Randomized comparison of transradial coronary angiography via right or left radial artery approaches

Different dose of heparin in preventing radial artery occlusion after transradial coronary angiography: A protocol for systematic review and meta-analysis of randomized controlled trials

BACKGROUND

When atherosclerosis occurs in the coronary artery, resulting in stenosis, occlusion, or spasm of the coronary artery, the supply of blood and oxygen to the myocardium will be reduced or even unavailable, resulting in myocardial necrosis and heart pain, chest tightness, dyspnea and other symptoms caused by myocardial necrosis are collectively referred to as coronary atherosclerotic heart disease. Coronary angiography can not only understand the degree of coronary artery damage, but also estimate the prognosis of coronary artery stenting, which provides a reliable reference for clinical treatment. Transradial coronary angiography (TCA) has the advantages of high success rate, small trauma, less complications, no bed rest, reduce hospital stay and other superiority, which accepted and used by physicians. Although the success rate of surgery is high, the postoperative complications will still affect the effect of surgery and the prognosis of patients. The main manifestations are radial artery occlusion (RAO), forearm hematoma formation, pseudoaneurysm formation, periosteal compartment syndrome, radial artery perforation, etc. Among the many ways to prevent RAO, anticoagulant therapy with common heparin is one of them, but the dosage of heparin is not clear. Therefore, we decided to use systematic evaluation to evaluate the clinical effectiveness and safety of different dose of heparin in preventing of RAO, and to provide clinical basis for the early prevention and treatment of RAO.

METHODS

Two reviewers independently searched PubMed, Embase, the Cochrance Library, Web of Science, Medline, CBM Disc, CNKI, and WANFANG Data to find the eligible research. The retrieval about the randomized controlled trials of different dose of heparin in preventing the occurrence of RAO after TCA in recent years. The retrieval time is set between January 1990 and June 2020. The retrieval language is Chinese/English. Two researchers independently searched, managed and screened the literature through the search terms. When the 2 parties have inconsistent opinions on the inclusion or not of certain literature, the literature will be referred to the third researcher for discussion and decision. The included studies are conducted bias risk assessment through bias risk assessment tool, which based on Cochrane Handbook 5.0. The extracted data uses RevMan5.3 software for statistical processing.

RESULTS

The research results of this systematic review will be published in peer-reviewed medical-related academic journals.

CONCLUSION

This study adopts the Meta-analysis method and expands the sample size, which will give high-quality evidence-based medicine evidence on the clinical effectiveness and safety of different dose of heparin in preventing the occurrence of RAO.

TRIAL REGISTRATION NUMBER

OSF, DOI 10.17605/OSF.IO/CPXJ3.

[Radial approach in the elderly]

Due to the steady increase in life expectancy, the number of patients over 80 years of age proposed for coronary angioplasty is increasing significantly. The elderly patient is a patient at high cardiovascular risk and high risk of bleeding; whose severity of prognosis depends of comorbidities. The radial approach presents particularities and technical difficulties that have to be known in this part of the population, but reduce vascular and hemorrhagic complications, as well as mortality. Because of greater safety, the radial approach is therefore the first choice for the elderly.

Comparison of right and left trans-radial catheterization for coronary angiography and intervention in patients with Acute myocardial infarction

Objective:

To compare the clinical characteristics between the right and left radial approach in treating acute myocardial infarction, helping physicians make treatment strategies correctly.

Methods:

The patients admitted at our institution and undergoing percutaneous coronary angiography and interventional procedures by left or right radial approach between November 2013 and July 2016 were retrospectively reviewed. The access time, compression time, ambulation time, the amount of contrast material used, fluoroscopy time, interventional procedural time, the number of catheters used, the percentage of procedures completed using the assigned approach and the major vascular complications were recorded and compared between the two groups.

Results:

There were no significant differences in access time, compression time, the amount of contrast material used, number of catheters used as well as the time to ambulation between the two groups (p>0.05), but the fluoroscopy time and interventional procedural time were significantly longer in right radial approach group than those in left radial approach group (p<0.05). The left radial approach group presented with a higher percentage of procedures completed using the assigned approach than that of right radial approach group (p<0.05).

