Transradial versus Transfemoral Access for Hepatic Chemoembolization: Intrapatient Prospective Single-Center Study

Application and Validation of a transRADial Access Score (RAD-Access) in Patient Selection for Safe Radial Access in Liver Cancer Intra-Arterial Procedures

Objectives: To develop and internally validate a pre-treatment score for the safe selection of the best candidates for the transradial approach when performing liver cancer intra-arterial procedures. Methods: One hundred and twenty-two patients undergoing hepatic endovascular treatments via radial access between January and December 2022 were retrospectively selected to develop a prediction model. Pre-procedural imaging data were analyzed, and variables were selected to develop the RAD-access score. Intra-procedural data were analyzed to assess effective procedural complexity (ePC). The relationship between ePC and pre-procedural variables was statistically tested, and cutoff points were defined. Results: A final score (RAD-access) was created and prospectively validated on 139 patients enrolled between June and September 2023. Aortic arch diameter and angulation, left subclavian artery angulation, suprarenal abdominal aorta diameter, celiac trunk take-off angle, and radial artery diameter were the significant variables used to build the score. In the validation cohort, based on the pre-treatment RAD-access score, 69 patients underwent a transradial approach, with a significantly lower ePC rate obtained (78.2% easy, 20.3% intermediate, 1.5% complex). No major adverse events occurred. Conclusions: Pre-treatment RAD-access score provides a good prediction for the procedural complexity of the transradial approach in patients undergoing liver cancer intra-arterial treatments, identifying the best candidates for an easy and safe transradial procedure.

All You Need to Know About TACE: A Comprehensive Review of Indications, Techniques, Efficacy, Limits, and Technical Advancement

Transcatheter arterial chemoembolization (TACE) is a proven and widely accepted treatment option for hepatocellular carcinoma and it is recommended as first-line non-curative therapy for BCLC B/intermediate HCC (preserved liver function, multifocal, no cancer-related symptoms) in patients without vascular involvement. Different types of TACE are available nowadays, including TAE, c-TACE, DEB-TACE, and DSM-TACE, but at present there is insufficient evidence to recommend one TACE technique over another and the choice is left to the operator. This review then aims to provide a comprehensive overview of the current literature on indications, types of procedures, safety, and efficacy of different TACE treatments.

Left radial vs right femoral: comparison between arterial accesses in c-TACE procedures in terms of operator radiations exposure and patient comfort

PURPOSE

This multicenter prospective study aims to compare transradial access versus transfemoral access in conventional transarterial chemoembolization (c-TACE) procedures, focusing on operators radiations exposure, patients comfort, technical success and vascular access complications.

MATERIALS AND METHODS

Patients were affected by hepatocellularcarcinoma (HCC) in intermediate stage or previous stages unfit for ablation and/or surgery; they were randomized into two groups according to arterial access site (Group F: right femoral access in standard position; Group R: radial access with left arm abduced 90°). Overall fluoroscopy time was recorded. Eight thermoluminescence dosimeters were positioned immediately before each procedure to monitor radiation doses. Technical success was intended as complete HCC nodules lipiodolization at final plain cone-beam CT.

RESULTS

Group F included 23 patients, while group R 19. Mean fluoroscopy time was lower in group F but difference was not statistically significant (p-value > 0.05). In terms of operators radiations exposure, no significant differences were found (p-value > 0.05). Technical success was obtained in 81.5% in group F and 84.8% in group R, without significant differences (p-value > 0.05). Patients discomfort was significantly (p-value < 0.05) higher in group F. Concerning minor complications, no statistical differences were appreciated (p-value > 0.05); no major complications occurred.

CONCLUSIONS

In this study, no statistical differences were observed in terms of operators radiations exposure, fluoroscopy time and technical success during c-TACE performed with left radial access compared to right femoral access; patients comfort was significantly better with radial access. These data should lead interventional radiologists to favor radial access in c-TACE interventions.

Procedural Feasibility and Peri-procedural Outcomes of Peripheral Endovascular Therapy via Transradial versus Transfemoral Access: A Systematic Review and Meta-Analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the safety and feasibility of transradial access for peripheral vascular interventions.

DATA SOURCES

MEDLINE and Embase.

REVIEW METHODS

MEDLINE and Embase databases were searched to June 2023 to identify studies investigating the outcomes of lower extremity, carotid, and visceral artery vascular interventions via transradial vs. transfemoral access. The primary outcome was procedural failure rate. Secondary outcomes were total access site complications, minor and major bleeding, stroke, access vessel occlusion, procedure time, fluoroscopy time, and contrast volume.

RESULTS

Eight randomised controlled trials and 29 observational studies yielded a total of 70 882 patients treated via transradial (n = 2 616) vs. transfemoral access (n = 68 338). The overall failure rate was 2.3 ± 0.7%, and the transradial approach was associated with a statistically significantly higher procedural failure rate than the transfemoral approach (3.9 ± 0.7% vs. 1.0 ± 0.3%; odds ratio [OR] 3.07, 95% confidence interval [CI] 1.84 - 5.12; I2 = 32%; p < .001). Subgroup analysis showed the highest failure rate in lower extremity interventions with 12.4 ± 4.9% for transradial vs. 4.0 ± 1.2% for transfemoral access. Conversely, procedural complications were statistically significantly fewer with transradial access for total access site complications (OR 0.64, 95% CI 0.45 - 0.91; I2 = 36%; p = .010). Minor bleeding was statistically significantly less with the transradial approach (OR 0.52, 95% CI 0.31 - 0.86; I2 = 30%; p = .010), whereas major bleeding and stroke rates were similar. Transradial access had more access vessel occlusion than transfemoral access (1.9% ± 0.5% vs. < 0.1% ± 0.0%; p = .004), although most remained asymptomatic. Procedure time, fluoroscopy time, and contrast volume were all comparable. GRADE certainty was low to moderate in most outcomes.

CONCLUSION

The transradial approach was associated with a higher procedural failure rate. Total access site complications and minor bleeding were lower with the transradial approach, albeit with more frequent access vessel occlusion. Transradial access may be a feasible and safe approach; however, appropriate patient selection is imperative.

