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The Radialist

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Transradial
approach

In the early fifties

When diagnostic coronary angiography was developed in the early fifties, it was performed initially through a brachial artery cut-down and later through percutaneous femoral artery approach. Within a few years the femoral approach became the default technique and several catheter curves were designed. The success of the percutaneous femoral technique compared to brachial artery cut-down was primarily related to a lower rate of vascular complications. Still, it was observed early on that vascular complications such as arterial thrombosis, pseudo-aneurysm, arterio-venous fistula, large hematoma or retroperitoneal bleeding albeit infrequent could be associated with significant mortality and morbidity risks and prolong hospitalization duration. Indeed, catheter sizes at that time were ≥7Fr, thus creating a significant hole in the vascular wall of the femoral artery.

In 1977

Dr A Gruntzig performed the first percutaneous coronary balloon angioplasty using 9Fr guiding catheters and femoral approach. This was the beginning of a new era of non-surgical treatment of coronary atherosclerotic lesions. Success has been huge since and today it is estimated that > 3 millions percutaneous coronary interventions (PCI) are performed worldwide every year. Vascular complications and access-site bleeding have remained associated with PCI throughout these years with a rather constant incidence due to the requirement for anticoagulation during coronary interventions. Industrial efforts have been mainly concentrated on downsizing guiding catheters (from 9Fr to 6-8Fr) and more recently to the development of femoral access-site closure devices. Closure devices have been associated with more rapid ambulation when successfully deployed but they remain costly and their exact benefits to reduce access-site complications remain highly controversial.

In 1989

Dr L Campeau in Montreal (Canada) reported for the first time a series of 100 patients using the percutaneous transradial artery approach to perform coronary angiography. Although his initial report went largely unnoticed by the community of interventional cardiologists, it created the impetus for Dr F Kiemeneij and Dr G Laarman to perform the first PCI using the transradial approach in 1992 in Amsterdam (The Netherlands, Europe). For almost 15 years, the transradial approach has been practiced and advocated by dedicated and very passionate operators especially in Europe, Canada, Japan and India. In the US, Dr Tift Mann in Raleigh (NC) performed the first transradial percutaneous coronary angioplasty in 1994 but was followed only by a limited number of US interventional cardiologists. Whereas transradial approach has become popular in many countries, it is only recently that US operators have regained interest in learning the technique.

Better recognition of the detrimental impact of bleeding and peri-procedural complications on outcomes and associated health costs have been major drivers to renew interest in the technique.

Based on many years of research,
it can be claimed that:

  • Transradial approach offers better patient comfort compared to standard femoral approach since patients can stand up immediately after completion of the procedures;
  • Compared to femoral approach, patients prefer transradial approach;
  • Transradial approach is associated with less risks of vascular complications;
  • Due to its superficiality and small size compared to femoral artery, hemostasis of radial artery is easier and transradial approach is associated with less risks of access-site bleeding;
  • Easier management of access-site with transradial approach is associated with less workload for nursing staff;
  • Less risks of access-site complications with radial approach is associated with a reduction in hospitalization length and significant costs benefits;
  • With current equipments and techniques, all types of percutaneous coronary procedures can be undertaken by transradial approach;
  • Several non-coronary procedures are also performed by transradial approach.

Since transradial approach has been associated with less risks of peri-procedural complications, it has recently been hypothesized that transradial approach could potentially reduce the risks of mortality compared to standard femoral approach. In the largest randomized study to date comparing transradial versus femoral approach in patients undergoing coronary angiography or interventions for acute coronary syndromes (RIVAL trial), Dr S Jolly and his colleagues observed less risks of vascular complications in the whole population. In the selected group of patients referred for acute myocardial infarction and primary PCI, there was a significant reduction in mortality at 30 days. However, it was also observed that better outcomes were associated with transradial centers (not operators!) volumes and experience.

Society for Cardiovascular Angiography and InterventionsThe Society for Coronary Angiography and Interventions (SCAI) has already emphasized the need for better training and education to learn transradial approach techniques. There are nowadays several initiatives to improve knowledge transfer and help operators and catheterization laboratories to adopt the transradial approach as the default technique for diagnostic angiography and interventions.

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The goal of this web-site Is to become
a “hub” of informations related to all
aspects of transradial approach.

Our objective is to reduce physicians’ health professionals’ and patients’ knowledge gaps. With the realization of well focused research projects, large clinical trials as well as up-to-date educational activities through existing and new collaborations, we aim to continue to promote the use of the transradial approach. We hope that this web-site will become YOUR preferred forum to all aspects related to transradial approach.

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