Limitations of successive transradial approach in the same arm: the Japanese experience

Snuffbox distal transradial access (dTRA) for arteriovenous fistuloplasty in Singapore: Going distal is safe

AIM

Arteriovenous fistula (AVF) dysfunction resulting from stenosis or occlusion, is a prevalent issue in end-stage renal failure patients reliant on autogenous AVFs for dialysis. Recently, a distal transradial approach (dTRA) has emerged, offering advantages such as diminished access site complications, better patient comfort and reduced risk of radial artery occlusion. Our study seeks to assess the effectiveness, outcomes and complication rates of employing dTRA for arteriovenous fistuloplasty in Singaporean patients.

METHODS

A retrospective review of all dTRA fistuloplasties performed on dysfunctional or slow to mature AVFs from 2017 to 2023 in our institution was performed. Patients with a distal radial artery measuring 2 mm or more with no evidence of occlusion or thrombosis were included. Patients who required central venoplasty or cutting balloon angioplasty were excluded. Outcome measures included technical success, mean procedure duration, complications and post-intervention primary patency at 1, 3 and 6 months. Patients were followed up for 12 months post-intervention.

RESULTS

A total of 37 patients were included. 97.3% of patients undergoing dTRA fistuloplasty had radiocephalic fistulas while 2.7% had brachiobasilic fistulas. There was 100% technical success (defined as success in radial artery cannulation, sheath insertion and crossing of stenotic lesions) in our study as all patients successfully underwent fistuloplasty via dTRA approach. One-month patency rate was 97.4%, 3-month patency rate was 92.1% and 6-month patency rate was 86.8%. There were no immediate complications (haematoma, infection, bleeding, pseudoaneurysm, occlusion) of the radial artery post-intervention.

CONCLUSION

Our paper illustrates the safety and efficacy of utilising dTRA for arteriovenous fistuloplasty. This approach offers distinct benefits in addressing non-mature or dysfunctional distal forearm arteriovenous fistulas and should be taken into account in anatomically suitable cases.

Comparison of long-term radial artery occlusion via distal vs. conventional transradial access (CONDITION): a randomized controlled trial

BACKGROUND

The distal transradial access (dTRA) has become an attractive and alternative access to the conventional transradial access (TRA) for cardiovascular interventional diagnosis and/or treatment. There was a lack of randomized clinical trials to evaluate the effect of the dTRA on the long-term radial artery occlusion (RAO).

METHODS

This was a prospective, randomized controlled study. The primary endpoint was the incidence of long-term RAO at 3 months after discharge. The secondary endpoints included the successful puncture rate, puncture time, and other access-related complications.

RESULTS

The incidence of long-term RAO was 0.8% (3/361) for dTRA and 3.3% (12/365) for TRA (risk ratio = 0.25, 95% confidence interval = 0.07-0.88, P = 0.02). The incidence of RAO at 24 h was significantly lower in the dTRA group than in the TRA group (2.5% vs. 6.7%, P < 0.01). The puncture success rate (96.0% vs. 98.5%, P = 0.03) and single puncture attempt (70.9% vs. 83.9%, P < 0.01) were significantly lower in the dTRA group than in the TRA group. However, the number of puncture attempts and puncture time were higher in the dTRA group. The dTRA group had a lower incidence of bleeding than the TRA group (1.5% vs. 6.0%, P < 0.01). There was no difference in the success rate of the procedure, total fluoroscopy time, or incidence of other access-related complications between the two groups. In the per-protocol analysis, the incidence of mEASY type ≥ II haematoma was significantly lower in the dTRA group, which was consistent with that in the as-treated analysis.

CONCLUSIONS

The dTRA significantly reduced the incidence of long-term RAO, bleeding or haematoma.

TRIAL REGISTRATION

ClinicalTrials.gov identifer: NCT05253820.

Preliminary Study on Retrograde Recanalization of Radial Artery Occlusion Through Distal Radial Artery Access: a Single-Center Experience

PURPOSE

Radial artery occlusion (RAO) is an unresolved complication after transradial artery (TRA) puncture. The aim of this observational study was to assess the feasibility and safety of retrograde recanalization of RAO through distal transradial access (dTRA).

METHODS

From June 2021 to March 2022, 28 consecutive patients with successful puncture and intubation through the dTRA in the anatomical snuffbox and RAO confirmed by angiography were enrolled.

RESULTS

Among the 28 patients, 27 (96.4%) patients with RAO were successfully retrogradely recanalized through the dTRA and successfully underwent coronary angiography or coronary intervention. After the procedure, only 1 (3.7%) patient developed a forearm hematoma, and there were no other bleeding complications or nerve disorders.

CONCLUSIONS

DTRA is a safe and feasible approach for retrograded recanalization of RAO, with a high procedure success rate and few complications.

Analysis of the Efficacy and Safety of Coronary Catheterization through Distal Transradial Access: A Single-Center Data

Background and Aims

The distal transradial access (dTRA) is a new puncture site for coronary catheterization. We sought to evaluate the feasibility, safety, and complication rates of using the dTRA for cardiac catheterization in Chinese patients.

Methods

A total of 263 consecutive patients who underwent catheterization through the dTRA were enrolled. The primary endpoint of the study was the rate of conversion to another access site due to the impossibility of successful artery puncture or intubation. Secondary safety endpoints were the rates of bleeding-related complications and nerve disorders.

Results

Among 263 patients, the puncture success rate was 96.2% (253/263). Eleven patients were successfully punctured, but the guide wire was difficult to advance. One patient had intubation failure, and the success rate of intubation was 91.6% (241/263). Two hundred thirty-three patients underwent puncture via the right dTRA, 5 patients underwent puncture via the left dTRA, and 3 patients underwent puncture via the bilateral dTRA. A total of 158 (65.6%) patients underwent coronary angiography, and 83 (34.4%) patients underwent percutaneous coronary intervention. After the procedure, only 2 (0.8%) patients had mild bleeding at the puncture site, 2 (0.8%) had a forearm hematoma, and no patient had a nerve disorder.

