Radialiszugang zur Koronarintervention

Radial artery access for coronary interventions was initially introduced as a useful vascular access site for reducing vascular complications (e.g. bleeding) and to enhance patient comfort, reduce hospital staff workload and costs. Although earlier data indicated comparable procedural success rates but longer procedural and fluoroscopy times with radial as compared to femoral access, recent data from prospective multicenter studies and large meta-analyses even revealed significantly better immediate and long-term outcomes in contemporary, real world clinical settings of percutaneous cardiovascular procedures including acute coronary syndrome (ACS) and acute myocardial infarction (AMI). From this perspective, the better cardiac outcome after transradial percutaneous coronary interventions may be explained by the lower necessity of cessation of anticoagulation and antiplatelet therapy due to significantly less bleeding complications after radial access. Bleeding complications occur only very rarely with this technique but procedural success of transradial access is occasionally limited by anatomical circumstances or radial spasms and postinterventional occlusions, which seems to be strongly related to the mandatory adjuvant pharmacological therapy (e.g. 3,000?U heparin, verapamil and nitroglycerine) and the anatomical variations, which can possibly be reduced by the use of smaller catheters. The most likely reason for sometimes longer fluoroscopy times (even for very experienced interventionalists) could be explained by the mandatory use of fluoroscopy while retrogradely passing the great thoracic vessels but this does not necessarily mean higher radiation exposure to the interventionists due to the potentially better possibilities of effective protection measures against backscatter radiation.     

Use of the Left Radial Artery as Vascular Access for Coronary Angiography and as a Bypass Conduit: A Clinical Dilemma?

PurposeInternational coronary revascularization guidelines recommend both, transradial vascular access for coronary angiography/intervention and use of the radial artery as a conduit for coronary artery bypass grafting (CABG). These recommendations may pose a clinical dilemma, as transradial access exposes these arteries to vascular trauma which makes them potentially unsuitable as future grafts. In this study, we investigated the awareness and views of cardiologists on these guideline recommendations.MethodsWe performed semi-structured interviews with 50 cardiologists from 19 centers, who regularly perform coronary angiographies or interventions, and outlined clinical scenarios to evaluate their preference of vascular access. In addition, we assessed whether preference was related to sub-specialization.ResultsThe interviewed cardiologists had 16 ± 9.3 years of professional experience. There were 23 (46%) cardiologists from 7 centers without percutaneous coronary intervention facilities, and 27 (56%) cardiologists from 12 interventional centers. All 50 (100%) cardiologists indicated familiarity with the guidelines, yet 28 (56%) said not to be familiar with the aforementioned dilemma, and 9 (18%) stated there was no dilemma at all. Responses did not differ significantly between interventional (n = 28) and non-interventional (n = 22) cardiologists; however, if the right radial artery was unavailable (e.g., occluded), interventional cardiologists more often said to prefer access via the left radial artery (18/28 (64%) vs. 5/22 (23%), p = 0.001).ConclusionMore than half of the interviewed cardiologists indicated that they had not realized that left transradial access preceding CABG may preclude later use of this artery as a conduit. Notably, in case of unavailability of the right radial artery, interventional cardiologists preferred left transradial access more often than non-interventional cardiologists.     

Transradial percutaneous coronary interventions: indications, success rates & clinical outcome