Transradial versus transfemoral access for treatment of HCC: a systematic review and meta analysis

AIM

Hepatic angiography procedures are essential in the treatment of hepatocellular carcinoma (HCC), with traditional transfemoral arterial (TFA) access being the traditional standard. Recently, transradial arterial (TRA) access has gained popularity, offering potential benefits. This study aims to conduct a systematic review and meta-analysis to compare TRA and TFA access in hepatic angiography oncologic procedures for HCC. The study investigates fluoroscopy time, radiation dose, patient preferences, and complications associated with each access method.

MATERIAL AND METHODS

A systematic review was performed using PRISMA guidelines, with 11 studies encompassing 2535 HCC procedures included. Statistical analysis was conducted using RevMan 5.4 software. Continuous outcomes were calculated as mean differences, and binary outcomes were measured as odds ratios. Patient preferences, procedural complications, and access site success rates were assessed.

RESULTS

The meta-analysis revealed that there were no significant differences in fluoroscopy time, radiation dose, or contrast dose between TRA and TFA. Access failure rates were similar for both methods. However, the odds of adverse events, excluding access failure, were significantly higher for TFA, while the overall rate of complications was comparable. Patients strongly preferred TRA over TFA due to reduced hospital stay and post-procedure discomfort.

CONCLUSION

This meta-analysis supports the use of TRA for hepatic angiography oncologic procedures for HCC with patient preferences in favor of TRA. Additional randomized clinical trials are encouraged to further evaluate the feasibility and benefits of both access sites.

French Interventional Radiology Centers' Uptake of Transradial Approach and Outpatient Hepatocellular Carcinoma Intra-Arterial Treatments

PURPOSE

This study aims to investigate the uptake of transradial approach (TRA) and outpatient setting for transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) in the treatment of hepatocellular carcinoma (HCC) among French interventional radiology centers.

MATERIALS AND METHODS

This cross-sectional study was based on a 34-question survey assessing center activity, radial access, and outpatient care. The survey was developed by a working group, tested by two external experts, and distributed to active members of two French radiological societies via a web-based self-reporting questionnaire in March 2022. The survey remained open for eight weeks, with two reminder emails sent to non-responders. Only one answer per center was considered.

RESULTS

Of the 44 responding centers, 39% (17/44) performed TRA for TACE and/or TARE, with post-procedure patient comfort as main motivation. Among the 27 centers not performing TRA, 33% (9/27) reported a lack of technical experience, but all 27 intended to adopt TRA within two years. Only six centers performed TACE or TARE in an outpatient setting. Reasons limiting its implementation included TACE for HCC not being a suitable intervention (61%, 27/44) and organizational barriers (41%, 18/44). Among centers not performing outpatient TACE or TARE, 34% (13/38) said "No," 34% (13/38) said "Maybe," and 32% (12/38) said "Yes" when asked about adopting it within two years.

CONCLUSION

French interventional radiologists have low TRA uptake for HCC treatment, but TRA adoption potential exists. Respondents were uncertain about performing TACE or TARE in an outpatient setting within a 2-year horizon.

Comparison Between Radial and Femoral Artery Access for Transarterial Chemoembolisation in Patients With Hepatocellular Carcinoma

PURPOSE

The purpose of this study was to compare the technical success rate, the selectivity of transarterial chemoembolisation (TACE), the complication rate, the radiation dose given to the patients and the hospitalization stay between TACE performed using femoral artery approach (FAA) and TACE performed using radial artery approach (RAA) in patients with hepatocellular carcinoma (HCC).

METHODS

Between June 2020 and April 2022, 49 patients with HCC who underwent 116 TACEs (75 using FAA and 41 using RAA) were included. Differences in technical success rate, selectivity of micro-catheterization, radiation dose given to the patients, fluoroscopy time, hospitalization stay duration, and complication rate were compared between FAA and RAA using Fisher exact or Student t tests.

RESULTS

No differences in technical success rates were found between RAA (93%; 39/41 TACEs) and FAA (100%; 75/75 TACEs) (P = .12). There were no differences between the two groups in terms of selectivity of catheterization, radiation dose, fluoroscopy time and hospitalization stay duration. Five patients had Grade 2 complications (hematoma) after FAA vs. one patient with one Grade 1 complication (radial artery occlusion) after RAA (5/75 [7%] vs. 1/41 [2%], respectively; P = .42). No major arterial access site complications occurred with FAA or RAA.

CONCLUSIONS

This study confirms that RAA is a safe approach that does not compromise the technical efficacy and the selectivity of TACE compared to FAA in patients with HCC.

The RAVI registry: prospective, multicenter study of radial access in embolization procedures - 30 days follow up

BACKGROUND

There is a lack of registry studies about transradial access (TRA) outcomes. This prospective registry evaluated the TRA and procedure outcomes of visceral embolizations performed via TRA with 30-day follow-up.

MATERIAL & METHODS

Prospective, multicenter registry included uterine fibroids (UFE), prostate artery (PAE), liver tumors (LT), and other hypervascular tumors (OHT) embolization performed in six US hospitals. Between February 2020 and January 2022, 99 patients underwent one radial artery visceral intervention (RAVI); 70 had UFE (70.7%), 16 PAE (16.2%), 7 LT (7.1%), and 6 OHT (6.1%). The mean age was 50.1 (±11.1) years, and 74/99 (74.7%) were females. The primary safety endpoints included hand ischemia, stroke, and death. Procedural success was defined as completing the intended procedure via radial artery (RA) access. Technical success was defined as the successful delivery of HydroPearl™ microspheres and complete embolization of the target vessel.

RESULTS

Procedural and technical successes were 100% and 97%, respectively. There was no stroke, hand ischemia, radial-to-femoral conversion, access-related serious adverse events, or clinically evident radial artery occlusion at 30 days. There were two deaths: one respiratory failure and one progression of liver disease. Minor RA-related adverse event included arterial spasm, hematoma, and post-procedure discomfort.