Conclusions

DTRA has a low incidence of complications, making it a safe and effective technique for cardiac catheterization.

Rationale and Design of the Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion Trial (CAPITAL-RAPTOR)

INTRODUCTION

Transradial access (TRA) has rapidly emerged as the preferred vascular access site for coronary angiography and percutaneous coronary intervention. Radial artery occlusion (RAO) remains as an important complication of TRA as it precludes future ipsilateral transradial procedures. While intraprocedural anticoagulation has been studied extensively, the definitive role of postprocedural anticoagulation has not yet been established.

METHODS AND ANALYSIS

The Rivaroxaban Post-Transradial Access for the Prevention of Radial Artery Occlusion trial is a multicentre, prospective, randomised, open-label, blinded-endpoint design study investigating the efficacy and safety of rivaroxaban to reduce the incidence of RAO. Eligible patients will undergo randomisation to receive either rivaroxaban 15 mg once daily for 7 days or to no additional postprocedural anticoagulation. Doppler ultrasound to assess radial artery patency will be performed at 30 days.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ottawa Health Science Network Research Ethics Board (approval number 20180319-01H). The study results will be disseminated via conference presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03630055.

The efficacy of nitroglycerin to prevent radial artery spasm and occlusion during and after transradial catheterization: A systematic review and meta-analysis of randomized controlled trials

Radial artery spasm (RAS) is the most common cause of transradial access site crossover and is a common intra-procedural complication. RAS incidence can lead to radial artery occlusion (RAO) postprocedure, preventing the radial artery as a future access site. We evaluated the efficacy of nitroglycerin preventing RAS and RAO during transradial catheterization discussing the different routes of administration, including topical, subcutaneous, and intra-arterial. A systematic review and meta-analysis included all relevant articles until April 23, 2022. We searched six databases Google Scholar, Web of Science, SCOPUS, EMBASE, PubMed (MEDLINE), and CENTRAL. We registered our review protocol in PROSPERO with ID: CRD42022330356. We included 11 trials with 5814 patients. Compared to placebo, the pooled analysis favored subcutaneous nitroglycerin in preventing RAS (risk ratio [RR]: 0.57 with 95% confidence interval [CI] [0.43-0.77], p = .0003) and RAO (RR: 0.39 with 95% CI [0.16-0.98], p = .05). In contrast to the intra-arterial nitroglycerin that showed nonstatistically significant results in preventing RAS and RAO (RR: 0.8 with 95% CI [0.63-1.02], p = .07)- (RR: 0.78 with 95% CI [0.6-1.01], p = .06)), respectively. Also, topical nitroglycerin did not prevent RAS (RR: 0.73 with 95% CI [0.42-1.24], p = .24). Compared with placebo, subcutaneous nitroglycerin during transradial catheterization reduced the incidence of RAS and RAO. Meanwhile, Intra-arterial and topical nitroglycerin did not show statistically significant outcomes. Subcutaneous nitroglycerin may be a practical and cost-effective technique to facilitate transradial catheterization; however, more RCTs are needed to evaluate the subcutaneous versus intra-arterial nitroglycerin administration.

The Retrograde Basilic Approach for Balloon-Assisted Maturation of Brachiocephalic Arteriovenous Fistulas

PURPOSE

To assess the feasibility and outcomes of an approach utilizing transbasilic access for balloon-assisted maturation (BAM) of brachiocephalic arteriovenous fistulas (BCAVF).

MATERIALS AND METHODS

This retrospective analysis comprised 28 patients (mean age 63 years ± 10.8) who underwent endovascular treatment of their immature BCAVFs via a basilic approach from December 2016 to December 2018. The mean age of the BCAVF was 3.3 months ± 1.4 at time of BAM. Other demographic data, vascular access characteristics, procedural data, technical and clinical success rates and adverse events were also evaluated.

RESULTS

All patients had inflow juxta-anastomotic stenoses, with 4 patients (14%) having concomitant outflow tract stenoses, and 1 patient (4%) having a short segment occlusion at the stenotic juxta-anastomotic segment. Technical success was achieved in 27 patients (96%). The mean diameter of the largest balloon used was 5.7mm ± 0.6. Clinical success was achieved in 22 patients (79%), with 6 patients (21%) requiring a subsequent additional intervention before successful cannulation. No perioperative adverse events were observed.

CONCLUSION

The retrograde basilic approach is feasible, safe and effective for balloon-assisted maturation of BCAVFs.

Clinical Efficacy of the Transradial Approach in Percutaneous Intervention for a Malfunctioning Arteriovenous Fistula

Purpose

To evaluate the effectiveness of the transradial artery approach (TRA) for treating malfunctioning arteriovenous fistulas (AVFs) in patients on hemodialysis.

Materials and Methods

A retrospective analysis was conducted in this single-center study of TRA endovascular procedures in 73 patients (43 male and 30 female; mean age of 67.4 years (range, 42–92 years) with malfunctioning AVFs, between January 2008 and April 2019. Patients’ baseline and lesion characteristics, technical and clinical success, and complications were evaluated, and functional patency was analyzed using the Kaplan-Meier method.

Results

Radial artery approaches were successful in all patients. Angioplasty performed using the TRA achieved technical and clinical success rates of 98.6%(72/73) and 91.7%(67/73), respectively. The median primary patency time was 18.8 ± 15.9 months. The primary functional patency rates at 3, 6, and 12 months were 82.1%, 68.6%, and 63.9%, respectively. There were no major complications or adverse events, such as hand ischemia, related to the radial artery approach.

Conclusion

In selected cases, the TRA can be used complementary to the transvenous approach to treat malfunctioning AVFs.

