Transradial catheterization

Transradial catheterization is an endovascular procedure or catherization procedure performed to diagnose and treat arterial disease (e.g., coronary artery disease, peripheral artery disease, etc.). Endovascular procedure can be performed achieving access in to body’s arterial system from either femoral artery (in groin), brachial artery (in elbow) or radial artery in the wrist. The transfemoral (through groin) approach to perform cardiac catheterization has typically been more prevalent in invasive cardiology. But, radial access has gained in popularity due to technical advances with catheters and lower complication rates than transfemoral access.[1]

History

In 1948, Radner[2] published one of the first descriptions of transradial central arterial catheterization and attempts at coronary artery imaging using radial artery cut-down. Transradial access to perform diagnostic cardiac catheterization procedures was introduced by Campeau[3] and was later adapted for therapeutic procedures of coronary angioplasty by Kiemeneij and Laarman.[4] In India, the transradial approach was modified by Tejas Patel by the design of the PATEL catheter which made the approach quicker and easier for the Asian arteries which were difficult to be accessed by traditional catheters used in the west.

In past few years, transradial access for coronary intervention has become increasingly popular. The most advantageous aspect is very low access-site bleeding complications even with aggressive use of anticoagulation and antiplatelet therapies.[5][6] During the angioplasty and stent procedures patients are given therapeutic (high) doses of anticoagulation (blood thinners) and platelet inhibiting medications.

Characteristics

With transfemoral access, the rate of bleeding complications is 3% - 6%. Occasionally, patients can develop retroperitoneal bleeding (bleeding into the pelvic cavity), and up to 1% of patients require blood transfusion to treat the bleeding complication after transfemoral catheterizations. Patients may also develop painful hematoma, A-V fistula or pseudoaneurysms. In modern interventional cardiology the procedural success rates are high and ischemic complications are relatively rare. However the bleeding complications associated with transfemoral catheterization have not been significantly reduced even after the introduction of new pharmacological strategies. There is strong evidence suggesting that post-PCI bleeding is associated with an adverse prognosis. Postprocedural blood transfusion is also associated with poor prognosis.[7] Bleeding complication, pseudoaneurysm, hematoma formation are less than 2% with transradial catheterization.[1] Possibility of blood transfusion requirement is extremely rare after transradial catheterization.

The other reason for the increased use of radial access is the technological advances in the sheath and catheter design, and improved physician experience with this approach. With improvement in the physician's experience, radial artery access is now being used with equal efficacy to treat almost every complex coronary artery disease, including acute myocardial infarction, chronic total occlusion, bifurcation coronary artery disease and rotablation. Radial access has also been used successfully to treat peripheral artery disease including bilateral iliac artery stenosis, renal artery stenosis and for carotid interventions.[8][9]

Due to rapid ambulation post procedure the radial interventions became particularly attractive for patients with back pain, chronic obstructive lung disease, prostatic hypertrophy and elderly patients.[10] As after catheterization through femoral approach patient is generally required to lay flat with immobilization of the leg for 4– 6 hours. Early ambulation and early discharge after transradial catheterization improves quality of life and reduces morbidity. Both patients and hospital staff typically strongly prefer the transradial approach as opposed to femoral access.[11][12]

In era of cost control, the savings in closure devices (which are used to allow earlier ambulation after transfemoral catheterization), and early discharge had made this a cost-saving approach.[11] Some of these savings are outweighed by a relatively long learning curve for physicians, which has likely slowed the adoption of the procedure in the U.S.

Although transradial procedures often have less complications than femoral procedures, they have some shortcomings. The procedure is technically more difficult and has a relatively long learning curve, which includes the potential for unsuccessful completion of procedure during said learning curve. In clinical trials before crossing the learning curve there is up to 5% failure in completing the catheterization successfully from radial approach.[4][6] Technical difficulties are because of loops and tortuosity of the radial and the subclavian artery, anatomical variations in radial artery, and radial spasm.