CONCLUSION

This prospective, multicenter, open-label registry confirmed the high safety profile and effectiveness of radial access in UFE, PAE, LT, and OHT embolization procedures without stroke, hand ischemia, or access-related serious adverse events at 30-day follow-up.

Chinese expert consensus on transradial access in percutaneous peripheral interventions

Transradial access (TRA) is a safe and comfortable approach and the preferred access for percutaneous coronary intervention. However, TRA is not widely used for peripheral interventions. Currently, there is a lack of data on patient selection, appropriate medical devices, complication prevention, and TRA adoption. Therefore, the Chinese Society of Interventional Oncology of the China Anti-Cancer Association organized nationwide experts to establish a Working Group of China Expert Consensus on TRA in percutaneous peripheral interventions in 2022, and jointly formulated this consensus to better promote the application of TRA in peripheral interventions to guide clinicians on patient selection, technical recommendations, and physician training. This consensus mainly focuses on the current situation, advantages and limitations of TRA in peripheral interventions, anatomical characteristics of the radial artery, patient selection, technical aspects, prevention and management of complications, radiation dose, and learning curve. A consensus was reached through a literature evaluation and by referring to the opinions of the expert group.

Predicting difficult transradial approach guiding into left internal carotid artery on unruptured intracranial aneurysms

BACKGROUND

The transradial approach (TRA) is less invasive than the transfemoral approach (TFA), but the higher conversion rate represents a drawback. Among target vessels, the left internal carotid artery (ICA) is particularly difficult to deliver the guiding catheter to through TRA. The purpose of this study was thus to explore anatomical and clinical features objectively predictive of the difficulty of delivering a guiding catheter into the left ICA via TRA.

METHODS

Among 78 consecutive patients who underwent coil embolization for unruptured intracranial aneurysms through TRA in a single institution between March 1, 2021, and August 31, 2022, all 29 patients (37%) who underwent delivery of the guiding catheter into the left ICA were retrospectively analyzed. Clinical and anatomical features were analyzed to assess correlations with difficulty in guiding the catheter into the left ICA.

RESULTS

Of the 29 aneurysms requiring guidance of a catheter into the left ICA, 9 aneurysms (31%) required conversion from TRA to TFA. More acute innominate-left common carotid artery (CCA) angle (P < 0.001) and older age (P = 0.015) were associated with a higher conversion rate to TFA. Receiver operating characteristic analysis revealed that optimal cutoff values for the innominate-left CCA angle and age to distinguish between nonconversion and conversion to TFA were 16° (area under the curve [AUC], 0.93; 95% confidence interval [CI], 0.83-1.00) and 74 years (AUC, 0.79; 95% CI, 0.61-0.96), respectively.

CONCLUSION

A more acute innominate-left CCA angle and older age appear associated with difficulty delivering the guiding catheter into the left ICA for neurointervention through TRA.

Distal radial artery access is a safe and feasible technique in the anatomical snuffbox for visceral intervention

Regarding the site of arterial access during the intervention, transracial intervention can reduce the risk of bleeding and vessel-related complications as well as improve patient comfort. Importantly, the distal radial artery (DRA) approach may reduce the incidence of radial artery occlusion and digital ischemia, but the feasibility and safety of DRA in performing subdiaphragmatic vascular interventions remain unclear. From January 2018 to December 2019, 106 patients were admitted to our department for visceral angiography and intervention by left distal radial artery accessing in an anatomical snuffbox. In total, 152 times of vascular interventions were performed during this period. Patients demographics, procedure details, technical success, and access site-related complications were recorded and evaluated. The mean age was 58.9 (range 22-86) years. Males accounted for 80.2%. Thirty-five patients (33%) had 2 or more procedures via the DRA approach. Technical success was achieved for 96.1% of procedures (146 cases) and 3.9% of cases failed to perform the intended procedure via the DRA approach (6 cases). The 4-Fr sheath was used in 86.8% of cases, and the 5 Fr sheath was used in the rest of the 13.2% of procedures. The rate of asymptomatic radial artery occlusion was 5.7% (6 of 106 patients). No patient suffered from distal limb ischemia after a long-time follow-up. Eight patients suffered postoperative local pain, transient numbness, or local bruised in the anatomical snuffbox without major complications. Patients with postoperative complications recovered quickly by using nonsteroidal anti-inflammatory drugs or without further treatment. Left distal radial artery access is safe and feasible as a new technique for visceral angiography and intervention.

A Single-Centre Retrospective Analysis of Radial Versus Femoral Prostate Artery Embolization

Purpose: To determine whether route of access, transradial or transfemoral, leads to any discernible differences in patient radiation or contrast medium exposure as well as procedure time in elective prostate artery embolization (PAE).Methods: This retrospective study included sixty patients in total: n = 30 in the radial PAE group, and n = 30 in the femoral PAE group. All procedures were performed in a single angiography suite between May 2018 and January 2021, using a standard kit for each type of vascular access, the same microcatheter/wire combination and embolic agent to super-selectively target and embolize one or both prostate arteries. Outcome measures included dose area product (DAP, µGym²), air kerma (mGy), fluoroscopy time (mins), procedure time (mins) and volume of contrast medium used (mL). Adverse events were also recorded.Results: The radial and femoral groups were matched for age (73.2 ± 7.5 vs 71.3 ± 10.14, P = .41) and body mass index (27.53 ± 5.08 vs 26.41 ± 3.93, P = .38).No significant difference in dose area product, air kerma, fluoroscopy time, procedure time or volume of contrast medium used was found between radial and femoral PAE. No adverse events occurred in either group.Conclusion: Radial PAE is safe and comparable to femoral PAE with respect to patient radiation exposure, contrast medium usage, and procedure duration. Radial access is a useful skill to add to the armament of the interventional radiologist in elective PAE.

Transradial versus transfemoral approach for TACE: a retrospective study

OBJECTIVE

Transcatheter arterial chemoembolization (TACE) has been widely applied in the treatment of hepatocellular carcinoma (HCC). Our study aimed to investigate the feasibility and efficacy of transradial access as an alternative to transfemoral access for TACE.