Feasibility and safety of the successive use of distal transradial access for coronary angiography and intervention in the same arm

Distal transradial access (dTRA) is a novel alternative to conventional radial artery access for coronary catheterization. However, the feasibility and safety of repeated use of dTRA have not been fully elucidated. This study aimed to evaluate the feasibility and safety of the repeated use of dTRA for coronary angiography and intervention in the same arm. A total of 1717 patients underwent angiography or angioplasty via dTRA. We retrospectively analyzed the catheterization records of patients who underwent repeated puncture of the distal radial artery in the same arm. The incidence of successive applications of dTRA and the reasons for dropout were retrospectively investigated. A total of 416 patients, including three who underwent coronary catheterization with the bilateral dTRA in the initial attempt were analyzed. A 3‐, 4‐, 5‐, or 6‐French sheath or sheathless guide catheter was used in the initial procedure. A maximum of four successive coronary catheterization procedures were performed. The second procedure with dTRA on the same arm was successfully performed in 395 cases (94.3%), with a successive rate of 89.6% for both the third and fourth dTRA procedures. Conversion to another approach site (n = 30) was attributed to radial artery occlusion (n = 9), narrowing of the distal radial artery (n = 19), and puncture failure (n = 2). The current data indicate that the repeated use of dTRA is safe and feasible, and this approach may become a standard approach site in the future.

Low-molecular-weight-heparin in radial artery occlusion treatment: the LOW-RAO randomized study

Radial artery occlusion (RAO) is the commonest complication of transradial catheterization. There is no evidence-based therapy, in the frame of a randomized control study, for the treatment of RAO. The purpose of the LOW-RAO study is to question the hypothesis if low-molecular-weight heparin is effective in the treatment of RAO after transradial coronary catheterization (both angiography and percutaneous coronary intervention). It is a prospective, open label, randomized controlled trial that will randomize 60 patients with RAO, irrespective of symptoms, into two groups, one receiving anticoagulation with low-molecular-weight heparin and the other receiving no treatment. The primary end point is improvement in radial artery patency rate at 4 weeks after the procedure. Trial registration number: NCT04196309 (ClinicalTrials.gov).

Vascular Complications of Transradial Access for Cardiac Catheterization

Transradial access has been increasingly adopted for cardiac catheterization. It is crucial for operators to recognize potential vascular complications associated with radial artery access. Prevention, early detection, and prompt treatment of vascular complications are essential to prevent serious morbidities. This review aims to raise awareness of transradial access vascular complications. Radial artery spasm is treated with intra-arterial verapamil and/or nitroglycerine. Hemorrhagic complications, such as perforation, hematoma, arteriovenous fistula, and pseudoaneurysm, are treated with prolonged compression. Patent hemostasis and adequate anticoagulation are used to prevent radial artery occlusion. Hand ischemia is a rare complication not associated with abnormal results of the Allen or Barbeau test, and can be treated with intra-arterial verapamil, IV heparin, and IV diltiazem. Finally, an attentive monitoring protocol for the timely detection of vascular complications should be implemented in daily practice.

Update on Transradial Access for Percutaneous Transcatheter Visceral Artery Embolization

Transfemoral access (TFA) is a widely used first-line approach for most peripheral vascular interventions. Since its introduction in cardiologic and neurointerventional procedures, several advantages of transradial access (TRA) over TFA have been demonstrated, such as patient preference, lower complication rates, early ambulation, and shorter hospital stay. However, studies reporting the safety and efficacy of this approach for peripheral vascular interventions performed by interventional radiologists are relatively few. This review aimed to summarize the technique and clinical applications of TRA in percutaneous transcatheter visceral artery embolization and the management of complications.

Evaluation of Railway Sheathless Access System for Transradial Coronary and Peripheral Interventions

OBJECTIVE

Evaluate efficacy and safety of Railway Sheathless Access System™ (Railway) in the first 200 consecutive cases at our center.

BACKGROUND

Transradial Intervention (TRI) is limited by the frequent occurrence of spasm, radial artery occlusion (RAO) and inability to use larger guide catheters (GC). The small size of radial artery (RA) is the primary reason for these limitations. Railway allows downsizing by sheathless GC access with GC of any shape or brand.

METHODS

Procedural and clinical variables were recorded prospectively for every case with intended use of Railway in the medical records. Hospital wide documentation of arm pain, radial spasm and pre-discharge evaluation of RAO with reverse Barbeau's test was performed by nurses. We retrospectively reviewed the data of the first consecutive 200 cases with the intended use of the Railway.

RESULTS

Railway was used successfully to complete intended procedure in 199 (99.5%) of the 200 patients. Railway was used with a 6 Fr (171) or 7 Fr (29) GC of various shapes to achieve sheathless access in 197 patients and for tracking the GC through severe RA tortuosity or mitral paravalvular leak in the rest. Three patients (1.5%) had spasm and forearm pain, two (1%) patients had small (<5 cm) hematoma, while one (0.5%) patient required access switch over and subsequently had RAO.

CONCLUSION

Railway Sheathless Access System can be used routinely for TRI with high success rate and low complication rate.

Feasibility of repeat transradial access for neuroendovascular procedures

Introduction

Transradial artery access (TRA) for cerebrovascular angiography is increasing due to decreased access site complications and overwhelming patient preference. While interventional cardiologists have reported up to 10 successive TRA procedures via the same radial access site, this is the first study examining successive use of the same artery for repeat procedures in neurointerventional procedures.1

Methods

We reviewed our prospective institutional database for all patients who underwent a transradial neurointerventional procedure between 2015 and 2019. Index procedures were defined as procedures performed via TRA after which there was a second TRA procedure attempted. Reasons for conversion to a transfemoral approach (TFA) for subsequent procedures were identified.

