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

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

Brachial access Not just another artery!

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

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

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

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

ACCESS Study Randomised comparison of different access sites Experienced operators No difference in procedural or fluoroscopy times Radial Brachial Femoral PCI s (n) 300 300 300 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 0 2.3 2.0 JACC 1997; 29: 1269-75. Amsterdam, NL

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* 2.1 2.1 Time 12.4 14.2* 11.2 X-rays 3.8 4.2 3.1* Quality?LCA OK OK Vasc. Complns 0 0 2 CCVI 2001; 52:181-7. Massy, France

Multiple procedures 812 patients 1438 procedures 6F 45% 5F 55% Men Failed procedures (%) 2 nd 3 rd 5 th 3.5 10 30 Women 7.9 20 50 CCVI 2001;54: 204-8. Fukuoka, Japan

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: 172-6. Greifswa, FRG

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: 289-94. Quebec Can 6 4 2 0 1000 500 0 PS PTF

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: 357-62 Tokyo, Japan

Difficult subclavian anatomy Retro-oesophageal right subclavian artery 11 patients in 3730 attempted transradial procedures Increased failure rate (7%) CCVI 2001; 54: 202-3. Massy, France

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

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: 157-9. Raleigh, NC, USA

Comparison with closure devices (2) 6 high volume operators in a high volume centre Prospective non-randomised registry Radial Prostar PCI s (n) 376 580 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: 417-21. Massy, Fr

GP IIb/IIIa inhibitors 150 consecutive patients treated with GPIIb/IIIa inhibitors Radial Femoral PCI s (n) 83 67 Event free @ 1/12 94% 94% Length of stay (days) 5.0 4.9 Major access site bleeding 0 5 (7.4%) Eur Heart J 2000; 21: 662-7. Toulouse, Fr.

Acute myocardial infarction Two centre registry of 1224 patients with AMI treated by primary PCI Radial Femoral Closure PCI s (n) 277 947 Success 95% 95% Time Major access site bleeding No difference Femoral No closure 0 2% 7% CCVI 2002; 55: 206-11. Massy, Fr

Non-coronary intervention Carotid - Case report Castriota F et al. J Endovasc Surg 1999; 6: 385-6 Vertebral - Case report Fessler RD et al (Buffalo, NY) Neurosurg 2000; 46: 1527-8 Renal - 25 patients; 27 arteries; 100% success Galli Met al (Como, It) J Inv Cardiol 2002; 14:386-90

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

The only artery!

Normal arterial anatomy in forearm

Brachial tortuosity