METHODS

Patients undergoing TACE were divided into the radial artery (RA) route group or the femoral artery (FA) route group according to the operation approach, namely, transradial or transfemoral access. We retrospectively analysed the clinical characteristics, technical outcomes, clinical efficacy and incidence of adverse events to compare the two technologies for intervention for HCC.

RESULTS

Transradial access was found to achieve superior technical outcomes and clinical efficacy, as the patients in the RA group had a lower rate of hepatic arterial spasm, a higher partial response rate and a lower progression rate than the patients in the FA group according to the mRECIST evaluations. In contrast, the liver function indices and VAS (visual analogue scale) pain scores were consistent across the two groups. Moreover, patients in the RA group had a shorter length of stay than those in the FA group, despite similar hospitalization expenses. The total adverse events were significantly reduced by transradial access for TACE (72.5% vs. 84.1%, P = 0.027).

CONCLUSION

Our study suggested that transradial access is an effective and feasible alternative to transfemoral access for TACE. Large-scale prospective randomized controlled studies are expected.

Transradial versus transfemoral access without closure device for transarterial chemoembolization in patients with hepatocellular carcinoma: a randomized trial

OBJECTIVES

To compare patient satisfaction, procedural variables, and safety with transradial access (TRA) and transfemoral access (TFA) in patients undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From February 2019 to August 2021, 130 patients undergoing TACE for HCC were randomly allocated to the TRA (n = 65) or TFA (n = 65) group. Vascular closure devices were not used after TFA-TACE. All patients completed the post-catheterization questionnaire and 8-item Short-Form Health Survey 1 day after TACE.

RESULTS

Technical success rate, crossover rate, contrast agent dose, fluoroscopy time, procedure time, air kerma, dose-area product, length of hospital stay, and total cost were similar between the two groups (all p > 0.05). The incidence and severity of adverse events were also similar between the two groups (all p > 0.05). However, overall discomfort, difficulty going to the bathroom, difficulty feeding or self-caring, difficulty walking, general health, physical function, role physical function, social function, mental health, and role emotional function were better in the TRA group than in the TFA group (all p < 0.001). Consequently, more patients preferred the current access for their next procedure in the TRA group than in the TFA group (90.8% vs. 24.6%; p < 0.001).

CONCLUSION

In patients undergoing TACE for HCC, using TRA instead of TFA can improve patient satisfaction without compromising procedural variables and safety.

KEY POINTS

• Transradial access (TRA) enabled early ambulation after transarterial chemoembolization (TACE), resulting in significant increase in activities of daily living and health-related quality of life (HRQoL) compared to transfemoral access (TFA) when vascular closure devices were not used. • Procedural variables (contrast agent dose, fluoroscopy time, procedure time, air kerma, dose-area product, length of hospital stay, and total cost) were not significantly different between patients who received TRA-TACE and TFA-TACE. • The incidence and severity of adverse events were similar between patients who received TRA-TACE and TFA-TACE.

SIRT in 2025

Selective internal radiation therapy represents an endovascular treatment option for patients with primary liver malignancies, in different clinical stages. Potential applications of this treatment are in early-stage hepatocellular carcinoma, as a curative option, or in combination with systemic treatments in intermediate and advanced-stages. This review, based on existing literature and ongoing trials, will focus on the future of this treatment in patients with hepatocellular carcinoma, in combination with systemic treatments, or with the use of new devices and technological developments; it will also describe new potential future indications and structural and organizational perspectives.

Safety, feasibility, and comfort of hepatic angiography and transarterial intervention with radial access for hepatocellular carcinoma

Background and Aim

Hepatic angiography procedures such as transarterial chemoembolization (TACE) are essential procedures for managing patients with hepatocellular carcinoma (HCC), and are usually performed with femoral access. However, femoral access causes patient discomfort and may be associated with the risk of hematoma or pseudoaneurysm at puncture site. We evaluated the safety, feasibility, and patient comfort of hepatic angiography procedures performed with radial access.

Methods

In this single‐institution, retrospective, time‐frame study, a total of 206 patients who underwent hepatic angiography procedures with radial access, which were first used on October 2017 at our institution, were compared with 240 patients who underwent the same procedures with femoral access before this period. Several measures were assessed, including procedure time and safety. In addition, a questionnaire was used to compare the access types regarding procedure‐associated discomfort.

Results

Hepatic angiography procedures performed with radial access, including TACE, were completed in all patients without complications. The procedure time was comparable between radial access and femoral access. Most patients preferred radial to femoral access. Patients taking anticoagulants were able to complete the procedures without discontinuing these drugs.

Conclusions

Hepatic angiography procedures with radial access resulted in less discomfort than those with femoral access, and the two approaches showed similar feasibility and safety. Radial access can be introduced as a routine technique for hepatic angiography procedures.

Outpatient Transradial Emborrhoid Technique: A Pilot Study

PURPOSE

To determine whether outpatient transradial emborrhoid technique can be performed safely and effectively in the treatment of symptomatic hemorrhoids.

MATERIALS AND METHODS

The transradial emborrhoid technique was used to treat 12 patients with symptomatic hemorrhoids in an outpatient setting during a 4-month period. After percutaneous catheterization of the left radial artery, a 5-Fr sheath was introduced to catheterize the inferior mesenteric artery and a microcatheter was advanced into the branches of the superior rectal artery for embolization with 0.018-inch detachable coils (Interlock and IDC-interlocking detachable coils). After embolization, the sheath was withdrawn and puncture site hemostasis was achieved using a wrist band. All patients were evaluated 6 h after the procedure to determine whether they meet the discharge criteria and were discharged the following day. The results of the emborrhoid treatment were assessed at the 4-week follow-up.