Results

104 patients underwent 237 procedures (230 TRA, 7 TFA). 97 patients underwent ≥2 TRA procedures, 20 patients >3, four patients >4, three patients >5, and two patients >6 TRA procedures. The success rate was 94.7% (126/133) with 52% (66/126) of successive procedures performed via the same radial access site (snuffbox vs antebrachial) while the alternate radial artery segment was used for access in 48% (60/126) of subsequent procedures. There were seven (5.3%) cases requiring crossover to TFA, six cases for radial artery occlusion (RAO) and one for radial artery narrowing.

Conclusion

Successive TRA is both technically feasible and safe for neuroendovascular procedures in up to six procedures. The low failure rate (5.3%) was primarily due to RAO. Thus, even without clinical consequences, strategies to minimize RAO should be optimized for patients to continue to benefit from TRA in future procedures.

Efficacy and safety of the distal transradial approach in coronary angiography and percutaneous coronary intervention: a Japanese multicenter experience

The novel distal transradial approach (dTRA) is expected to further build upon the advantages of transradial access. However, the incidence of radial artery occlusion (RAO) and hemorrhagic events with the dTRA has not been fully elucidated. The objective of this study was to investigate the effects of using the dTRA on RAO and postprocedural hemorrhage. From April 2018 to July 2018, 228 consecutive patients who underwent coronary angiography or intervention through the dTRA at two hospitals were analyzed. The RAO rate, change in the forearm and distal radial artery diameter and cross-section area after the dTRA (at 1 day and 1 month) on vascular ultrasonography, and incidence of hemorrhagic complications were investigated. Forearm and distal RAO occurred in 1 (0.4%) and 8 (3.1%) patients at 1 month, respectively. No forearm hematomas occurred. Ultrasonographic findings indicated that the radial artery diameter and cross-section area were significantly larger after the dTRA (2.9 ± 0.5 mm vs. 2.7 ± 0.5 mm, p < 0.001 and 6.5 ± 2.4 mm² vs. 5.6 ± 2.0 mm², p < 0.001, respectively). The distal radial artery diameter and cross-section area in the anatomical snuffbox were also significantly larger after the dTRA (2.5 ± 0.5 mm vs. 2.3 ± 0.4 mm, p < 0.001 and 4.7 ± 2.0 mm² vs. 4.2 ± 1.6 mm², p < 0.001, respectively). The DTRA was associated with a low incidence of RAO at both the puncture site and the forearm, postprocedural dilatation of the radial artery, and no bleeding complications extending to the forearm.

Acute Kidney Injury Post Cardiac Catheterization: Does Vascular Access Route Matter?

BACKGROUND

Acute Kidney Injury as a complication of cardiac catheterization is associated with increased length of hospital stay and mortality. In recent years, the use of the radial artery for cardiac catheterization is increasing in frequency.

OBJECTIVE

The objective of this concise review was to evaluate the method of cardiac access site and its impact on Acute Kidney Injury following cardiac catheterization.

METHODS

After a thorough search on Medline, Google Scholar and PubMed, we included all the literature relevant to Acute kidney injury following transradial and transfemoral cardiac catheterization.

RESULTS

While acute kidney injury was caused due to a variety of reasons, it was important to consider each case on an individual basis. We found a trend towards increased use of transradial approach in patients at high risk of developing kidney injury. However, limitations such as operator experience, anatomical challenges and so on do exist with this approach.

CONCLUSION

Transradial access offers several advantages to a patient at high risk of acute kidney injury undergoing cardiac catheterization. Further large studies are needed to establish this trend in the years ahead.

Role of vascular ultrasound scanning in repeated trans-radial coronary artery intervention (prospective randomized study)

OBJECTIVES

We aimed to detect if pre-procedure vascular ultrasound scanning (VUS) of radial arteries (RAs) can increase the radial access success (RAS) rate and/or reduce the vascular access time (VAT), by guiding the choice of the proper access site for repeated trans-radial interventions (TRIs).

BACKGROUND

Currently, repeated-TRIs are encountered more frequently in most of the cath. labs. However, structural changes of the RAs after TRA may hinder it is usage for repeated-TRI. VUS is the most accurate noninvasive test for assessing RAs, nonetheless, its role in the setting of repeated-TRIs has not been studied before.

MATERIAL AND METHODS

We randomly assigned 300 patients undergoing repeated-TRI, to either planning the vascular access site based upon the result of VUS that was performed pre-procedural (group A, 150 patients) or to be left to the operator's discretion (group B, 150 patients).

RESULTS

In group A (143/145 [98.6%]), RAS rate was only numerically higher than group B (143/150 [95.3%]), P = 0.08. There was a statistically significant differences between both groups in VAT [(1.25 ± 0.17 min), vs. (4.95 ± 0.87 min) for group A and B, respectively, P = 0.02] and in procedure duration [(37.2 ± 19.8 min) vs. (51.8 ± 18.6 min) for group A and B, respectively, P = 0.04]. RA spasm was more common in group B [18% (27/150)] than group A [2% (3/145)], P = 0.001.

CONCLUSION

VUS of RAs prior to repeated-TRI is associated with significant reduction in VAT, procedure duration, RA spasm and a mild increase in the RAS rate.

Incidence and Clinical Course of Limb Dysfunction Post Cardiac Catheterization - A Systematic Review

BACKGROUND

We systematically reviewed the available literature on limb dysfunction after transradial access (TRA) or transfemoral access (TFA) cardiac catheterization. Methods and Results: MEDLINE and EMBASE were searched for studies evaluating any transradial or transfemoral procedures and limb function outcomes. Data were extracted and results were narratively synthesized with similar treatment arms. The TRA group included 15 studies with 3,616 participants and of these 3 reported nerve damage with a combined incidence of 0.16% and 4 reported sensory loss, tingling and numbness with a pooled incidence of 1.61%. Pain after TRA was the most common form of limb dysfunction (7.77%) reported in 3 studies. The incidence of hand dysfunction defined as disability, grip strength change, power loss or neuropathy was low at 0.49%. Although radial artery occlusion (RAO) was not a primary endpoint for this review, it was observed in 3.57% of the participants in a total of 8 studies included. The TFA group included 4 studies with 15,903,894 participants; the rates of peripheral neuropathy were 0.004%, sensory neuropathy caused by local groin injury and retroperitoneal hematomas were 0.04% and 0.17%, respectively, and motor deficit caused by femoral and obturator nerve damage was 0.13%.

