Transradial Interventions: - Our experience
Milan Chag*Satya Gupta
The Heart Care Clinic, Ahmedabad .Gujarat

Introduction
The usual site of vascular access for coronary angiography or angioplasty is through the femoral artery, and the vast majority of coronary procedures are performed this way. The transfemoral route is popular, as puncturing the accessible and large caliber femoral artery is relatively easy, and most coronary catheters are in fact pre-shaped to facilitate procedures performed from this route. In 1989, Campeau introduced transradial access for performing coronary angiography1, and in 1993, Kiemeneij reported his experience with coronary angioplasty through the radial route2,3 The transradial route is now becoming increasingly popular, with the primary advantages of allowing earlier mobilization of patients post procedure, and significant less vascular complications when compared to transfemoral access.
As a team of Heart Care Clinic, we have been performing transradial angiography and angioplasty since 2005 in increasing numbers. At present, our more than 90% of coronary procedures are via transradial route. We have performed thousands of angiographies and angioplasties by this route in past several years. Here we performed an analysis of our experience with transradial angiography and angioplasty, demonstrating this to be a safe and effective technique suitable for most of the patients.

Methods
Patients

20,870 patients underwent coronary procedures both by transfemoral and transradial route over the past five year period. Trend toward femoral route was more during initial phase which over time taken by transradial approach (Fig1). Presently our more than 92% of procedures are transradial. Patients were selected   for transradial route only after care full assessment of adequate collateral circulation from the ulnar artery. We usually avoid transradial route in patients with chronic renal failure and post coronary artery bypass graft surgery.

Figure 1a. Total number of radial and femoral angiographies from year 2005 to 2009* Data till Oct 2009

Correspondence: Dr. Milan Chag* The Heart Care Clinic, 201, Balleshwar Avenue, Opp Rajpath Club, Sarkhej - Gandhinagar Road,Bodakdev, Ahmedabad – 380015 Gujarat
Email: milan.chag@heartcareclinic.org

Figure 1b. Total number of radial and femoral angioplasties from year 2005 to 2009* Data till Oct 2009

Procedure
No specific cathlab modification or preparation require for performing transradial coronary interventions. A modified arm board can be used to support the extremity (Fig2). Puncture of the radial artery was performed approximately 2cm cephalic to the radial styloid(Fig3) . The right radial artery was used more commonly. After subcutaneous infiltration with 1% lidocaine, a 21-gauge needle was used to enter the radial artery. After arterial puncture, 0.0018-inch guidewire was inserted. Although single wall puncture is considered to be ideal, we were more comfortable in through puncture and retraction technique (Fig4). The Guident 5F radial sheaths were used for most of the diagnostic procedure and 6F for most of the angioplasties. Few angioplasties were also done through 5F sheaths. We used intra arterial Nitroglycerine, Diltiazam and Nikorandil to prevent arterial spasm. Most of the diagnostic angiography were done using Tiger catheter.

Post procedure care
We usually remove sheath immediately post procedure both after angiography and angioplasty irrespective of the types of anticoagulants and antiplatelet agents used. In our center we apply tight dynaplast bandage for couple of hours (Fig5). Patients were allowed to sit up immediately after the procedure, if their medical condition allowed it. Most of the patients who underwent only diagnostic catheterization were discharged with in 4 hours while those who underwent angioplasty were kept in intensive care unit for next 24 hours under observation.     

Results
There were 20,870 procedures done over four and half year period. Most of the patients were males. There were no inclusion and exclusion criteria except patients with renal impairment and patients with post coronary bypass surgery. For analysis, patients were divided into two groups; Group1: patients who underwent transfemoral angiography and Group 2: patients who underwent transradial angiography. Year wise analysis and other procedural variables are shown in table1. The two groups were similar with respect to procedure variables, except for the procedure time and Fluro time, which was higher initially in transradial group and subsequently become equal and lesser than the tranfemoral group.

Figure 3: Ideal site of radial puncture which should be performed approximately 2cm cephalic to the radial styloid.

Figure 4:  Through and through puncture technique, Cannula needs to be withdrawn till a drop of blood in the upper end of needle is seen.