Conclusion:

The left radial approach has more advantages than right radial approach in treating acute myocardial infarction.

Radiation Exposure of the Operator During Coronary Interventions (from the RADIO Study)

We sought to compare operator radiation exposure during procedures using right femoral access (RFA), right radial access (RRA), and left radial access (LRA) during coronary angiography (CA) and percutaneous coronary intervention (PCI). Because of an increased incidence of long-term malignancy in interventional cardiologists, operator radiation exposure is of rising concern. This prospective study included all consecutive patients who underwent elective or emergency CA ± PCI from September 2014 to March 2015. The primary end point was operator radiation exposure, quantified as the ratio of operator cumulative dose (CD) and patient radiation reported as dose-area product (DAP) (CD/DAP). Secondary end points included CD, DAP, and fluoroscopy time (FT). Overall 830 procedures (457 CA [55%] and 373 PCI [45%]) were performed, 455 (55%) through RFA, 272 (33%) through RRA, and 103 (12%) through LRA. The CD/DAP was lower in RFA (0.09 μSv/Gycm(2) [0.02 to 0.20]) compared with RRA (0.47 μSv/Gycm(2) [0.25 to 0.75], p <0.001). The LRA showed lower CD/DAP compared with RRA (p <0.001). CD was significantly lower in RFA (3 μSv [1 to 7]) compared with RRA (12 μSv [6 to 29], p <0.001). The LRA showed lower CD compared with RRA (p <0.001). There were no significant differences in DAP among the 3 access sites. FT was similar for the 3 groups (RFA 7 ± 7, RRA 5 ± 5, LRA 6 ± 5 minutes, RFA vs RRA: p = 1, RFA vs LRA: p = 0.16, RRA vs LRA: p = 0.52). In conclusion, the use of RFA during CA ± PCI is associated with significantly lower operator radiation exposure compared with RRA. LRA is associated with significantly lower operator radiation exposure compared with RRA.

Comparison of Safety and Effectiveness Between Right Versus Left Radial Arterial Access in Primary Percutaneous Coronary Intervention for Acute ST Segment Elevation Myocardial Infarction

BACKGROUND

Transradial approach (TRA) is now considered the standard of care in many centres for elective and primary percutaneous intervention (PCI). The use of the radial approach in ST segment elevation myocardial infarction (STEMI) patients has been associated with a significant reduction in major adverse cardiac events. However, it is still unclear if the side of radial access (right vs. left) has impact on safety and effectiveness of TRA in primary PCI. So this study was conducted to compare the safety, feasibility, and outcomes of right radial access (RRA) vs. left radial access (LRA) in the setting of primary PCI.

METHODS

We retrospectively analysed the data of 400 consecutive patients presenting to our institution with STEMI for whom primary PCIs were performed via RRA and LRA.

RESULTS

Mean age of the whole studied population was 57±12.8 years, with male predominance (77.2%). There were 202 cases in the RRA group and 198 in the LRA group, with no significant difference in demographics and clinical characteristics for patients included in both groups. There was no significant difference in procedure success rate (97.5% for RRA vs. 98.4% for LRA; P=0.77). In addition, no significant difference between both approaches was observed in the contrast volume, number of catheters, fluoroscopy time (FT), needle-to-balloon time, post-procedure vascular complications, in hospital reinfarction, stroke/transient ischaemic attack (TIA) or death.

CONCLUSION

Right radial access and LRA are equally safe and effective in the setting of primary PCI. Both approaches have a high success rate and comparable needle-to-balloon time.

Comparison of transradial coronary procedures via right radial versus left radial artery approach: A meta-analysis

INTRODUCTION

Coronary angiography and angioplasty via transradial approach is shown to be associated with significant reduction in access site complications. Due to a lack of sufficient data, the use of the right or left radial approach is still operator-dependent. We performed a meta-analysis of prospective randomized studies to compare right versus left radial artery approach for coronary procedures.

METHODS

We found 12 randomized studies meeting the predetermined inclusion criteria. A total of 6,450 patients were included in the meta-analysis of which 3,217 patients underwent coronary procedures via right radial approach and 3,233 patients via left radial approach. The primary endpoint was the comparison of fluoroscopy time, procedure time, contrast use and cross-over rates between two radial approaches.