CONCLUSIONS

Limb dysfunction post cardiac catheterization is rare, but patients may have nonspecific sensory and motor complaints that resolve over a period of time.

Altered Hand Temperatures Following Transradial Cardiac Catheterization: A Thermography Study

BACKGROUND

There is concern about potential detrimental effects of transradial access (TRA) on radial artery structure, endothelial and hand function. This thermography study evaluated TRA impact on hand microvascular perfusion.

METHODS AND RESULTS

We prospectively measured hand thermography, radial and ulnar artery size and blood flow velocities in both catheterization and non-catheterization hands at baseline and 30-days after TRA in 158 patients. There were no differences in radial or ulnar arterial diameters or velocities pre- and post-TRA in catheterization and non-catheterization hands (p = NS). The absolute total hand thermography values post-TRA were increased in both catheterization and non-catheterization hand (pre-TRA 30.4 ± 2.9 vs. post-TRA 31.6 ± 2.6 p < 0.01; pre-TRA 30.2 ± 2.9, post-TRA 31.6 ± 2.6 p < 0.01, respectively). After ulnar artery occlusion, hand temperatures decreased in both catheterization and non-catheterization hands, both pre- and post-TRA and were similar in the catheterization and non-catheterization hands (p = NS). Total hand temperature decreased with ulnar artery occlusion and was significantly attenuated post-TRA (p < 0.001 both catheterization and non-catheterization hands).

CONCLUSIONS

TRA is associated with temperature changes in both catheterization and non-catheterization hands at one month after the index procedure. These changes likely represent a systemic response to local TRA stimulus.

Incidence, Determinants, and Outcomes of Left and Right Radial Access Use in Patients Undergoing Percutaneous Coronary Intervention in the United Kingdom: A National Perspective Using the BCIS Dataset

OBJECTIVES

The authors sought to determine the relationships between left radial access (LRA) or right radial access (RRA) and clinical outcomes using the British Cardiovascular Intervention Society (BCIS) database.

BACKGROUND

LRA has been shown to offer procedural advantages over RRA in percutaneous coronary intervention (PCI) although few data exist from a national perspective around its use and association with clinical outcomes.

METHODS

The authors investigated the relationship between use of LRA or RRA and clinical outcomes of in-hospital or 30-day mortality, major adverse cardiovascular events (MACE), in-hospital stroke, and major bleeding complications in patients undergoing PCI between 2007 and 2014.

RESULTS

Of 342,806 cases identified, 328,495 (96%) were RRA and 14,311 (4%) were LRA. Use of LRA increased from 3.2% to 4.6% from 2007 to 2014. In patients undergoing a repeat PCI procedure, the use of RRA dropped to 72% at the second procedure and was even lower in females (65%) and patients >75 years of age (70%). Use of LRA (compared with RRA) was not associated with significant differences in in-hospital mortality (odds ratio [OR]: 1.19, 95% confidence interval [CI]: 0.90 to 1.57; p = 0.20), 30-day mortality (OR: 1.17, 95% CI: 0.93 to 1.74; p = 0.16), MACE (OR: 1.06, 95% CI: 0.86 to 1.32; p = 0.56), or major bleeding (OR: 1.22, 95% CI: 0.87 to 1.77; p = 0.24). In propensity match analysis, LRA was associated with a significant decrease in in-hospital stroke (OR: 0.52, 95% CI: 0.37 to 0.82; p = 0.005).

CONCLUSIONS

In this large PCI database, use of LRA is limited compared with RRA but conveys no increased risk of adverse outcomes, but may be associated with a reduction in PCI-related stroke complications.

Ankaferd blood stopper as a new strategy to avoid early complications after transradial procedures: A randomized clinical trial

BACKGROUND

We planned a three arm randomized study to evaluate the safety and efficacy of a new blood stopper, Ankaferd blood stopper (ABS) along with short-time compression, compared to either short-time compression with conventional sterile gauzes (CSG) or with a TR band after transradial (TRA) procedures.

METHODS

The Ankaferd blood stopper as a new strategy to avoid early complications. After transradial procedures (ABS transradial) trial is designed in a prospective, randomized, placebo-controlled fashion and registered with http://clinicaltrials.gov (NCT02982733). Six hundred and thirty patients were randomized into three arms in a 1:1:1 fashion corresponding to three different strategies of patent hemostasis techniques after diagnostic or interventional catheterization.

RESULTS

One (0.49%) patient in the CSG group and one patient (0.48%) in the TR Band group developed RAO at the end of the hemostasis, compared with 0 (0%) in the ABS group. At 30 days follow-up none of the groups had any patients with RAO. As a secondary end-points the difference was not statistically significant regarding hematoma among the three groups (P = 0.70). Bleeding during deflation of the TR Band or removal of the elastic bandage occurred in 55 patients (26.96%) in the CSG group and in 56 (27.31%) patients in the TR Band group compared to 19 patients (9.40%) in the ABS group (P < 0.001).

CONCLUSION

Ankaferd blood stopper is a promising device for use in patent hemostasis, with no evidence on RAO at short-term or long term and with reduced risk of re-bleeding at the end of hemostasis.

Same-day dual radial artery puncture examination in patients requiring percutaneous coronary intervention and the incidence of radial artery occlusion

BACKGROUND

We sought to investigate the rate of radial artery occlusion (RAO) after same-day dual radial artery puncture. The trans-radial arterial approach (TRA) for diagnostic and interventional procedures has risen significantly in the United States. Although becoming more commonly performed, TRA is not without risk, and a potential complication is RAO. The rate of RAO after same-day dual artery puncture is unknown.