Before ten years, radial artery was discovered as a useful vascular access site for percutaneous coronary procedures. It has the advantage of reduced access site complications but is associated with specific technical challenges in comparison with the transfemoral approach. Although earlier data from a meta-analysis indicated higher procedure failure rates with radial--as compared to femoral access (7.2 vs. 2.4%), more recent data from prospective multicenter studies and large meta analysis showed significantly better outcomes with radial access versus femoral access in contemporary, real-world clinical settings of percutaneous cardiovascular procedures (e.g. PREVAIL-, PRESTO-ACS-studies). This includes also challenging coronary procedures in acute coronary syndromes (NSTEMI and STEMI) where the radial access was associated with fewer bleeding complications leading to better long-term outcomes. Transradial procedure failures can sometimes be due to variation in radial artery anatomy (e.g. vessel diameter, anomalous branching patterns, tortuosity) or risk factors for radial spasms (e.g. smoking, anxiety, vessel diameter, age, gender). Postprocedural radial occlusions (0.6-1.2%) seems strongly be related to these anatomical variances, which possibly may be reduced by the use of smaller catheter, however 5 French lumen diameter guiding catheter include limitations regarding treating options in complex coronary lesion. In conclusion, the transradial access for coronary angiography and interventions is not only to enhance patients comfort, but shows significant better long-term results due to less bleeding complications as compared to the femoral access.     

Recanalization and reuse of early occluded radial artery within 6 days after previous transradial diagnostic procedure

Late radial artery (RA) thrombosis occurs in 3–9% after transradial interventions. RA occlusion has made this approach unsuitable for repeat interventions and obviated the need for alternative vascular access for catheterization, e.g., left RA (with certain risk of bilateral RA occlusion) or femoral artery with its shortcomings and, sometimes, life‐threatening complications requiring surgical treatment (large groin hematoma, arterio‐venous fistula or false aneurysm, retroperitoneal hemorrhage). We demonstrate the possibility of retrograde RA recanalization, dilatation, and restoration of the RA patency within 6 days after first transradial coronary diagnostic catheterization complicated with acute RA occlusion. Thus we were able to recanalize previously occluded RA and reuse it for repeat transradial coronary interventions. © 2011 Wiley‐Liss, Inc.     

Anatomical considerations in transradial intervention

The radial artery is currently regarded as a useful vascular access site for coronary procedures. The transradial approach for percutaneous coronary procedures has the advantage of reduced access site complications but is associated with specific technical challenges in comparison with the transfemoral approach. Transradial procedure failures can sometimes be due to failure to puncture the artery, radial artery spasm and anatomic variations of radial-brachial-axillary-subclavian artery axis or arch of aorta. Therefore, adequate anatomical information of the radial artery should be helpful in performing the transradial coronary procedure. In short proper patient selection and pre-procedure preparation; gentle and patient approach; liberal use of dye injection (check shoots) when in doubt; asking patient to breathe deeply when needed and thoughtful problem solving approach are the key factors to achieve high transradial success rate.     

Minimally invasive transradial intervention using sheathless standard guiding catheters

Objectives : We evaluated a sheathless transradial technique for interventions using standard five and six French nonhydrophilic guiding catheters. Background : Miniaturization of transradial interventions may serve to improve patient comfort and reduce the risk of access‐site complications. Guiding catheters carry an outer diameter approximately 2 Fr sizes smaller than their corresponding introducer sheaths. Methods : We identified consecutive patients who underwent transradial intervention between August 2010 and December 2010 using 5 or 6 Fr guides with a sheathless technique. Results : A total of 11 patients were identified (mean age 70.7 ± 10.9 years; 73% male). Single coronary intervention was performed in 10 patients and renal artery intervention in one. Right radial access and 6 Fr guide catheters were used in the majority (each 73%). Five techniques were used to create an inner dilator as the taper. Four of these inner tapers (standard diagnostic catheters, hydrophilic diagnostic catheters, long sheath dilators and guide extensions) enabled successful sheathless guide insertion in all 10 patients attempted. One technique (a partially inflated angioplasty balloon protruding from the guide) attempted in one patient was unsuccessful. All interventional procedures were successful, there were no radial artery access‐site complications and in no case was cross‐over to femoral artery access‐site required. Conclusion : Sheathless transradial intervention using standard 5 and 6 Fr guiding catheters is a safe and effective method for treatment of coronary and peripheral vascular lesions. © 2011 Wiley Periodicals, Inc.     