RESULTS

Pooled analysis of the included studies showed a similar rate of cross-over events (4.2% for right radial approach vs. 4.1% for left radial approach, odds ratio (OR)=1.08, P = 0.68), and similar total procedure times (18.8 ± 10.3 min vs. 18.1 ± 10.0 min, standard difference (SD) of the mean = 0.09, P = 0.162) between the two radial approaches. However, the right radial approach was found to be associated with minimally longer fluoroscopy times (5.8 ± 4.4 min vs. 5.3 ± 4.2 min, SD of the mean = 0.157, P < 0.001) and greater contrast use (84 ± 35 mL vs. 82 ± 34 mL, SD of the mean = 0.082, P = 0.003). Access site complications and the incidence of stroke were similar between two radial approaches.

CONCLUSION

Our meta-analysis suggests a small but statistically significant difference in terms of contrast use and fluoroscopy time in favor of coronary procedures performed via left radial approach in comparison to right radial approach without any significant difference in access site or other procedural complications between the two radial approaches. © 2016 Wiley Periodicals, Inc.

Comparative efficacy and safety of the left versus right radial approach for percutaneous coronary procedures: a meta-analysis including 6870 patients

The radial approach is widely used in the treatment of patients with coronary artery disease. We conducted a meta-analysis of published results on the efficacy and safety of the left and right radial approaches in patients undergoing percutaneous coronary procedures. A systematic search of reference databases was conducted, and data from 14 randomized controlled trials involving 6870 participants were analyzed. The left radial approach was associated with significant reductions in fluoroscopy time [standardized mean difference (SMD)=-0.14, 95% confidence interval (CI)=-0.19 to -0.09; P<0.00001] and contrast volume (SMD=-0.07, 95%CI=-0.12 to -0.02; P=0.009). There were no significant differences in rate of procedural failure of the left and the right radial approaches [risk ratios (RR)=0.98; 95%CI=0.77-1.25; P=0.88] or procedural time (SMD=-0.05, 95%CI=0.17-0.06; P=0.38). Tortuosity of the subclavian artery (RR=0.27, 95%CI=0.14-0.50; P<0.0001) was reported more frequently with the right radial approach. A greater number of catheters were used with the left than with the right radial approach (SMD=0.25, 95%CI=0.04-0.46; P=0.02). We conclude that the left radial approach is as safe as the right radial approach, and that the left radial approach should be recommended for use in percutaneous coronary procedures, especially in percutaneous coronary angiograms.

Transradial versus Transfemoral Approach in Coronary Angiography: A Matched Pair Analysis of Cath Lab Equipment Costs

Introduction

There is an ongoing struggle to understand the potential economic benefits that radial access may offer. Cost savings are thought to primarily occur after the procedure. The aim of our study was to analyze cath lab expenses resulting from transradial (TRA) and transfemoral approaches (TFA).

Methods

A total of n = 1890 matched pairs of patients were analyzed. A traditional Judkins catheter strategy was pursued for coronary angiography. Three large databases were merged to collect and compare procedural data as material, medication costs and fluoroscopy time.

Results

Compared to TFA diagnostic catheterization from TRA was associated with significantly lower procedural costs (€181.0 versus €167.5; p<0.001). Extra costs in TFA were primarily produced by frequent use of vascular closure devices (VCDs) in 86% of patients. However, the potential saving amount related to VCD use was only partly realized due to the higher number of extra catheters (0.53 ± 0.9 versus 0.23 ± 0.6; p<0.001) and hydrophilic guidewires (0.088 ± 0.3 versus 0.014 ± 0.1; p<0.001) used in TRA. Weak correlations were observed between the total number of cases and fluoroscopy time (r = −0.13; p<0.001) as well as material costs (r = 0.31; p<0.001).

Conclusions

Significant cost savings can be realized by TRA at the procedural level even when adhering to a conventional Judkins catheter strategy. Hydrophilic guidewires and additional catheters are the main cost drivers in TRA. In contrast to fluoroscopy time material costs steadily increase during the early stage of the TRA learning curve.