METHODS

A retrospective analysis of 27 patients who underwent same-day dual radial artery puncture for percutaneous coronary intervention (PCI) at our institution (Providence Heart Institute in Southfield, MI, USA) from November 2011 to December 2013 were included after initially presenting for cardiac catheterization at a non-PCI-capable facility. The study patients were asked to follow up for evaluation of the radial artery, including obtaining a duplex ultrasound evaluation.

RESULTS

The mean age of the patients was 65 years old with 66% of the patients being male. Of the 27 study participants, there were no symptoms reported that were related to RAO. Overall, one (3.7%) patient had an absent radial pulse. The modified Allen's test was normal in all of the patients with a mean return of palmar flush time of 4 seconds. Duplex ultrasound revealed subtotal RAO in four (14.8%) patients and no patients experienced total occlusion following the intervention.

CONCLUSION

Dual radial artery puncture appears to be a well-tolerated and viable strategy in patients that are transferred to a PCI-capable hospital for coronary interventions.

Feasibility and Safety of Early Repeat Transradial Access Within 30 Days of Previous Coronary Angiography and Intervention

Transradial approach (TRA) is the default access site for diagnostic angiography and intervention in many centers. Repeat ipsilateral radial artery access late after index procedure has been associated with failures. It is unknown whether early (≤30 days) and very early (<24 hours) repeat radial access is technically feasible and safe. Study population consisted of consecutive patients undergoing repeat (≥2) procedures within 30 days in a high-volume TRA center. Transradial access failure and resulting femoral approach was categorized as primary (no repeat attempt) or secondary (crossover). Timing of repeat access and reasons for failure were recorded. From November 2012 to December 2014, repeat catheterization by TRA was performed twice in 573 of 626 patients (92%) (median delay 4 [2 to 9] days), 3 times in 29 of 38 (76%) patients (median delay 15 [5 to 26] days), and 4 times in 1 patient within 21 days. When repeat catheterization occurred during the first 24 hours following the index procedure, 53% and 75% of patients had second and third procedures using the same ipsilateral radial artery, respectively. Primary radial failure occurred in 5.8% for second attempt and 13% for a third attempt, whereas crossovers were noted in 2.7% and 2.6%, respectively. Main reasons for failed re-access of ipsilateral radial artery were related either to operator's reluctance to repeat attempt (primary failure) or to issues with puncture site (crossover). In a high-volume TRA center, patients who required repeat catheterization within 24 hours and within the first 30 days had the same radial artery re-accessed in the majority of cases.

Comparison of very-high-frequency ultrasound assessment of radial arterial wall layers after first and repeated transradial coronary procedures

BACKGROUND

Transradial coronary procedure (TRP) traumatizes the radial artery (RA), especially resulting in changes to arterial wall morphology. This study explored the significance of the early onset of traumatic effects to wall layers of the RA following the first TRP (FTRP) and repeat TRP (RTRP) using very-high-frequency ultrabiomicroscopy (VHFUBM).

METHODS

A total of 1431 patients that received TRP were divided into the FTRP group that comprised 781 patients and the RTRP group that comprised 650 patients depending on the number of procedures. Two-dimensional RA images were acquired by 30-55 MHz ultrasound one day before and one day after the procedure.

RESULTS

After TRP, the incidence of intimal tears, medial dissections and external elastic lamina fracture were greater in the RTRP (P < 0.001). The RTRP group showed significantly thicker intimal thickness (IT), media thickness (MT), adventitia thickness and all complex layer thicknesses as compared with the FTRP group (P < 0.001).

CONCLUSIONS

Multivariate linear regression analysis discovered that repeated TRP and other observations were independent predictors of increased IT in post-operative RA. VHFUBM provides an approach to study structural and histopathological injury in the wall layers of RA which showed increased trauma to the RA following RTRP.

Radial Artery Occlusion - Incidence, Predictors and Long-term outcome after TRAnsradial Catheterization: clinico-Doppler ultrasound-based study (RAIL-TRAC study)

Background and aim The purpose of this study was to assess incidence, predictors and outcome of radial artery occlusion (RAO) after transradial catheterization (TRC) based on clinical and Doppler ultrasound study. Methods A total of 1,945 consecutive patients undergoing transradial catheterization for diagnostic evaluation or intervention were included. Radial artery examination was based on palpation and colour Doppler study on the day before, 1 day (D₁), 1 month (D₃₀) and 6 months (D₁₈₀) following the procedure. RAO was defined as absence of pulse on palpation and forward flow on Doppler study. Predictors of RAO were found by logistic regression analysis. Results Baseline demographic and procedural data were recorded. The mean radial arterial diameter was 2.56 ± 0.29 mm. On D₁, radial artery Doppler examination revealed RAO in 339 patients (17.4%) but pulse was still palpable in 115 (34%) of them. At D₃₀, these were 221 (11.4%) and 114 (52%), respectively, as no new RAO were noted. Interestingly, 118 (34.8%) patients had spontaneous recanalization of their radial artery as shown by catch-up in patency rate. At D₁₈₀, these were 99 (5.1%) and 68 (69%), respectively, meaning further new catch-up implying further recanalization. Patients with persistent RAO remained asymptomatic. On multivariate analysis, female sex, diabetes, lower BMI, radial artery diameter ≤2.2 mm and radial artery-to-sheath ratio (AS ratio) < 1 were predictors of RAO. Conclusion TRC for coronary angiography, ad hoc and staged angioplasty can be performed with similar efficacy and safety though RAO occurs more frequently in patients with prior radial artery cannulation and with larger sheath size. Persistent RAO remains asymptomatic.

Radial artery occlusion after transradial coronary catheterization

The transradial approach (TRA) for coronary angiography and interventions is increasingly utilized around the world. Radial artery occlusion (RAO) is the most common significant complication after transradial catheterization, with incidence varying between 1% and 10%. Although RAO is rarely accompanied by hand ischemia, it is an important complication because it prohibits future transradial access and radial artery utilization as a conduit for coronary artery bypass grafting or arteriovenous fistula formation. In this review, we discuss factors predicting the occurrence of RAO, aspects of accurate and prompt recognition, methods that contribute to its prevention and possible treatment options.