RESULTS

The emborrhoid technique was successful in all patients. There was no major complication associated with the procedure. All patients met the discharge criteria 6 h after the procedure. Reduction of local edema and of hemorrhoidal congestion was observed in all patients. At the follow-up visit, the mean Rorvik score (HDSS + SHS-HD) decreased from 31.50 (7.50) to 13.11 (8.33) (p < .001).

CONCLUSIONS

Transradial rectal artery embolization is a safe and effective treatment option for patients with chronic symptoms of hemorrhoid disease.

Transradial Access: A Comprehensive Review

Transradial access (TRA) via the left radial artery is an alternative to traditional transfemoral access for catheter-based procedures that is becoming increasingly more relevant in all types of arterial vascular interventions. First investigated in the realm of cardiology, TRA has been proven to provide many benefits (such as lower complication rates, lower cost, and improved patient comfort during and after the procedure) when compared with traditional femoral access while maintaining efficacy. This article provides an in-depth summary of the technical aspects of radial access while incorporating more recent data to explain patient preference for TRA, and the ways that TRA can improve peri-procedure workflow and compensation. It also describes potential complications, such as radial artery spasm, difficult anatomic variants and radial artery occlusion, and then gives techniques for mitigating and treating these complications. The article explains why TRA has become an important option for vascular and interventional radiology physicians, and why it is likely that this will continue to grow in relevance.

Radial vs. Femoral Artery Access for Procedural Success in Diagnostic Cerebral Angiography : A Randomized Clinical Trial

BACKGROUND AND PURPOSE

Radial artery access has become the standard of care in percutaneous coronary procedures due to demonstrated patient safety and comfort benefits; however, uptake of radial access for diagnostic cerebral angiography has been limited by practitioner concerns over the ability to achieve procedural success. We aimed to provide randomized clinical trial evidence for the non-inferiority of radial access to achieve procedural success.

MATERIAL AND METHODS

Monocentric open label randomized controlled trial with a non-inferiority design and blinded primary outcome assessment. Adult patients referred in-hours for diagnostic cerebral angiography were eligible. Participants underwent permuted block randomization to radial or femoral artery access with an intention-to-treat analysis. The primary outcome was procedural success, defined as selective cannulation and/or diagnostic angiography of predetermined supra-aortic vessels of interest. The non-inferiority limit was 10.0%. Secondary outcomes included postprocedural complications, fluoroscopy and procedural times, radiation dose, contrast volume and rates of vertebral artery cannulation.

RESULTS

A total of 80 participants were enrolled (female 42, male 38, mean age 47.0 years, radial access group n = 43, femoral n = 37). One patient in the radial group was excluded after enrollment due to insufficient sonographic radial artery internal diameter. Procedural success was achieved in 41 of 42 participants in the radial group (97.6%) and 36 of 37 in the femoral group (97.3%). The difference between groups was -0.3% (one-sided 95% confidence interval, CI 6.7%) and the null hypothesis was rejected.

CONCLUSION

Radial artery access is non-inferior to femoral artery access for procedural success in cerebral angiography. A large multicenter trial is recommended as the next step.

Effects and safety of body positioning on back pain after transcatheter arterial chemoembolization in people with hepatocellular carcinoma: A randomized controlled study

BACKGROUND

People with hepatocellular carcinoma who undergo transcatheter arterial chemoembolization usually experience back pain due to lie supine for at least 4 hours to avoid bleeding and hematoma. Body positioning is an effective and safe method for decreasing back pain in people with transfemoral cardiac catheterization; however, its effects and safety among patients with high bleeding tendency are unknown.

OBJECTIVE

To investigate whether body positioning could decrease back pain without increasing the chance of bleeding after transcatheter arterial chemoembolization.

DESIGN

A single-blind randomized controlled trial (ClinicalTrials.gov No.: NCT03784469).

METHODS

A total of 78 people with liver cancer who had undergone chemoembolization through the femoral artery were enrolled. Each person was randomly assigned to either the control or intervention group (each consisted of 39 participants). The control group received the usual care, remaining flat and lying in a supine position, whereas the intervention group had their positions changed in the second and fourth hour after chemoembolization. Participants' pain level was rated by using numerical rating scale -11 (score from 0 to 10), bleeding was measured by using volume of blood (cc.) in gauze and hematoma size in diameter (cm), and satisfaction was self-rated from 1 to 5. Repeated-measure analysis of variance (ANOVA) was used to compare the difference in pain levels over time within each group and independent t test to compare the mean difference of pain between groups at 5 endpoints, both methods with Bonferroni adjustment. Independent t test, chi-squared test, and Fisher's exact test compared postembolization discomfort, puncture sites bleeding, satisfaction between groups.

RESULTS

Significant changes of pain levels over time in both intervention [F(2.93, 111.20)=7.64, p<.001] and control groups [F(2.66, 101.17)=20.55, p<.001]. The intervention group had a significantly lower mean pain score in the second hour (t = -2.838, p = .006) and fourth hour (t = -4.739, p < .001) when patients turning to the side than did the control group lying supine. Furthermore, patients in the intervention group had significantly higher satisfaction than did those in the control group (t = -2.422, p = .018). No hematoma and significant difference of post-procedural bleeding between groups.

CONCLUSION

Changing patients' body positions in bed after transcatheter arterial chemoembolization is a safe and effective method of decreasing back pain, and increasing patients' satisfaction, without increasing the complications of bleeding and hematoma. Clinicians should change the positions of people with hepatocellular carcinoma 2 hours after they receive transcatheter arterial chemoembolization.

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.

Transarterial chemoembolisation of colorectal liver metastases with irinotecan-loaded beads: What every interventional radiologist should know

The last decade has seen important developments in the treatment of metastatic colorectal cancer (mCRC). In this scenario, interventional locoregional treatments could play an expanding role offering safe and effective integrated options in the continuum-of-care offering curative as well as palliative approaches. Based on ESMO guidelines, the toolbox of ablative treatments also includes intra-arterial palliative options, like chemoembolization, that can be offered as an alternative option in patients failing the available chemotherapeutic regimens. However, to date, there is still a limited use of chemoembolization in clinical practice. Based on this background, a comprehensive review of the methodologic and technical considerations as well as clinical indications and future perspectives seems to be useful with the aim to demonstrate the field's value of the procedure, highlight their advantages, and ensure an increased role in treatment management of patients with colorectal liver metastases.

