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Radial Angioplasty and Angiography Safer For Elderly Patients
German Study Reports That the Use of the Wrist for Catheter Access Results in Lower Bleeding and Vascular Complications for Patients 75 Years and Older; Chinese Study Finds Similar Safety for Elderly Patients with Acute Myocardial Infarction

November 20, 2008 -- A recent study of 400 consecutive patients, published in Catheterization and Cardiovascular Interventions, looked at the transradial approach for catheterization, angioplasty and stenting in patients 75 years of age and older. The conclusion of the study:

"In elderly patients, transradial coronary angiography and intervention has a high technical success rate and lower complication rates than the transfemoral approach."

Recent Studies Show Lower Complications for Radial
A number studies have reported significantly lower complication rates when the radial approach is utilized. The M.O.R.T.A.L. study of over 30,000 patients showed 50% less blood transfusions for radial patients, and associated that with a significant decrease in mortality. halving of reduction in mortality.

Angioplasty.Org Image
Sunil V. Rao, MD, FACC
Duke Univ. Medical Center

In the August issue of JACC: Interventions, a study of 600,000 procedures showed a 58% reduction in bleeding complications with the radial approach. Lead author Dr. Sunil V. Rao told Angioplasty.Org:

"There's a lot of attention being paid to bleeding complications and their association with mortality, and the focus has really been on the pharmacological therapy.... What a lot of people have forgotten is that the majority of bleeding complications in patients undergoing stenting is related to the access site. The radial approach has sort of been in the background for a long time, but I think radial is gaining."

Results of New Study on Elderly Patients
However, this new study, appearing in the November 1 issue of Catheterization and Cardiovascular Interventions, specifically looked at patients of advanced age, a population where complications are known to be higher. The study was conducted at the University of Erlangen-Nürnberg (incidentally, a pioneering locale in the development of angioplasty, under the guidance of Dr. Eberhard Zeitler). 400 consecutive patients 75 years old with known or suspected coronary artery disease were enrolled. 93 were excluded because they had contraindications for one of the approaches. The remaining 357 patients were randomized to the femoral (leg) or radial (wrist) approach. A diagnostic angiogram was performed and, if intervention was judged to be efficacious, the procedure continued as an ad-hoc intervention (balloon or stent).

Of the 152 patients randomized for transradial, 13 (9%) could not be done via the wrist, due to arterial spasm or difficult anatomy, and they crossed-over to femoral. The authors note that 9% is similar to what other studies have shown to be the rate of unselected patients who are contra-indicated for the radial approach. In real-world practice, the radial approach usually is performed only after an Allen's test or other criteria are examined, so the actual success rate of transradials is very high. Even including the time for patients to be crossed-over, the mean procedural time for the radial cases was only three minutes longer (18 minutes) than for femoral (15 minutes) -- the time was measured from the arterial puncture to completion of the final cine-angiogram.

In all randomized patients, the physicians succeeded in obtaining the diagnostic angiograms -- and about 1/4 continued on to ad-hoc intervention. Fluoroscopy time, dose-area product, amount of contrast agent, and the number of diagnostic and guiding catheters were not significantly different between the two groups.

No Major Adverse Complications with Transradial Approach
What was different, however, was the incidence of major complications: 3.2% in the femoral group versus none in the radial group. There was one stroke, three cases of severe bleeding with the need for transfusion, and one local hematoma that required surgical intervention -- all of which occurred in the transfemoral group. There were also 11 minor complications, defined as clinically apparent bleeding of the access site which was symptomatic, but did not lead to surgical intervention, transfusion, or a drop in the hemoglobin level of more than 3 g/dl. Nine of these occurred in the transfemoral group. Interestingly, the two minor complications in the transradial group were actually cross-overs, and the complications occurred during the femoral procedure at the access site. So, in effect, there were no complications, major or minor, that occurred in patients where the transradial approach was performed.

The importance of this study for treatment of elderly patients is explained by the authors:

"Numerous studies have demonstrated the clinical utility of an invasive strategy for the management of coronary artery disease in elderly patients. On the other hand, advanced age constitutes one of the major risk factors concerning complications of coronary angiography. Arterial access complications are significantly more frequent in patients above 75 years of age than in younger individuals. Therefore, the development and clinical use of strategies for invasive diagnosis and therapy, with simultaneous reduction of vascular access complications, would be important especially for the increasing number of patients who are present with known or suspected coronary artery disease at an advanced age."

    Dr. Stephan Achenbach
Co-author Dr. Stephan

The authors conclude:

"Our trial clearly demonstrates that routine use of the transradial approach for coronary angiography and intervention in patients at advanced age has a high clinical success rate and can be performed without substantial disadvantages concerning procedural duration, radiation exposure, use of contrast agent, or other resources such as catheters. However, it is associated with a substantially lower rate of complications as compared to the transfemoral approach and a more widespread use of the transradial route, especially in patients at increased risk for vascular complications, should be strongly encouraged."

Chinese Study Shows Similar Safety for Elderly Patients Presenting With Acute MI
Another comparison between the transfemoral and transradial approach in elderly patients was published in the May issue of the Chinese Medical Journal. Physicians at Anzhen Hospital in Beijing randomized 103 consecutive patients older than 64 years who presented to the hospital with AMI to either transradial or transfemoral intervention. There were no significant differences in the success rates of puncture and PCI, puncture time, cannulation time, reperfusion time, total time of the procedure, use rates of temporary pacemaker and IABP, or MACE. However, the hospital stay of the transfemoral group was longer than that of the transradial group ((10.1±4.6) vs (7.2±2.6) days, P<0.01). As for complications, one radial occlusion was observed in the radial group, but the patient experienced no ischemic syndrome in hand. However, in the femoral contingent, four patients had hematosis, one experienced a pseudoaneurysm, and one had major bleeding. Vascular access site complications were seven times higher in the femoral group (1.8 % vs 13.1%, P<0.05).

As more of these types of studies are published, those physicians practicing the radial approach feel that the momentum will grow and the demand increase for more radial procedures in the United States, which currently account for less than 4% of all diagnostic and interventional procedures.


Reported by Burt Cohen, November 20, 2008