Endothelial dysfunction and the occurrence of radial artery spasm during transradial coronary procedures: the ACRA-Spasm study

AIMS

The aim of this study was to analyse the relation between endothelial dysfunction (ED) and the occurrence of radial artery spasm (RAS) during transradial coronary procedures.

METHODS AND RESULTS

From May 2014 to June 2015, endothelial function was assessed by EndoPAT and FMD before the procedure in 165 patients referred for coronary angiography or intervention. The primary endpoint was RAS, defined by patient's symptoms and procedural characteristics. The mean age of the study population was 63 years and 71% were male. In total 16% of the patients experienced RAS. The incidence of RAS did not differ between patients with and without ED (13.8% vs. 20.2%, OR 0.63, 95% CI: 0.25-1.58, p=0.32). The strongest predictors of RAS were a ratio of radial artery inner diameter and sheath outer diameter smaller than 1 (OR 4.7, 95% CI: 1.35-16.5, p=0.009) and a combination of clinical characteristics presented as an RAS risk score of at least 4 (p=0.007, OR 3.7, 95% CI: 1.37-9.89).

CONCLUSIONS

Endothelial dysfunction was not found to be a predictor of the occurrence of radial artery spasm in a cohort of patients undergoing elective heart catheterisation. Radial artery-sheath mismatch is the strongest pre-procedural predictor of RAS.

Radial Artery Occlusion After Transradial Interventions: A Systematic Review and Meta-Analysis

BACKGROUND

Radial artery occlusion (RAO) may occur posttransradial intervention and limits the radial artery as a future access site, thus precluding its use as an arterial conduit. In this study, we investigate the incidence and factors influencing the RAO in the current literature.

METHODS AND RESULTS

We searched MEDLINE and EMBASE for studies of RAO in transradial access. Relevant studies were identified and data were extracted. Data were synthesized by meta-analysis, quantitative pooling, graphical representation, or by narrative synthesis. A total of 66 studies with 31 345 participants were included in the analysis. Incident RAO ranged between <1% and 33% and varied with timing of assessment of radial artery patency (incidence of RAO within 24 hours was 7.7%, which decreased to 5.5% at >1 week follow-up). The most efficacious measure in reducing RAO was higher dose of heparin, because lower doses of heparin were associated with increased RAO (risk ratio 0.36, 95% CI 0.17-0.76), whereas shorter compression times also reduced RAO (risk ratio 0.28, 95% CI 0.05-1.50). Several factors were found to be associated with RAO including age, sex, sheath size, and diameter of radial artery, but these factors were not consistent across all studies.

CONCLUSIONS

RAO is a common complication of transradial access. Maintenance of radial patency should be an integral part of all procedures undertaken through the radial approach. High-dose heparin along with shorter compression times and patent hemostasis is recommended in reducing RAO.

Radial artery occlusion after transradial approach to cardiac catheterization

Radial artery occlusion (RAO) is the most common complication of the transradial approach (TRA) to cardiac catheterization, with a reported incidence between 0.8 % and 30 %. RAO is likely the result of acute thrombus formation and complicated by neointimal hyperplasia. Most RAO are asymptomatic with rare cases of acute hand or digit ischemia reported in the literature. The role of testing for dual circulation to the hand in determining the safety of TRA as it relates to symptomatic RAO is controversial; however, modifiable risk factors like low sheath-to-artery ratio, adequate anticoagulation, and non-occlusive ("patent") hemostasis are likely to prevent RAO. This review examines the incidence of RAO, potential mechanisms leading to RAO, and strategies to prevent and treat RAO.

Feasibility of the Transradial or the Transbrachial Approach in Various Neurointerventional Procedures

Purpose

The generally preferred vascular access for neurointerventional procedures is the transfemoral approach (TFA). In complicated cases such as patients with aortic diseases or tortuous vessels, transradial or transbrachial approaches (TRA or TBA) could be good alternatives. The purpose of this study is to review a single medical center experience using the alternative accesses.

Materials and Methods

We reviewed the medical records of 30 TRA and 10 TBA cases among 2,073 cases treated between January 2010 and July 2013. We reviewed and analyzed the frequency of TRA and TBA, the reason the operator had chosen the TRA or TBA, the category of the procedure, caliber of the sheath, the success rate, and the complications rates.

Results

The most common reason the non-TFA route was chosen was due to the patient's tortuous vascular system (n=24, 60%). The most common category of intervention was balloon angioplasty and/or stent placement (n=18, 45%). The largest caliber of the introducing sheath was 6 Fr in TRA and 7 Fr in TBA. Procedural success was achieved in 37 cases (success rate: 92.5%), and in three cases it failed. Six patients with complications were reported. Among them, four cases of minor complications (10%) occurred. There was no serious complication directly related to the access problem.

Conclusion

Both TRA and TBA can be good alternative access routes when TFA is not appropriate in various neurointervential procedures.

Minimising radial injury: prevention is better than cure

Transradial (TR) coronary intervention is associated with fewer access-site-related bleeding complications and is independently associated with a lower risk of mortality following PCI compared to procedures undertaken through the femoral route. However, recent studies that have undertaken imaging of the radial artery through the use of IVUS and OCT, as well as histological studies, suggest that TR cardiac catheterisation is associated with significant injury to the radial artery wall resulting in significant endothelial cell dysfunction. The vascular endothelium plays a central role in the regulation of vascular tone, angiogenesis and vascular remodelling through the release of vasoactive mediators in response to a variety of stimuli. Hence, trauma to the vascular endothelium and subsequent changes in endothelial cell function may contribute to patterns of injury such as intimal hyperplasia and radial artery occlusion observed following TR cardiac catheterisation. Such injury patterns to the radial artery following TR procedures may limit the success and future utility of the TR approach. Minimisation of radial artery injury should be a key procedural component of procedures undertaken through the transradial approach.