Radial Artery Access as an Emerging Factor for Decreasing Mortality in Cardiovascular Interventions

Transradial access for coronary interventions provides increased patient comfort, fewer access site complications, and reduced hospital stay and costs. However, the potential benefits favoring transradial access may be even more than these apparent advantages. Major bleeding after coronary interventions is an important factor contributing to mortality rates and can be dramatically reduced with the selection of the radial artery as the access site. Recent evidence suggests that the decrease in bleeding complications with transradial access may translate into a short- and long-term decrease in mortality in patients undergoing elective or urgent coronary interventions. In the era of complex coronary interventions with use of multiple antiplatelet and antithrombotic treatment regimens, the simple choice of transradial access for increasing patient comfort and decreasing bleeding complications and mortality is promising. (J Interven Cardiol 2010;23:95–99)     

Acute Hand Ischemia and Digital Amputation After Transradial Coronary Intervention in a Patient With CREST Syndrome

The radial artery approach for coronary angiography and intervention is rapidly replacing the femoral artery approach, largely because it reduces bleeding and vascular access site complications. However, complications associated with transradial access warrant attention, notably radial artery occlusion. This report focuses on a case of radial artery occlusion after percutaneous coronary intervention in a 46-year-old woman with CREST (calcinosis, Raynaud phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia) syndrome, which ultimately led to acute hand ischemia necessitating amputation of her middle and index fingers.     

Radial Artery Access Complications: Prevention,Diagnosis and Management

The transradial approach for cardiac catheterization, coronary angiography, and percutaneous intervention is associated with a lower risk of access site-related complications compared to the transfemoral approach. However, with increasing utilization of transradial access for not only coronary procedures but also peripheral vascular procedures, healthcare personnel are more likely to encounter radial access site complications, which can be associated with morbidity and mortality. There is significant heterogeneity in the reporting of incidence, manifestations, and management of radial access site complications, at least partly due to vague presentation and under-diagnosis. Therefore, physicians performing procedures via transradial access should be aware of possible complications and remain vigilant to prevent their occurrence. Intraprocedural complications of transradial access procedures, which include spasm, catheter kinking, and arterial dissection or perforation, may lead to patient discomfort, increased procedure time, and a higher rate of access site cross over. Post-procedural complications such as radial artery occlusion, hematoma, pseudoaneurysm, arteriovenous fistula, or nerve injury could lead to patient discomfort and limb dysfunction. When radial access site complications occur, comprehensive evaluation and prompt treatment is necessary to reduce long-term consequences. In this report, we review the incidence, clinical factors, and management strategies for radial access site complications associated with cardiac catheterization.     

The transradial approach

In the 20 years since its introduction, radial access for diagnostic and interventional coronary procedures has been well validated in countless scientific studies. Nevertheless, the use of this access route varies greatly among--and even within--countries. Fear of the unknown may make some experienced interventionalists hesitant to adopt the transradial approach in spite of its proven advantages. In our review, we describe practical aspects of the transradial access, such as the role of Allen's test in patient selection and considerations on the optimal puncture technique of the radial artery. Catheter selection, anatomic variations which may complicate access, as well as strategies to avoid and/or manage possible complications are outlined. Finally, we review the literature on the reduction of access site complications by adopting the transradial approach. Even in interventions for acute myocardial infarction, transradial access can be used safely and effectively. In addition to a reduced rate of access site complications, a reduction in overall in-hospital major adverse cardiac events has been demonstrated. The advantage regarding access site complications could be seen even when closure devices were utilized for transfemoral procedures.     