Major complication associated with a transradial interventions include early and late radial artery occlusion. Most of the radial artery occlusions are asymptomatic. Post PCI radial artery occlusion can be reduced by using smaller diameter catheters and anticoagulation. Also by avoiding prolonged compression of the radial artery and applying just enough pressure to achieve hemostasis reduces this complication of asymptomatic radial occlusion significantly. Implying this approaches the radial artery occlusion rate has come down to 1.1-1.8%.[13]

The transradial technique is an effective, minimally invasive approach to perform coronary and peripheral angiograms and interventions. Transradial catheterization is typically a safer, more cost-effective and patient friendly procedure. Studies show a lower rate of complications with transradial than with transfemoral catheterization in non-coronary interventions as well..[14] However, for women, the rate of complications may be about equal between transradial and transfemoral catheterization.[15]

See also

References

  1. 1 2 Major improvement of percutaneous cardiovascular procedure outcomes with radial artery catheterisation: results from the PREVAIL study. Pristipino C, Trani C, Nazzaro MS, Berni A, Patti G, Patrizi R, Pironi B, Mazzarotto P, Gioffrè G, Biondi-Zoccai GG, Richichi G, Prospective REgistry of Vascular Access in Interventions in Lazio Region Study Group Heart. 2009 Mar; 95(6):476-82.
  2. ↑ Radner S. Thoracal aortography by catheterization from the radial artery; preliminary report of a new technique Acta Radiol 1948;29:178-180.
  3. ↑ Campeau L. Percutaneous radial artery approach for coronary angiography. Cathet Cardiovasc Diagn 1989;16:3-7.
  4. 1 2 Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, Wieken RV: A Randomized Comparison of Percutaneous Transluminal Coronary Angioplasty by the Radial, Brachial and Femoral Approaches: The Access Study JACC. 1997;29:1269-75.
  5. ↑ Kiemeneij F, Laarman GJ, Odekerken D, et al. A Randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: The ACCESS study. J Am Coll Cardiol 1997;29:1269–1275.
  6. 1 2 Pierfrancesco Agostoni, Giuseppe G. L. Biondi-Zoccai, M. Luisa De Benedictis, Stefano Rigattieri, Marco Turri, Maurizio Anselmi, Corrado Vassanelli, Piero Zardini, Yves Louvard, and Martial Hamon. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures: Systematic overview and meta-analysis of randomized trials. J. Am. Coll. Cardiol., Jul 2004; 44: 349 - 356.
  7. ↑ Rao SV, Eikelboom JA, Granger CB, Harrington RA, Califf RM, Bassand JP. Bleeding and blood transfusion issues in patients with non-ST-segment elevation acute coronary syndromes Eur Heart J 2007;28:1193-1204.
  8. ↑ Transradial intervention of iliac and superficial femoral artery disease is feasible. Kintur Sanghvi, Damian Kurian, John Coppola. Journal of interventional cardiology. 2008;21:385-87.
  9. ↑ contralateral transradial approach for carotid artery stenting: A feasibility study. Tejas Patel, Sanjay Shat et al. catheterization and cardiovascular interventions. 2009;75:268-75
  10. ↑ Caputo RP, Simons A, Giambartolomei A, Grant W, Fedele K, Abraham S, Reger MJ, Walford GD, Esente P. Transradial cardiac catheterization in elderly patients. Catheterization and Cardiovascular Interventions 2000; 51: 287-290
  11. 1 2 C-H Lee. Satisfaction and Acceptance after Transradial Coronary Intervention in Elderly. International Journal of Angiology 9:147-150(2000)
  12. ↑ Cooper CJ. El-Shiekh RA, Cohen DJ, Blaesing L, Burket MW, Basu A, Moore JA. Effect Of Transradial Access on Quality of Life and Cost of Cardiac Catheterization: A Randomized Comparison. Am Heart J.1999; 138(3):430-436.
  13. ↑ Pancholy S, Coppola J, Patel T, Roke-Thomas M. Prevention of radial artery occlusion-patent hemostasis evaluation trial (PROPHET study): a randomized comparison of traditional versus patency documented hemostasis after transradial catheterization Catheter Cardiovasc Interv 2008;72:335-340.
  14. ↑ Posham R, Fischman AM. Transradial Approach for Noncoronary Interventions: A Single-Center Review of Safety and Feasibility in the First 1,500 Cases. Journal of vascular and interventional radiology : JVIR. 2016;27(2):159-66.
  15. ↑ Loh YJ, Nakao M, Tan WD, Lim CH, Tan YS, Chua YL. SAFE-PCI Trial. Factors influencing radial artery size. Asian Cardiovasc Thorac Ann. Aug 2007;15(4):324-6.
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