Delayed severe median nerve palsy due to undiagnosed brachial pseudoaneurysm

Post-catheterization pseudoaneurysms are a well-known complication of many endovascular procedures at the site of arterial puncture. However, long-term neurological complications due to undiagnosed compression are rare. A 60-year-old man presented to our unit for round, non-pulsatile, painless swelling in the inner side of his upper arm. Clinical examination showed finger paralysis, associated with amyotrophy of the forearm. Large brachial pseudoaneurysm with median nerve compression was diagnosed. The patient underwent autologous vein bypass, with poor 6-month neurological recovery. Early diagnosis of pseudoaneurysms is paramount because, when associated with nerve compression, the longer the diagnostic delay, the poorer the neurological prognosis.

Operator learning curve for transradial liver cancer embolization: implications for the initiation of a transradial access program

PURPOSE

We aimed to analyze transradial access (TRA) learning curve on patients undergoing hepatic chemoembolization, investigating the relationship between procedural volumes and various benchmarks of procedural success.

METHODS

We enrolled 60 consecutive patients who received two unilobar hepatic chemoembolizations within a 4-week interval performed by a single interventional radiologist, highly-trained in conventional transfemoral access (TFA) procedures, but without any previous practical experience in TRA procedures and with a preliminary 2-day theoretical training only. Consecutive patients were prospectively enrolled and analyzed in 3 groups: A (cases 1 to 20), B (cases 21 to 40), and C (cases 41 to 60). All patients underwent one hepatic chemoembolization using TRA and the other one using TFA in random order. All TFA procedures performed by the same operator in the same series of patients were considered as the control group. Primary endpoint was to analyze the relationship between TRA procedure operator experience and benchmarks of procedural success, to define the optimal procedural learning curve.

RESULTS

Technical success was obtained in all patients, with a crossover rate (radial to femoral access) of 0%. An association between incremental TRA operator experience (in terms of performed procedures) and decrease of preparation, puncture, fluoroscopy, and total examination times was observed. Similarly, inverse associations between incremental TRA operator experience and contrast medium (CM) volumes (P < 0.001) and radiation dose (RD) values (in terms of RAK - Reference Air Kerma) (P < 0.001) were also observed. Compared with TFA, CM volumes and RD values were significantly higher only in group A (cases 1-20). Procedure success remained high in all TRA groups and no significant association between TRA incremental experience and postprocedural outcomes was found. Higher postprocedural complaints at the access route and more limitations in performing basic activities were recorded after TFA vs. TRA (P < 0.001).

CONCLUSION

TRA catheterizations can be safely performed in patients treated for liver cancer embolization after a relatively short training in controlled conditions and with a better performance in comparison with TFA. Operator proficiency improves with greater TRA experience, with a threshold needed to overcome the learning curve represented by about 20 procedures.

Nonfemoral Arterial Hemostasis Following Percutaneous Intervention Using a Focused Compression Device

Purpose

Upper extremity and tibiopedal arterial access are increasingly used during endovascular therapies. Balloon compression hemostasis devices in these anatomic locations have been described, but most utilize a compression surface extending well beyond the puncture site. We report single-center experience with an arterial puncture-focused compression device following upper extremity and tibiopedal access.

Patients and Methods

A series of 249 focused compression hemostasis devices (VasoStat, Forge Medical, Bethlehem, Pennsylvania, USA) were used in 209 patients following lower extremity (n = 63) and upper extremity (n = 186; radial: 90%) arterial access procedures using 4–7 French sheaths. Demographic, operative, and follow-up data were collected. Logistic regression was used to evaluate potential association between patient/operative variables and time to hemostasis.

Results

Primary hemostasis was achieved in 97.2% (242/249) following sheath removal; in 7 cases (2.8%) puncture site oozing occurred after initial device removal and required reapplication. Secondary hemostasis was 100% (249/249). Seven complications (2.8%) were recorded: 5 minor hematomas (2%) and 2 transient access artery occlusions (0.8%). Mean time to hemostasis enabling device removal was 55 ± 28 min. Elevated body mass index (BMI) was not associated with increased time to hemostasis (p = 0.31). Accessed artery, sheath size, and heparin dose were also not associated with time to hemostasis (p = 0.64; p = 0.74; p = 0.75, respectively).

Conclusions

The focused compression hemostasis device enabled rapid hemostasis with a low complication rate. Time to hemostasis was independent of BMI, access site, sheath size, or heparin dose.

Transradial and Transfemoral Uterine Fibroid Embolization Comparative Study: Technical and Clinical Outcomes

PURPOSE

To compare clinical and technical outcomes of transradial (TRA) uterine artery embolization (UAE) with those of the transfemoral (TFA) approach.

MATERIALS AND METHODS

Consecutive patients who underwent UAE with TRA and TFA in an academic hospital between May 2014 and June 2018 were included in this study. The ability to perform the procedure as planned, complication rates, and reduction in uterine volume, fibroid enhancement, and symptomatic improvement were compared using descriptive statistics, Student t-test, and chi-square test.

RESULTS

There were 91 patients in the TFA group and 91 patients in the TRA group, with 1 crossover to TFA due to vasospasm (1 of 91; 1%). The tallest patient in the TRA UAE group was 178 cm and 4 patients taller than 178 cm in the TFA UAE group. Larger particles (900-1,200 μm) were more often used in the TFA group than in the TRA group (P < .001). There were similar low rates of minor access site complications. In the TFA group (6 of 91, 7%), 5 patients had groin hematomas, and 2 patients had groin pain compared to the TRA group (5 of 91, 5%): in which 4 patients had transient focal occlusion of the radial artery and 1 patient had focal pain, all of which resolved with conservative management. There were similar rates of uterine volume reduction in 40% ± 17% in the TFA versus 36% ± 16% in the TRA group (P = .22) and no residual enhancement in 49 of 58 [84%] in the TFA group versus 66 of 77 [86%] in the TRA group (P = .84). There were similar reductions in modifying symptoms (60 of 64 [94%] in the TRA group; and 37 of 40 [93%] in the TFA group; P = NS) was noted at follow-up.

