstrated a survival advantage in patients with ACS who underwent transradial intervention compared with transfemoral intervention.
However, these trials were conducted at centers where transradial intervention was the predominant strategy. This likely resulted in major bias in favor of transradial intervention, as operators were proficient with transradial access, but may have less experience with transfemoral access. Furthermore, operators may not have used optimal techniques for transfemoral intervention in the randomized trials. The trials did not mandate specific bleeding avoidance strategies, which may have decreased vascular access complications. Such strategies include:
- fluoroscopy to identify the head of the femur;
- repeat fluoroscopy to ensure the needle is inferior to the middle of the femoral head, but superior to the inferior border;
- ultrasound guidance for vascular access;
- a micropuncture system;
- vascular closure devices;
- avoidance of large-bore sheaths; and
- optimal antithrombotic therapies, including the use of more potent P2Y12 inhibitors, avoidance of glycoprotein IIb/IIIa inhibitors and achieving adequate activated clotting times if unfractionated heparin is used.
Upper-extremity Complications
At EuroPCR in May 2016, new data were presented regarding upper-extremity complications in patients who underwent transradial intervention.
In a prospective, multicenter study, 191 patients underwent a series of sophisticated tests to assess for radial artery occlusion, swelling, sensation of the fingertips, palmar grip, and isometric strength measurements at the wrist and elbow. Nearly three-quarters of patients who underwent transradial intervention reported upper-extremity dysfunction within 2 weeks, including decreased sensation of the fingertips, decreased wrist strength and increased volumetry of the hand (see Table). Radial artery occlusion was present in 9.8% in patients with upper-extremity dysfunction.
Eva Zwaan, MD, from Albert Schweitzer Hospital in Dordrecht, the Netherlands, and principal investigator for the trial, stated: “I want to be a surgeon myself, and if I should have an elective PCI, I would not want it through the radial artery; I would want the femoral artery.”
Default PCI Strategy
Despite several clinical trials demonstrating a survival advantage, the American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Interventions have yet to provide a class I, level of evidence A recommendation for transradial intervention. Operators continue to perform transfemoral intervention as their default strategy given its familiarity and ease of use despite the clinical data demonstrating lower mortality rates with transradial intervention. In contrast, the European Society of Cardiology gave a class I recommendation to transradial access over transfemoral access when performing coronary angiography or PCI in patients with ACS (see Sidebar).
Whether transradial intervention should be the default PCI strategy is unknown and remains controversial. What is known is that patients who experience vascular access complications have increased mortality. Transradial intervention is perceived as more technically challenging because of the small diameter of the radial artery. However, transfemoral intervention has a lower threshold for an ideal puncture and requires more skill to access the common femoral artery, which is deeper below the skin surface compared with the radial artery, to avoid penetration of the posterior wall and femoral vein.
Interventionalists should be proficient with both transradial and transfemoral access. Meticulous care should be applied when performing transfemoral intervention, as it is less forgiving in terms of complications compared with transradial intervention. Bleeding avoidance strategy may decrease vascular access complications associated with transfemoral intervention. Transradial access will not obviate the need for obtaining transfemoral access successfully, especially with the need for hemodynamic support devices in patients with cardiogenic shock and the expanding role of transcatheter aortic valve replacement for the treatment of severe aortic stenosis.
For transradial intervention to become the standard of care and result in the change of the guidelines, a properly conducted trial is needed that includes centers and operators who are proficient not only with transradial intervention but also with transfemoral intervention, and trial protocols mandating bleeding avoidance strategies to truly determine whether transradial intervention is associated with a mortality benefit.
- Reference:
- Zwaan E, et al. Upper extremity function post-transradial PCI: Interim results. Presented at: EuroPCR; May 18, 2016; Paris.
- For more information:
- Michael S. Lee, MD, FACC, FSCAI, is an interventional cardiologist and associate professor of medicine at UCLA Medical Center. He can be reached at 100 Medical Plaza, Suite 360, Los Angeles, CA 90095; email: mslee@mednet.ucla.edu.
Disclosure: Lee reports receiving an honorarium from Cardiovascular Systems Inc.