经桡动脉冠状动脉介入诊疗术后桡动脉损伤的影响因素分析

目的:探讨接受桡动脉冠状动脉介入诊疗患者术后,桡动脉损伤的情况及影响因素。方法:入选2008年5月至2009年10月,于安贞医院就诊拟行冠状动脉造影的患者966例,随机分为4F动脉鞘管组和6F动脉鞘管组。分析两组患者桡动脉并发症〔如桡动脉闭塞(RAO)、桡动脉痉挛(RAS)等〕的发生率,通过多因素Logistic回归分析RAO的危险因素。结果:4F鞘管组和6F鞘管组中,RAO(0.8%vs.2.9%,P=0.018),RAS(1.2%vs.3.5%,P=0.021),桡动脉内膜增厚率(1.0%vs.4.1%,P=0.002),前臂小血肿(0.6%vs.2.5%,P=0.020),患肢疼痛(1.2%vs.4.1%,P=0.006)等的发生率及压迫止血时间〔(4.62±0.98)vs.(6.36±0.93)h,P<0.001〕,4F组均低于6F组,差异有统计学意义。两组患者均未出现前臂大血肿、假性动脉瘤、动静脉瘘及骨筋膜室综合征。RAO经多因素回归分析显示,大尺径动脉鞘管、术后压迫止血时间过长是发生RAO的危险因素。结论:经桡动脉PCI中选择小直径动脉鞘管,避免术后长时间的压迫止血有利于降低RAO的发生率,同时减少桡动脉内膜损伤,提高患者舒适度。     

Radial artery spasm during transradial cardiac catheterization and percutaneous coronary intervention: incidence,predisposing factors,prevention, and management

Transradial cardiac catheterization and percutaneous coronary intervention are increasingly being performed worldwide in elective and emergency procedures, with many centers adopting the transradial route as their first choice of arterial access. One of the most common complications encountered during transradial procedures is radial artery spasm. This article reviews the current literature on the incidence, predisposing factors, preventive, and treatment measures for radial artery spasm.     

Comparison of Transradial and Transfemoral Approaches for Coronary Angiography and Percutaneous Intervention in Patients with Coronary Bypass Grafts

ObjectiveWe sought to compare the transradial and transfemoral approaches for coronary angiography and percutaneous intervention in patients with coronary artery bypass grafts in terms of volume of radiographic contrast administered during cardiac catheterization, fluoroscopy time, and total procedure time.BackgroundThe transradial access has been increasingly used as an alternative to transfemoral. Several studies demonstrated that such access is associated with lower rates of vascular and bleeding complications. Although coronary artery bypass graft patients comprise a significant portion of the coronary artery disease population, this subpopulation was often excluded or underrepresented in transradial access studies.MethodsSingle center, retrospective cohort study. In the study period, all patients who had previously undergone coronary artery bypass graft surgery and had received cardiac catheterization at our institution were included in the study population.ResultsA total of 2153 patients were included in the study. From these, 1937 were performed by femoral artery and 216 by transradial approach. Compared to the transfemoral approach, transradial access was associated with lower contrast use (136.3 ± 74.4 ml vs. 122.8 ± 59.1 ml, p = 0.035) and longer fluoroscopy time (13.9 ± 25.6 min vs. 15.9 ± 14.3 min, p < 0.001).ConclusionDiagnostic and interventional catheterization through the transradial approach in patients with previous coronary artery bypass graft surgery was associated with less contrast amount used and longer fluoroscopy time compared to the transfemoral approach. The transradial approach was also associated with lower crossover rates and less vascular complications.     

Severe catheter kinking and entrapment during transradial coronary angiography: Percutaneous retrieval using a sheathless guide catheter

The transradial (TR) approach for coronary angiography and intervention is increasingly used worldwide because of several advantages such as reduced bleeding and vascular complications. During TR procedures, aggressive catheter manipulation in the setting of complex and tortuous arterial anatomy can lead to catheter kinking and entrapment. Several percutaneous retrieval techniques using either homolateral radial access or femoral access have been described previously. We demonstrate, for the first time, the use of a sheathless guide catheter as a rescue technique to successfully retrieve a severely kinked and entrapped diagnostic catheter during TR access. © 2014 Wiley Periodicals, Inc.     