A prospective randomized comparison of left and right radial approach for percutaneous coronary angiography in Asian populations

Background

The efficacy of coronary angiography may be different in the right radial approach (RRA) and the left radial approach (LRA) due to more common vascular tortuosity in the RRA. The aim of the study was to determine whether LRA is a valid alternative for coronary angiography compared with RRA in Asian populations.

Methods

This is a single-center, prospective, randomized controlled study. A total of 1,400 consecutive patients undergoing diagnostic coronary angiography were recruited and randomized to the RRA (number [n]=700) or LRA (n=700) group. The primary end point was total procedural duration. Secondary end points included fluoroscopy time, dose of radiation including cumulative air kerma and dose area product, contrast volume, and the incidence of vascular complications.

Results

Coronary procedural success was achieved in 682 of 700 (97.4%) patients in the RRA and 680 of 700 (97.1%) in the LRA. The total procedural time (RRA 14.1±6.3 minutes versus LRA 13.2±6.0 minutes; P=0.006) and fluoroscopy time (RRA 3.8±3.3 minutes versus LRA 3.4±2.8 minutes; P=0.046) were significantly shorter via LRA in comparison to RRA. The percentage of hydrophilic wire use was also lower in the LRA group (14% [RRA] versus 10% [LRA]; P=0.016). The dose of radiation and contrast volume were not different between the two approaches. No cases of major bleeding and vascular complications requiring surgical intervention were reported, other than with one patient who experienced a symptomatic stroke and died in the RRA group compared with none in the LRA group.

Conclusion

The LRA seems to be a feasible alternative for coronary angiography in Asian patients due to shorter procedural duration and fluoroscopy time, as well as less hydrophilic wire use in comparison to RRA.

Comparison of procedural and long-term outcomes between transradial and transfemoral approach in one-stage intervention for triple vessel coronary artery disease

OBJECTIVES

The aim of the present study was to evaluate the safety, feasibility, procedural, and long-term outcomes by the transradial (TR) approach as compared to transfemoral (TF) approach in patients with triple vessel coronary artery disease undergoing one-stage percutaneous coronary intervention.

BACKGROUND

The feasibility, safety, and efficacy between the TR and TF approach for coronary interventional treatment have been compared in some complex situations including AMI and unprotected left main disease. However, in terms of triple vessel disease (3VD) intervention, there has been no comparison regarding procedural and long-term outcomes between the TR and TF approach.

METHODS

A total of 4,974 consecutive patients (TR n = 3,856, TF n = 1,118), who were diagnosed with 3VD without LM disease and underwent one-stage percutaneous revascularization, were enrolled in the study. Procedural results and clinical outcomes were obtained through database and follow-up. We used the propensity score matching method and obtained 930 pairs of patients with comparable baseline data in order to compare the procedural and long-term outcome between TR and TF groups. In the study cohort, risk reduction of all the clinical outcomes were evaluated with Cox's proportional-hazards models. Cumulative incidences concerning safety and efficacy of the cohort were estimated by the Kaplan-Meier method and a comparison was made utilizing the log-rank test.

RESULTS

After propensity score matching, the baseline clinical and angiographic characteristics were similar between the 2 groups. Regarding procedural results, no significant differences were observed between the 2 groups, with the exception of a decreased hospital stay (TR 7.49 ± 4.46 days vs. TF 8.63 ± 6.23 days, P < 0.0001) and fewer bleedings (TR 1.0% vs. TF 2.9, P = 0.003) in the TRI group. After an average 21-month follow-up, the all-cause mortality (TR 1.7% vs. TF 4.2%, P = 0.0014; HR 0.44, 0.25-0.79) was significantly lower with TRI patients. Other clinical outcomes were comparable between the 2 groups.

CONCLUSIONS

As compared to TFI, TRI for 3VD intervention is feasible, safe, and associated with similar procedural success, shorter hospitalization, reduced bleeding, lower incidence of death, and comparable long-term efficacy.