Slender Approach and Sheathless Techniques

Most radial arteries cannot accommodate 7- and 8-French introducer sheaths for large-bore percutaneous coronary intervention without overstretch. In addition to being uncomfortable, radial artery overstretch is associated with spasm and higher rates of procedure-related radial artery occlusion. Methods for the transradial interventionist to overcome the limitation of radial artery-sheath size mismatch include both sheath-based and sheathless approaches. In this article we discuss a variety of techniques that can be used to minimize radial artery stretch for straightforward and complex coronary procedures.

Complications related to radial artery occlusion, radial artery harvest, and arterial lines

Recent publications have suggested that there may be an important role for the radial artery regarding long-term perfusion of the hand. The increasing popularity of the radial artery as an access site for cardiac catheterization has also resulted in the recognition of acute and chronic radial artery occlusion, and cardiologists have placed renewed emphasis on preserving the patency of this artery for future interventional procedures. This article reviews the present literature on radial artery harvest and occlusion. Also discussed are the complications associated with radial artery occlusion and treatment options to prevent such complications.

Ultrasonography-guided radial artery catheterization is superior compared with the traditional palpation technique: a prospective, randomized, blinded, crossover study

BACKGROUND

Radial artery catheterization is gaining popularity for diagnostic and interventional procedures. Palpation technique is widely used for the procedure, but ultrasonography has been shown to increase catheterization success. A recently described ultrasonography technique is termed 'dynamic needle tip positioning'. We aimed to compare the traditional palpation technique and dynamic needle tip positioning technique in regard to clinically relevant end points.

METHODS

The study was conducted as a randomized, patient-blinded, crossover study. Patients underwent bilateral radial artery catheterization using both techniques. The primary end point of the study was needle manipulation time. Additional end points were (1) the number of skin perforations, (2) the number of attempts targeting the vessel, (3) the number of catheters placed in first attempt and (4) the number of catheters used.

RESULTS

Forty patients were analyzed. There was no significant difference in median needle manipulation time [32 s (range 11-96 s) vs. 39 s (range 9-575 s), P = 0.525], although the variance was lower in the dynamic needle tip positioning group (P < 0.001). In the traditional palpation technique group, a higher number of skin perforations (57 vs. 40, P = 0.003), catheters (46 vs. 40, P = 0.025) and attempts targeting the vessel (104 vs. 43, P < 0.001) were necessary compared with the ultrasonography dynamic needle tip positioning group. First attempt success rate was significantly higher in the ultrasonography dynamic needle tip positioning group (23/40 vs. 38/40, P < 0.001).

CONCLUSION

Ultrasonography guidance using the dynamic needle tip positioning technique for radial artery catheterization significantly improves clinically relevant aspects of the procedure.

Symptomatic radial artery thrombosis successfully treated with endovascular approach via femoral access route

Radial access has been increasingly utilized for coronary intervention due to higher safety profile in comparison to femoral access site with lower bleeding rate. Radial artery occlusion is not uncommon with radial access site. This usually does not lead to any harm due to ulnar artery collaterals that are sufficient to prevent hand ischemia and is usually left alone. However, in the case of significant hand ischemia, treatment is often necessary. We are reporting an interesting case of symptomatic radial artery thrombosis leading to arm ischemia that was successfully treated percutaneously using femoral access. Using femoral access for radial artery intervention has not been reported previously. This case is followed by review of the literature.

A case of sheathless transradial coronary intervention for complex coronary lesions with a standard guiding catheter

One of the major limitations of transradial coronary intervention is the inability to use large guiding system, which leads to the development of dedicated sheathless guide catheter system. However, these devices are not available in the Republic of Korea. We present a case in which conventional guiding catheter was used for sheathless transradial coronary intervention in the treatment of complex coronary anatomy.

Successive transradial access for coronary procedures: experience of Quebec Heart-Lung Institute

BACKGROUND

Transradial approach (TRA) for cardiac catheterizations and interventions improves clinical outcomes compared with transfemoral access, and its use is increasing worldwide. However, there are limited data on successive use of same artery for repeat procedures.

METHODS

Between May 2010 and May 2011, all consecutive patients undergoing a repeat TRA procedure (≥2) were retrospectively identified. Success rates and reasons for failure to use ipsilateral radial artery for repeat access were identified.

RESULTS

A total of 519 patients underwent 1,420 procedures. In 480 patients (92%), right radial artery was used as initial access, and left radial artery, in 39 patients. All patients underwent ≥2 procedures; 218 patients, ≥3; 87 patients, ≥4; 39 patients, ≥5; 19 patients, ≥6; 11 patients, ≥7; and 5 patients, ≥8 procedures. Two patients had, respectively, 9 and 10 procedures. The success rate for second attempt was 93%, 81% for third, and declining to 60% for ≥8. Linear regression analysis estimated a 5% failure rate for each repeat attempt (R(2) = 0.87, P = .007). The main reason for failure was related to clinical radial artery occlusion (RAO) including absent or faint pulse, poor oximetry, and failed puncture. All patients with clinical RAO were asymptomatic. By multivariate analysis, female gender (odds ratio [OR] 3.08, 95% CI 1.78-5.39, P < .0001), prior coronary artery bypass graft (OR 5.26, 95% CI 2.67-10.42, P < .0001), and repeat radial access (OR 2.14, 95% CI 1.70-2.76, P < .0001) were independent predictors of radial access failure.

CONCLUSION

Successive TRA is both feasible and safe in most cases for up to 10 procedures. However, failure rate for TRA increases with successive procedures, primarily due to clinical RAO. Strategies to minimize the risks of chronic clinical RAO and allow repeat use of ipsilateral radial artery need to be further defined.