经鼻咽窝区桡动脉介入路径在冠脉造影及介入治疗中的经验分析

目的 探讨经鼻咽窝区桡动脉入路行冠脉造影及介入治疗的有效性与安全性。 方法 选取2020年6月～2020年12月在青岛阜外心血管病医院行冠脉造影及介入治疗的199例患者,分为对照组（经腕部近端桡动脉穿刺入路,n = 98）和研究组（经鼻咽窝区桡动脉入路,n = 101）;搜集患者的一般性住院资料、冠心病高危因素、穿刺时间、术后即刻疼痛（NRS）评分、术后3 h（NRS）评分、压迫止血时间、术后并发症等数据。 结果 对照组共成功穿刺近端桡动脉96例,成功率98 %,研究组共成功穿刺鼻咽窝桡动脉96例,成功率95 %;差异无统计学意义;与对照组比较,研究组穿刺时间较长（P<0.01）,术后3 hNRS评分较低（P<0.05）,术后压迫时间较少（P<0.01）,并发症二者差异无统计学意义。 结论 经鼻咽窝区远端桡动脉介入路径行冠脉造影及介入治疗具有可行性、安全性和有效性,且在术后止血时间及术后3 h舒适度方面要优于近端桡动脉入路。     

Characteristics and Outcomes of Patients With History of CABG Undergoing Cardiac Catheterization Via the Radial Versus Femoral Approach

ObjectivesThe aims of this study were to examine rates of radial artery access in post–coronary artery bypass grafting (CABG) patients undergoing diagnostic catherization and/or percutaneous coronary intervention (PCI), whether operators with higher procedural volumes and higher percentage radial use were more likely to perform diagnostic catherization and/or PCI via the radial approach in post-CABG patients, and clinical and procedural outcomes in post-CABG patients who undergo diagnostic catherization and/or PCI via the radial or femoral approach.BackgroundThere are limited data comparing outcomes of patients with prior CABG undergoing transradial or transfemoral diagnostic catheterization and/or PCI.MethodsUsing the National Cardiovascular Data Registry CathPCI Registry, all diagnostic catheterizations and PCIs performed in patients with prior CABG from July 1, 2009, to March 31, 2018 (n = 1,279,058, 1,173 sites) were evaluated. Temporal trends in transradial access were examined, and mortality, bleeding, vascular complications, and procedural metrics were compared between transradial and transfemoral access.ResultsThe rate of transradial access increased from 1.4% to 18.7% over the study period. Transradial access was associated with decreased mortality (adjusted odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.75 to 0.91), decreased bleeding (OR: 0.57; 95% CI: 0.51 to 0.63), decreased vascular complications (OR: 0.38; 95% CI: 0.30 to 0.47), increased PCI procedural success (OR: 1.11; 95% CI: 1.06 to 1.16; p < 0.0001), and significantly decreased contrast volume across all procedure types. Transradial access was associated with shorter fluoroscopy time for PCI-only procedures but longer fluoroscopy time for diagnostic procedures plus ad hoc PCI and diagnostic procedures only. Operators with a higher rate of transradial access in non-CABG patients were more likely to perform transradial access in patients with prior CABG.ConclusionsThe rate of transradial artery access in patients with prior CABG undergoing diagnostic catheterization and/or PCI has increased over the past decade in the United States, and it was more often performed by operators using a transradial approach in non-CABG patients. Compared with transfemoral access, transradial access was associated with improved clinical outcomes in patients with prior CABG.     

Anatomic variations of the radial artery in patients undergoing transradial coronary intervention.

Anatomic variations of the radial artery and their effect on the use of the radial artery as a route for transradial coronary intervention (TRI) were studied. Ultrasonography of the radial artery was performed prospectively in 115 patients selected to undergo elective TRI. Anatomic variations were observed in 11 of 115 patients (9.6%). Variations included six tortuous configurations (5. 2%), two stenoses (1.7%), two hypoplasias (1.7%), and one radioulnar loop (0.9%). The hypoplastic radial arteries and the radioulnar loop were inaccessible for catheterization, and coronary intervention was planned via the femoral artery. The transradial approach was attempted in the remaining 112 patients (97.4%) with only one instance of access failure, in a patient who had a stenotic vessel. These findings indicate that anatomic variations of the radial artery is not rare, and that preoperative ultrasound examination may help to exclude patients with inaccessible arteries and those at high risk for access failure.     