Left radial access for percutaneous coronary procedures: from neglected to performer? A meta-analysis of 14 studies including 7,603 procedures

BACKGROUND

Radial artery is currently the preferred access route for percutaneous coronary procedures. The major reason for its widespread use is the higher safety as compared to femoral artery access. Initially most centers have preferred the right radial artery. However, an advantage has been hypothesized for the left radial access especially for the more favorable vascular anatomy. For this reason, the aim of the present meta-analysis was to compare procedural performance of left and right radial artery access for percutaneous coronary interventions.

METHODS

We performed a meta-analysis of all available studies comparing right radial access and left radial access for coronary procedures. Corrected standardized mean difference (Hedges' g) and odds ratios (OR) were used to estimate the mean effect respectively for continuous variables and frequencies.

RESULTS

The present analysis includes 14 studies with 7603 procedures. A statistically significant difference in the amount of contrast medium utilized for the procedure (0.12 [0.03-0.21], p=0.007), in fluoroscopy time (0.16 [0.06-0.25], p=0.001) and in total procedural time (0.22 [0.11; 0.33], p<0.001) was observed in favor of the left radial access. At the same time, no significant difference in the rate of procedural failure was observed between the right and the left radial access routes (OR=1.01 [0.70-1.47], p=0.942).

CONCLUSIONS

Left radial access is associated to a modest yet significant reduction in fluoroscopy time, procedural time and in the amount of contrast medium administered, while failure rate was similar between right and left radial approaches.

Left radial access is preferable to right radial access for the diagnostic or interventional coronary procedures: a meta-analysis involving 22 randomized clinical trials and 10287 patients

OBJECTIVE

The transradial approach has been used extensively for both diagnostic and interventional coronary procedures; however, there is no universal consensus hitherto on the optimal choice of radial access from either the left or the right artery. We therefore sought to meta-analyze available randomized clinical trials to compare the left with the right radial access for the diagnostic or interventional coronary procedures.

METHODS AND RESULTS

Four electronic databases including the PubMed, EMBASE, Wanfang, and CNKI were searched up to April 2013. In total, there were 22 qualified randomized trials involving 5317 and 4970 patients assigned to the left and the right radial accesses, respectively. Data were extracted independently by two investigators. Analyses of the full data set indicated significant reductions in fluoroscopy time (seconds) (weighted mean difference; 95% confidence interval; P: -36.18; -53.28 to -18.53; <0.0005) and contrast use (mL) (-2.88; -5.41 to -0.34; 0.026) in patients with the left radial access compared to those with the right radial access, and there was strong evidence of heterogeneity but low probability of publication bias. The failure rate of radial access from the left was relatively lower than that from the right (odds ratio: 0.83; 95% confidence interval: 0.68-1.01; P = 0.064). Further in meta-regression analyses, body mass index was found to be a potential source of heterogeneity for both fluoroscopy time (regression coefficient: 35.85; P = 0.025) and catheter number (regression coefficient: 0.35; P = 0.018).

CONCLUSIONS

Our findings demonstrate that left radial access is preferable to right radial access in terms of fluoroscopy time and contrast use for the diagnostic or interventional coronary procedures. The import of this study lies in its great shock to the concept of convenient radial access from the right artery.

Comparison of the feasibility and effectiveness of transradial coronary angiography via right versus left radial artery approaches (from the PREVAIL Study)

It remains undefined if transradial coronary angiography from a right or left radial arterial approach differs in real-world practice. To address this issue, we performed a subanalysis of the PREVAIL study. The PREVAIL study was a prospective, multicenter, observational survey of unselected consecutive patients undergoing invasive cardiovascular procedures over a 1-month observation period, specifically aimed at assessing the outcomes of radial approach in the contemporary real world. The choice of arterial approach was left to the discretion of the operator. Prespecified end points of this subanalysis were procedural characteristics. Of 1,052 patients consecutively enrolled, 509 patients underwent transradial catheterization, 304 with a right radial and 205 with a left radial approach. Procedural success rates were similar between the 2 groups. Compared to the left radial group, the right radial group had longer procedure duration (46 ± 29 vs 33 ± 24 minutes, p <0.0001) and fluoroscopy time (765 ± 787 vs 533 ± 502, p <0.0001). At multivariate analysis, including a parsimonious propensity score for the choice of left radial approach, duration of procedure (beta coefficient 11.38, p <0.001) and total dose-area product (beta coefficient 11.38, p <0.001) were independently associated with the choice of the left radial artery approach. The operator's proficiency in right/left radial approach did not influence study results. In conclusion, right and left radial approaches are feasible and effective to perform percutaneous procedures. In the contemporary real world, however, the left radial route is associated with shorter procedures and lower radiologic exposure than the right radial approach, independently of an operator's proficiency.