CONCLUSIONS

Transradial UAE in women up to 178 cm tall and transfemoral UAE have similar technical and clinical outcomes, with low rates of access site complications.

Transradial access chemoembolization for hepatocellular carcinoma in comparation with transfemoral access

Background

This study aimed to compare the safety and efficacy of transradial access (TRA) with transfemoral access (TFA) chemoembolization in treatment of hepatocellular carcinoma (HCC).

Methods

HCC patients who were late for curative treatment on initial diagnosis or HCC patients who had undergone one or several rounds of transarterial chemoembolization (TACE) were enrolled. The clinical and angiographic characteristics, the procedure related details, and the follow-up data from patients who underwent TRA and TFA were analyzed and compared.

Results

In total, 112 patients undergoing 160 TRA-TACE and 107 patients undergoing 163 TFA-TACE were included. The technical success rate of TRA was 95.0% and that of TFA was 98.8% (P=0.102). In the TFA-TACE group, 5.5% of cases suffered access site-related complications, including 6 with minor bleeding and 3 with severe bleeding or pseudoaneurysm. In the TRA-TACE group, 1.9% of cases underwent crossover to femoral access for selective cannulation failure. The rate of radial artery occlusion (RAO) was 2.7% (3 of 112 patients), and none of the RAO patients suffered paresthesia, pain at the site of occlusion, hand function loss or distal ischemia. Comparing patients with/without access site-related complications in the TFA-TACE group, there was a statistical difference in patient age and in the percentage of patient with a PT time >15 s (72.6% vs. 57.1%, P<0.001; 44.4% vs. 11.7%, P=0.022).

Conclusions

TRA is a safe and effective method for patients undergoing TACE. Compared with TFA, TRA may reduce the occurrence of access site-related bleeding and vascular complications. TRA-TACE may especially benefit older patients or those with a longer prothrombin time (PT).

Procedural success with radial access for carotid artery stenting: systematic review and meta-analysis

BACKGROUND

Femoral access is the traditional approach for endovascular carotid artery stenting. Radial access is increasingly used as an alternative approach due to its known anatomical advantages in patients with unfavorable aortic arch morphology via the femoral approach and its excellent access site safety profile. Our objective was to analyze procedural success using radial access for carotid artery stenting as reported in the literature.

METHODS

Three online databases were systematically searched following PRISMA guidelines for studies (n ≥20) using radial artery access for carotid artery stenting (1999-2018). Random-effects meta-analysis was used to pool the procedural success (successful stent placement with no requirement for crossover to femoral access), mortality, and complication rates associated with radial access.

RESULTS

Seven eligible studies reported procedural success outcomes with a pooled meta-analysis rate of 90.8% (657/723; 95% CI 86.7% to 94.2%; I²=53.1%). Asymptomatic radial artery occlusion occurred in 5.9% (95% CI 4.1% to 8.0%; I²=0%) and forearm hematoma in 1.4% (95% CI 0.4% to 2.9%; I²=0%). Risk of minor stroke/transient ischemic attack was 1.9% (95% CI 0.6% to 3.8%; I²=42.3%) and major stroke was 1.0% (95% CI 0.4% to 1.8%; I²=0%). There were three deaths across the seven studies (0.6%; 95% CI 0.2% to 1.3%; I²=0%). The meta-analysis was limited by statistically significant heterogeneity for the primary outcome of procedural success.

CONCLUSION

Radial access for carotid artery stenting has a high procedural success rate with low rates of mortality, access site complications, and cerebrovascular complications. The potential benefits of this approach in patients with unfavorable aortic arch access should be explored in a prospective randomized trial.

Distal Radial Artery Access for Noncoronary Endovascular Treatment Is a Safe and Feasible Technique

PURPOSE

To evaluate safety and feasibility of distal radial artery (DRA) access for noncoronary interventional radiology procedures.

MATERIALS AND METHODS

All interventional radiology procedures by means of DRA puncture from July 2017 to August 2018 were retrospectively reviewed. Eighty-two punctures in 56 patients were included, mostly in male patients (84% vs 16%). Mean age was 67.8 years (range, 33.3-87.3 years); mean height was 172 cm (range, 142-190 cm); and mean weight was 83 kg (range, 43-120 kg). Procedural characteristics, technical success, and complication rates were gathered from the medical records and follow-up ultrasound when available. Prerequisites for DRA access were adequate radioulnar collateral circulation, sufficient radial artery diameter, and informed consent in patients initially intended for conventional transradial access.

RESULTS

Procedures included transarterial chemoembolization (n = 34), yittrium-90 pretreatment angiography (n = 21), yittrium-90 administration (transarterial radioembolization; n = 20), and embolization of visceral organs (n = 7). Both 4-Fr (n = 35) and 5-Fr (n = 46) sheaths were used. Technical success of DRA access was 97.6%, with conversion to transfemoral access in 2 cases (2.4%). No major complications were reported as a result of DRA access.

CONCLUSION

DRA access is a feasible and safe technique for abdominal interventional radiology embolization procedures. No radial artery occlusion or other major complications were observed in patients who underwent follow-up ultrasound.

Patient Experience and Preference in Transradial versus Transfemoral Access during Transarterial Radioembolization: A Randomized Single-Center Trial

PURPOSE

To determine patient preference for transradial access (TRA) or transfemoral access (TFA) after experiencing both.

MATERIALS AND METHODS

A randomized controlled crossover trial was conducted at a single institution. Thirty patients with hepatocellular carcinoma undergoing mapping and transarterial radioembolization (TARE) were enrolled to experience 1 TRA and 1 TFA procedure each, with randomization of which access approach was experienced first. Surveys assessing pain and quality of life (QOL) were administered after each procedure. Access site preference was collected after completion of both procedures.