Transradial percutaneous coronary interventions: technique, materials & procedure in the light of anatomical and technical considerations

Transradial access is associated with enhanced patients' comfort, significant lower complication rates in diagnostic coronary angiography and better immediate and long-term outcomes after transradial percutaneous coronary interventions. Access failure has been reported to occur in less than 3-7% of cases due to anatomical circumstances (e.g., anomalous radial branching patterns, tortuosity e.g. radial loops, and small radial artery diameters). Radial coronary angiography and angioplasty entail a secondary learning curve of at least 150 cases in order to become familiar and comfortable with this technique. In contrast to previous established techniques (e.g. Sones-arteriotomy), the patient should be positioned in a comfortable supine position with his right arm next to his hip and the interventionist next to the right side of the patient. 19 gauge needles and 0.018 inch wires enhance the chance of successful cannulation the radial artery. A spasmolytic cocktail (3 mg Dinitrate, 3 mg verapamil, at least 3.000 U Heparine) should always be given intraarterially. Longer sheaths (> 13 cm) are not necessary. Essential for easy passage of the vertebralian artery and the common brachio-cephalic trunc (as the most dangerous part of the procedure) in order to reach the ascending aorta, the patient should be asked for a deep inspiration and/or dorsoflexion of his head An Amplatz-II catheter can be used for LCA, RCA and in some cases for LV-angiogram. The sheath should always be removed immediately and hemostasis achieved by radial compression (e.g. clamp). There is a close relationship between access failure respective radial spasm or occlusions and anatomical circumstances (i.e., hypoplastic radial artery, radioulnar loop, or small radial diameters: radial diameter-to-catheter ration < 1.0; assessment by Duplex). Although the radial access can be used in the majority of patients, the use is limited in patients with very small radial diameters and/or with complex lesions (e.g kissing balloon, etc).     

Distal Radial Access: Consensus Report of the First Korea-Europe Transradial Intervention Meeting

Among patients undergoing percutaneous coronary procedures, transradial access, compared with transfemoral access, is associated with a reduced risk for complications including mortality, especially in higher risk patients. However, transradial access is limited by radial artery occlusion (RAO) that despite being mostly asymptomatic because of the extensive anastomoses between the forearm arteries restricts future use of the same radial artery. Distal radial access (DRA) in the anatomic snuffbox or on the dorsum of the hand has recently gained global popularity as an alternative access route for vascular procedures. A strong anatomic and physiological rationale yields potential for significantly reduced risk for RAO and positive impact on procedural outcome for better patient care. Indeed, currently published studies buttress very low rates of RAO after DRA, hence supporting its development. The authors provide an analysis of the foundation of DRA, provide historical background, and offer a critical review of its current status and future directions. Also, given the limited evidence currently available to properly perform DRA in the real world, consensus opinion on what is considered optimal practice is also presented to supplement this document and enhance the implementation of DRA while minimizing its complications.     

Transradial versus transfemoral approach for percutaneous coronary procedures

Selective coronary angiography was originally performed through open brachial arteriotomy. Thereafter, the percutaneous Seldinger technique and the use of preformed Judkins-type catheters popularized the femoral approach. More recently, after the first report of successful coronary angiography by the transradial approach in 1989, the radial artery has been increasingly used as an alternative access site. The main advantage offered by the transradial approach is represented by the very low (< 1%) incidence of relevant vascular access site complications, which on the contrary occur in about 3% to 7% of patients undergoing procedures through the femoral route. The main disadvantage is a higher incidence of procedural failure that leads to a crossover to the femoral route. In this review, we examine the available evidence on transradial and transfemoral approach advantages, disadvantages, and complications in coronary angiography and intervention. Their use in the acute myocardial infarction setting and other situations is described. Vascular closure device usefulness is also considered.