Right versus left transradial approach for coronary catheterization in octogenarian patients

OBJECTIVES

The aim of the study was to evaluate if the left radial approach (LRA) confers any additional advantage compared to the right radial approach (RRA) in octogenarian patients who undergo a coronary diagnostic procedure.

BACKGROUND

Octogenarians, an increasing segment of patients in our society, present a higher risk of access-site complications related to invasive coronary catheterization. Transradial approach has been shown to be an effective alternative to reduce vascular complications. Although some studies have suggested that elderly people might benefit from a LRA, the advantages of using the left or right radial access remain not clear.

METHODS

One hundred octogenarian patients undergoing a transradial coronary angiogram with normal Allen test and without previous history of coronary artery by-pass grafting were randomized to either LRA (n = 50) or RRA (n = 50). The primary end-points of the study were procedural and fluoroscopy times.

RESULTS

Mean age was 82.6 years (80-88) and 59% were males. Procedural and fluoroscopy times were similar among study groups. Crossover was required in two patients (4%) with RRA and five patients (10%) with LRA (P = 0.24). Subclavian tortuosity was more frequent in the right side (32% vs. 6% in the left side; P = 0.002) but this difference did not translate into longer procedural or fluoroscopy times or higher cross-over, procedural difficulty or wire manipulation.

CONCLUSIONS

In our series of octogenarian patients, the LRA was a valid alternative for diagnostic procedures but its usage was not associated with a significant reduction in procedural and fluoroscopy times compared to the RRA.

Right versus left radial artery access for coronary procedures: an international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients

BACKGROUND

Radial artery access is a mainstay in the diagnosis and treatment of coronary artery disease. However, there is uncertainty on the comparison of right versus left radial access for coronary procedures. We thus undertook a systematic review and meta-analysis comparing right versus left radial access for coronary diagnostic and interventional procedures.

METHODS

Pertinent studies were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus, together with international conference proceedings. Randomized trials comparing right versus left radial (or ulnar) access for coronary diagnostic or interventional procedures were included. Risk ratios (RR) and weighted mean differences (WMD) were computed to generate point estimates (95% confidence intervals).

RESULTS

A total of 5 trials (3210 patients) were included. No overall significant differences were found comparing right versus left radial access in terms of procedural time (WMD=0.99 [-0.53; 2.51]min, p=0.20), contrast use (WMD=1.71 [-1.32; 4.74]mL, p=0.27), fluoroscopy time (WMD=-35.79 [-3.54; 75.12]s, p=0.07) or any major complication (RR=2.00 [0.75; 5.31], p=0.49). However, right radial access was fraught with a significantly higher risk of failure leading to cross-over to femoral access (RR=1.65 [1.18; 2.30], p=0.003) in comparison to left radial access.

CONCLUSIONS

Right and left radial accesses appear largely similar in their overall procedural and clinical performance during transradial diagnostic or interventional procedures. Nonetheless, left radial access can be recommended especially during the learning curve phase to reduce femoral cross-overs.

Effectiveness and safety of transradial artery access for cardiac catheterization

The transradial approach for coronary angiography and angioplasty, while not new, is gaining momentum again as a viable alternative to the transfemoral approach. While technically it may have some challenges, there are significant benefits including reduced patient discomfort, improved time to ambulation, reduction in costs, and reduction in potentially life-threatening complications. The technique is not difficult to learn, and the equipment is similar to that used in more traditional approaches. To expand awareness of this method, this article discusses the history of the technique, reviews the data comparing it to the more widely used transfemoral technique, and discusses some of the experience at Baylor University Medical Center at Dallas, where this approach has been gaining popularity.