RESULTS

Twenty-two subjects (73.3%) preferred TRA, 4 (13.3%) preferred TFA, and 4 (13.3%) had no preference; 14 (46.7%) reported bruising after TRA, and 17 (53.3%) reported bruising after TFA. TRA was associated with significantly lower pain scores overall during the procedure, at the access site during the procedure, and in the recovery room compared with TFA (2.0 vs 2.9, P = .0046; 2.0 vs 3.0, P = .0004; 2.1 vs 2.9, P = .0357). Pain score after discharge was not significantly different (1.4 vs 1.5, P = .4235). QOL scores were not significantly different between TRA and TFA. No significant differences were found for fluoroscopy time, air kerma, dose-area product, or procedure time between TRA and TFA for either mapping (P = .1442, P = .5871, P = .6667, P = .6131) or radioembolization (P = .8574, P = .2344, P = .1119, P =.8474). For radioembolizations, TRA had significantly shorter recovery times compared with TFA (108 min vs 153 min, P = .0193).

CONCLUSIONS

Patients exhibited a strong preference for TRA. With TRA, patients experienced less periprocedural pain and shorter recovery times without significant differences in radiation exposure or procedure length.

Palmar Warming for Radial Artery Vasodilation to Facilitate Transradial Access: A Randomized Controlled Trial

PURPOSE

To investigate the efficacy of palmar warming to induce radial artery vasodilation.

MATERIALS AND METHODS

After informed consent was obtained, healthy volunteers (n = 45) were randomized 2:1 in palmar warming and control groups, respectively, for this prospective, randomized, single-blind clinical trial (NCT03620383). The palmar warming group was given a warm, commercially available, air-activated heat pack (Kobayashi Consumer Products LLC, Dalton, Georgia) to hold in the left hand for palmar warming. The control group was given a deactivated version of the same heat pack. Left radial artery cross-sectional area (CSA) measurements were obtained at baseline and in 5-minute intervals up to 20 minutes in both groups. Differences in the trends of changes in the radial artery CSA between palmar warming and control groups were examined with the age- and sex-adjusted repeated measure analysis of variance. Propensity score-matched treatment effect analysis was conducted to quantify the effect of heat on radial artery CSA.

RESULTS

The palmar warming group and the control group were significantly different in terms of subject sex (males/females: 7/23 and 10/5, respectively; P = .005) and baseline CSA (2.5±0.2 mm² vs 3.2±0.3 mm², respectively; P = .014). Radial artery CSA showed an increasing trend over time in the palmar warming group compared to a stable trend over time in the control group (P < .0001). Propensity score-matched comparison showed a 43.9% increase (95% confidence interval: 34.1%-53.8%) in CSA in the palmar warming group compared to the control group (P < .0001).

CONCLUSIONS

The palmar warming technique is effective at dilating the radial artery and may be a beneficial technique to facilitate transradial access.

Transradial vs transfemoral access in patients with hepatic malignancy and undergoing hepatic interventions: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to compare transradial access (TRA) approach with transfemoral access (TFA) approach in patients undergoing hepatic interventions.

METHODS

We conducted a comprehensive search of the PubMed, Embase, and the Cochrane Library database to identify relevant available articles. Patients' preference, success rate, intra- and postoperative outcomes were analyzed. The risk difference (RD), relative risk (RR), and weighted mean difference (WMD) values were reported with 95% confidence intervals (CIs). We used RevMan 5.3 to perform the pooled analyses.

RESULTS

Nine cohort studies were included. A total of 1096 procedures were performed in 877 patients. Of those, 545 procedures (49.7%) were performed by TRA, and 551 procedures (50.3%) were performed by TFA. Patients were significantly prefer the TRA (86.5%) to the TFA (13.5%) (RD = 0.88, P < .00001). The procedure time in TRA groups was longer (WMD = 3.36, 95% CI 1.24-5.47, P = .002). But there were no significant difference in terms of success rate, fluoroscopy time, radiation dosage, contrast volume, and postoperative vascular complications.

CONCLUSION

For patients suffer from primary or secondary hepatic malignancy and undergoing hepatic interventions, the present meta-analysis demonstrated that patients prefer the TRA approach to the TFA approach. But the procedure time is longer in TRA group.

Patient Radiation Exposure in Transradial versus Transfemoral Yttrium-90 Radioembolization: A Retrospective Propensity Score-Matched Analysis

PURPOSE

To compare differences in patient radiation exposure (PRE) during transarterial yttrium-90 (⁹⁰Y) radioembolization (TARE) between transradial access (TRA) and transfemoral access (TFA).

MATERIALS AND METHODS

A total of 810 consecutive first-time TARE procedures in patients from 2013 to 2017 were retrospectively reviewed. A propensity score-matching (PSM) analysis matched TRA and TFA groups on the basis of patient age, sex, weight, height, cancer type, ⁹⁰Y microsphere type, and number of previous procedures from the same and opposite approaches. Matched groups were then compared by PRE measures fluoroscopy time (FT), dose-area product (DAP), and cumulative air kerma (AK). Effect size for each PRE measure was calculated.

RESULTS

Before PSM, TRA and TFA groups differed significantly in mean age, weight, and number of previous procedures from the same and opposite approach (all P < .05). After PSM, each group consisted of 302 procedures (overall, n = 604) and no longer differed in any procedure performed before surgery measure. TRA did not differ from the matched TFA group regarding median FT (9.50 vs 9.40 minutes, P = .095), median DAP (67,066 vs 67,219 mGy·cm²; P = .19), or median AK (323.63 vs 248.46 mGy; P = .16). Effect sizes were 0.068, 0.054, and 0.110 for FT, DAP, and AK, respectively.

CONCLUSIONS

No statistical differences were found for PRE measures between the matched TRA and TFA approach groups. Furthermore, practical effect sizes were considered to be small for AK and less than small for FT and DAP, and therefore, any differences in PRE between the radial and femoral approaches for TARE are minor and unlikely to be noticeable in everyday clinical practice.