Figure 5: Patient sitting comfortably after transradial procedure, Elastoplast has been applied to puncture site.

Table 1: Baseline characteristics and procedural variables* Data till Oct 2009

Only minor complications were observed during transradial approach, most common being pain, ecchymoses and minor hematoma . In the transfemoral group, 13 patients (0.06%) developed major hematoma at the access site which was fatal and needed blood transfusion. Three patients who underwent transradial angioplasty developed major hematoma (Compartment syndrome) which was managed conservatively with decompressive bandage. None of the patients lost limb due to hematoma.

In the beginning we had more patients who were transferred to transfemoral approach from transradial. The main reasons for switching were radial loops, severe arterial spasm or patient’s discomfort due to long procedural time. Subsequently our switching rate reduced (16.3% to 2.2%). In the year 2008 and 2009, out of total 9957 procedures, 4554(82.2%) and 4271(92.4%) were transradial respectively.  

Discussion  
Our recent past data confirmed that transradial interventions are safe and effective. The advantages of transradial procedures are of shorter hospital stay, patients comfort and lower complications rates. This approach has been used for several years in the world4-6 and has become popular in our country recently. However, technical difficulties and long learning curve limit the use of transradial technique by many interventional cardiologists.

Currently our more than 90% of the procedures are transradials. The experience of the physician has been shown to play a major role in the procedural success.7   Initially the puncture time, procedure time and fluro time was more which over time reduced significantly. Our results were in concordance with findings of Louvard et al7 and Yigit et al8, which depicts reduced length of hospital stay and complications rate as experience increased. Our findings were comparable with similar reports available in literature9-11.

Most of our patients received intra arterial nitroglycerin and diltiazem cocktail to prevent radial artery spasm. The use of vasodialting agents such as nitroglycerin or verapamil during transradial interventions has been recommended by several interventional cardiologist to prevent radial artery spasm12,13. 

We used single catheter to cannulate both coronaries during transradial angiography to shorten procedure time, radiation time and to avoid radial artery spasm due to multiple catheter exchange. The use of a single catheter costs less than the use of two catheters for coronary system and we did not encountered any complications or technical difficulties using single catheter for diagnostic angiography. For angioplasties, the choice of guiding catheter was similar as done for transfemoral interventions.   

  
Conclusion
Transradial angiography and angioplasty procedures are safe with lesser complication rates. The initial learning curve and anatomical knowledge of the arterial course are required to initiate transradial procedures.with experience of about hundred procedures, the operator doesn’t find any technical difference between transfemoral and transradial approach.    

References
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2.Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary stent implantation. Cathet Cardiovasc Diagn 1993; 30:173-8.
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4.Saito S, Miyake S, Hosokawa G, Tanaka S, Kawamitsu K, Kaneda H et al. Transradial coronary intervention in Japanese Patients. Cathet Cardiovasc Interv 1999; 46:37-41.
5.Choussat R, Black A, Bossi I, Fajadet J, Marco J. Vascular complications and clinical outcome after coronary angioplasty with platelet IIb/IIIa receptor blockade. Comparison of transradial vs transfemoral arterial access. Eur Heart J 2000; 21:662-7.
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10.Spaulding C, Lefevre T, Funck F, Thebault B, Chaeveau M, Ben Hamda K, et al. Left radial approach for coronary angiography: results of a prospective study. Cathet Cardiovasc Diagn 1996; 39:365-70.
11.Louvard Y, Krol M, Pezzano M, Sheers L, Piechaud JF, Marien C, et al. Feasibility of routine transradial coronary angiography: a single operator’s experience. J Invasive Cardiol 1999; 11:543-8.
12.Coppola J, Patel T, Kwan T, Sanghvi K, Srivastava S, Shah S, et al. Nitroglycerin, nitroprusside, or both in preventing radial artery spasm during transradial artery catheterization. J Invasive Cardiol 2006; 18:155-8.
13. Kiemeneij F, Vajifdar BU, Eccleshall SC, Laarman G, Slagboom T, van der Wieken R. Evaluation of a spasmolytic cocktail to prevent radial artery spasm during coronary procedures. Cathet cardiovasc Interv 2003; 58:281-4.