As we enter the year 2010, my personal outlook in Coronary Angiography has made a dramatic diversion ….it began with the Femoral approach, the technique I learnt way back in 1985 (25 years ago), to a point of no return… Radial approach …
In the late 1980s, French-Canadian physician Dr Lucien Campeau1 started using right radial artery for diagnostic catheterizations and by 1993, Dr Kiemeneij and his team2 explored ways to use the radial artery for interventional procedures such as delivering balloons and stents.
Most of the disadvantages of femoral technique are non-existent in the radial; lower risk of bleeding, shorter recovery time, no “nicking” of nerves or development of fistula or pseudoaneurysm, lower rates of pain and vagal reaction. In contrast, the only contraindication for transradial approach lies in the absence of perfusion from the ulnar artery when the radial artery is occluded by pressure as assessed by the Allen’s test. However, the M.O.R.T.A.L. study (Mortality benefit of Reduced Transfusion After PCI via the Arm or Leg) findings showed that still only a small percentage of patients (1.32%) undergo angioplasty by the wrist in the US but the same procedure can account for more than 50% of cases in parts of Europe, Asia and Canada3.
Personalizing my experience, our team at The Heart Care Clinic has evolved since 2000 gearing from femoral to radial approach. In line with other centers across the world, our centre also perceived an explosion of transradial procedures in the last 4 years. From about a dozen radial procedures in 2005 to more than 3500 radial procedures in 2008, over 4000 Radial Procedures in 2009; one of the largest performers in India, we are witness to this improved option for interventional procedures. The current trend depicts a gradual decline in femoral procedures, with an increase in radial approaches globally as well as in India.
Thus the obvious questions arise as to-
- Why is such a trend?
- What are the reasons behind such an evolution over the last decade?
Answers to above questions could be justified in context of the recent reports cited. Brueck and co-workers4 (2009) showed that transradial coronary angiography and angioplasty are safe, feasible, and effective with similar results to those of the transfemoral approach, although the procedural duration and radiation exposure were higher with the transradial access. Moreover, in contrast to the transfemoral route, the rate of major vascular complications was negligible using the transradial |
approach. Also, Rao et al (2008) showed that that bleeding complications associated with PCI were reduced by 58% with the transradial approach as compared to the femoral access5. A recent prospective registry of 13,499 PCI cases showed fewer vascular access complications (1.5% vs. 0.6%, p < 0.001) and a shorter length of hospital stay with the use of transradial approach6.
Hetherington and coworkers7 (2009) concluded that in the setting of acute ST-elevation myocardial infarction without cardiogenic shock, transradial primary angioplasty is safe, with lower risk of vascular complications as compared to outcomes of a femoral approach.
A very recent data from the RAPTOR (Radial Access Versus Conventional Femoral Puncture: Outcome and Resource Effectiveness in a Daily Routine) trial presented at the American Heart Association Scientific Sessions in November, 2009 by Schäufele TG8, inferred that interventional cardiologists experienced with the femoral approach (>5000 procedures each) can switch to a radial-based practice with relative ease, achieving comparable procedure times and radiation doses. In terms of staff resources, there was a time savings with the radial approach of 17.9±30 minutes for each diagnostic angiography sheath removal (P < 0.01 vs. femoral access). The data emphasized that switching to radial access leads to only mild procedural prolongation when diagnostic coronary angiography is performed and the procedure is safe and well tolerated by patients.
Peter C. Block from Emory University Hospital (Atlanta, GA), an eminent panel member of the American Heart Association Scientific Sessions 2009 held at Orlando, Florida, USA, cited a different reason to consider radial access. According to him, “Radial access saves money and is very fast to learn”.
As an attempt to envisage and evolve transradial approach, the present supplement entitled “Transradial Coronary Angioplasty; Where are we today? What are Future Directions, Consensus 2010” is brought forward to you.
This supplement, as a document with inputs from transradial stalwarts of the world, hopes to answer numerous questions and matters in the transradial approach. The scope of this supplement is designed to act as a lifelong learning guide that can be accessed to provide effective information. The A-Z of transradial has been judiciously included in this supplement.
The manuscripts have been authored by transradial giants across the world with contributions from Italy, USA, Germany, UK, France, Canada, Brazil and India.
I am thankful to the Editor-in-chief of the Indian Heart Journal for honoring me with this guest editorship. I also thank my fellow cardiologists and team at the Heart Care Clinic, Ahmedabad, who have worked whole-heartedly for the success of this endeavor. |