Radial Access Just another artery? Keith G Oldroyd Department of Cardiology Western Infirmary Glasgow

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1 Radial Access Just another artery? Keith G Oldroyd Department of Cardiology Western Infirmary Glasgow

2 Brachial access Not just another artery!

3 Femoral access Not just another artery! Incidence of femoral artery false aneurysms 1.20% 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% Pre Dr X Post Dr X C Ilsley; personal communication

4 Femoral access Not just another artery! 45 year old women Moderate obesity Elective catheterisation RFV/RFA Major retroperitoneal haemorrhage CT scan; 6 unit transfusion Discharged on day 6 Readmitted on day 9 RCFA false aneurysm Doppler, CT, thrombin injections Discharged day 13

5 History of transradial catheterisation 1964 Campeau, Montreal Heart Institute Cut-down on proximal RRA 1970/80 s Percutaneous approach Axillary > Femoral > Brachial 1989 Percutaneous transradial coronary angiography/ptca

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7 Why bother? Pre-Colombian Aspirin Persantin Warfarin Dextran 8-9F sheaths 1 week in hospital No closure devices 10% bleeding 5-10% SAT Post-Colombian Aspirin Clopidogrel 6F(5F) sheaths day case/23 hours Closure devices <1% bleeding <1% SAT

8 ACCESS Study Randomised comparison of different access sites Experienced operators No difference in procedural or fluoroscopy times Radial Brachial Femoral PCI s (n) Coronary cannulation 93% 95.7% 99.7% Procedural success 91.7% 90.7% 90.7% Length of stay (days) 1.5(2.5) 1.8(3.8) 1.8(4.2) Major access site complications JACC 1997; 29: Amsterdam, NL

9 Carafe Study Randomised Two experienced operators ~50% follow-on PCI with closure devices for femoral cases Radial groups Reduced pain Earlier ambulation and discharge Lower costs RRA (n=70) LRA (n=70) Fem (n=70) X-overs 1-LRA 0 0 Caths 1.4* Time * 11.2 X-rays * Quality?LCA OK OK Vasc. Complns CCVI 2001; 52: Massy, France

10 Multiple procedures 812 patients 1438 procedures 6F 45% 5F 55% Men Failed procedures (%) 2 nd 3 rd 5 th Women CCVI 2001;54: Fukuoka, Japan

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12 Difficult radial anatomy small vessels (1) Randomised trial of 5Fr vs 6Fr transradial PCI in 171 patients with a +ve Allen test 5Fr 6Fr Procedural success 95.4% 92.9% Failed coronary cannulation 1.1% 4.8% Minor haematoma 1.1% 4.8% Radial occlusion 1.1% 5.9% CCVI 2002; 57: Greifswa, FRG

13 Difficult radial anatomy small vessels (2) 90 patients Randomised to hydrophilic sheath vs conventional sheath Automatic pullback with an electronic traction guage CCVI 2001; 54: Quebec Can PS PTF

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18 Difficult radial anatomy Preprocedural ultrasound in 115 patients Anatomic variations in 11 (9.6%) Tortuosity 6 - proceed Stenoses 2 - proceed Hypoplasia 2 - femoral Radioulnar loop 1 - femoral Success 111 (97.4%) CCVI 2000; 49: Tokyo, Japan

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20 Difficult subclavian anatomy Retro-oesophageal right subclavian artery 11 patients in 3730 attempted transradial procedures Increased failure rate (7%) CCVI 2001; 54: Massy, France

21 Difficult coronary anatomy LIMA LRA is access site of choice Specific catheters to approach from RRA RIMA RRA is access site of choice Anomalous origin of RCA from L sinus of valsalva Series of case reports RRA appears to be access site of choice Saphenous vein grafts Avoid during initial experience

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23 Comparison with closure devices (1) Two groups of 109 consecutive PCI s Not randomised but matched for usual demographic parameters Experienced operators Radial Perclose Device not used N/A 20 (18%) Failed haemostasis 0 9 (10%) Procedural time 44 (22) mins 57 (22) mins* Ambulated same day 95% 56% CCVI 2000; 49: Raleigh, NC, USA

24 Comparison with closure devices (2) 6 high volume operators in a high volume centre Prospective non-randomised registry Radial Prostar PCI s (n) Device not used N/A 3% Failed haemostasis 0 9.6% Infection requiring a/b s 0 2 patients Transfusion 0 1 patient CCVI 2000; 51: Massy, Fr

25 GP IIb/IIIa inhibitors 150 consecutive patients treated with GPIIb/IIIa inhibitors Radial Femoral PCI s (n) Event 1/12 94% 94% Length of stay (days) Major access site bleeding 0 5 (7.4%) Eur Heart J 2000; 21: Toulouse, Fr.

26 Acute myocardial infarction Two centre registry of 1224 patients with AMI treated by primary PCI Radial Femoral Closure PCI s (n) Success 95% 95% Time Major access site bleeding No difference Femoral No closure 0 2% 7% CCVI 2002; 55: Massy, Fr

27 Non-coronary intervention Carotid - Case report Castriota F et al. J Endovasc Surg 1999; 6: Vertebral - Case report Fessler RD et al (Buffalo, NY) Neurosurg 2000; 46: Renal - 25 patients; 27 arteries; 100% success Galli Met al (Como, It) J Inv Cardiol 2002; 14:386-90

28 Potential effect on interventional activity Elective day case PCI Reduced costs compared to groin closure No failed haemostasis Convert beds to reclining chairs In-patient PCI programme Reduced bed utilisation Fewer complications Reduced LOS

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30 The only artery!

31 Normal arterial anatomy in forearm

32 Brachial tortuosity