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Transradial Angioplasty at ACC.09 and i2 Summit
Oral and Poster Presentations from the 2009 American College of Cardiology Meeting Involving the Transradial Approach to Catheter-Based Procedures


April 17, 2009 -- Following are summaries of all studies concerning transradial access that were presented during the American College of Cardiology 58th Annual Scientific Session held March 29-31, 2009.

There was a single 15 minute oral contribution made on the last day, and six poster presentations, made as part of the i2 Summit.

The take-away message from these studies was that the radial approach is comparable in success rate to the femoral with significantly lower complications. Radial access also makes possible same-day discharge of patients after stenting.

ACC.Oral Contributions -- Hot Topics in Percutaneous Coronary Intervention
A Randomized Comparison of Transradial Versus Transfemoral Approach for Coronary Angiography and Angioplasty
Presentation Time: Tuesday, Mar 31, 2009, 10:30 AM -10:45 AM
Martin Brueck, Dirk Bandorski, Wilfried Kramer, Harald Tillmanns, Clinic of Wetzlar, Wetzlar, Germany
Background: Coronary angiography and angioplasty are usually performed via the transfemoral approach. Transradial access may offer some advantages in comparison with transfemoral access especially under conditions of aggressive anticoagulation and antiplatelet treatment, increasingly used in today's complex interventions. The aim of this study was to evaluate the safety, feasibility and efficacy by the transradial approach compared to the transfemoral access in a standard population of patients undergoing coronary angiography and angioplasty.
Methods: Between July 2006 and January 2008, 1024 patients were randomly assigned to transradial or transfemoral approach. Patients with an abnormal Allen test or history of coronary artery bypass surgery were excluded. Both groups were comparable concerning baseline clinical characteristics (age, sex, body mass index, cardiovascular risk factors, acute and recent myocardial infarction, LV ejection fraction, previous PCI). Procedures were performed by four experienced physicians.

Transfemoral (n=512) Transradial (n=512) p-value
Catheterization success 511 (99.9%) 494 (96.5%) <0.0001
Cross over 1 (0.001%) 18 (3.5%) <0.0001
Angioplasty 192 (37.5%) 178 (34.8%) NS
Procedural success 191 (99.5%) 172 (96.6%) NS
Duration of procedure (min) 37.0 + 25.9 40.2 + 25.8 <0.05
Contrast dye (ml) 128.8 + 65.0 132.0 + 76.0 NS
Radiation exposure (Gycm2) 38.21 + 26.26 41.85 + 29.69 <0.05
Fluoroscopy time (min) 5.79 + 5.96 9.02 + 8.65 <0.01
Vascular complications 19 (3.7%) 3 (0.6%) 0.001

Conclusions: The finding of the present study shows that transradial coronary angiography and angioplasty are safe, feasible and effective with similar results to those of the transfemoral approach. However, using the transfemoral approach, procedural duration, fluoroscopy time and radiation exposure were higher, and vascular complications were seen in 4 patients out of a hundred. In contrast, the rate of major vascular complications was negligible using the transradial access.

i2 Poster Contributions (summarized)
2503-570/570. A Clinical Risk Prediction Tool for Post-PCI Bleeding From the National Cardiovascular Data Registry® (NCDR®)
Jason B. Lindsey, Sameer K. Mehta, Andrew D. Frutkin, John A. Spertus, Sunil V. Rao, Fang-Shu Ou, Matthew T. Roe, Eric D. Peterson, Steven P. Marso -- Mid America Heart Institute, Kansas City, MO, Duke Clinical Research Institute, Durham, NC
Summary: Bleeding after percutaneous coronary intervention (PCI) is associated with increased morbidity and mortality. The authors developed a clinical tool to estimate bleeding risk in order to help physicians tailor peri-PCI therapy and reduce risk. Authors used the NCDR® database. 440 centers from the years 2004-06 were examined. Bleeding was defined as resulting in transfusion, increased length of stay, and/or >3gm/dL decrease in hemoglobin occurring at vascular entry site, retroperitoneal, gastrointestinal, genitourinary or other location. There were 302,152 patients with a bleeding rate of 2.4%. (Editor's note: These procedures were virtually all done from the femoral approach. Previous studies using the NCDR database have shown radial use for 2004-06 to be only 1-2%.) This tool to estimate post-procedural bleeding risk is potentially actionable, enabling physicians to consider alternative strategies in high risk patients that are associated with lower rates of bleeding, namely use of transradial approach to PCI, smaller sheath size and alternative anticoagulation strategies.

left radial access2503-576/576. Left Radial Versus Femoral Approach in Primary Percutaneous Coronary Intervention - Prospective Comparison
Ivo Bernat, Jiri Koza, Jan Pesek, Jitka Tesarova, Richard Rokyta -- University Hospital, Plzen, Czech Republic
Summary: Althought the right radial artery is routinely used for coronary interventions, 90% of the population is right handed. The aim of this study was to compare the left radial and femoral approach in primary percutaneous
coronary intervention (PCI). In 2007, 297 consecutive patients with acute myocardial infarction (STEMI) were treated by primary PCI in the author's center. 255 were enrolled to this prospective non randomized study: LR 129 pts versus (vs) FA 126 pts. Groups were similar in age, gender, body mass index and Killip class I (105 vs 107), II (21 vs 12), III (3 vs 7). Procedural duration, fluoroscopy time and technical procedural success were not significantly different between the groups. Contrast consumption was lower in the left radial group. Serious access site bleeding complications occured only in the femoral group; none in the radial group. In hospital mortality was 2,3% in the left radial group and 4,0% in the femoral group. The authors concluded that left radial approach for primary PCI is safe, feasible and effective in STEMI patients without cardiogenic shock. Minimal risk of serious access site bleeding complications is the main advantage in comparison with femoral approach. Postprocedural immediate normal right hand mobility is an added benefit for right handed patients.

2503-577/577. Quality of Life after Same-day Discharge or Overnight Hospitalization after Transradial Coronary Stenting and Maximal Antiplatelet Therapy. Results of the Randomized EASY Trial
Olivier F. Bertrand, Javier Courtis, Stéphane Rinfret, Olivier Costerousse, Éric Larose, Rodrigo Bagur, Helena Tizon-Marcos, Can M. Nguyen, Robert De Larochellière, Paul Poirier, Louis Roy, Josep Rodes-Cabau -- Laval Hospital, Quebec Heart-Lung Institute, Quebec, QC, Canada
Summary: The EASY trial studied whether same-day home discharge after PCI impacts differently health-related quality of life (HRQOL) measures compared to standard overnight hospitalization. 1,005 patients with acute coronary syndrome (ACS) were randomized to be discharged home the same-day (n=504) or after overnight stay (n=501) after transradial coronary stenting and maximal antiplatelet therapy. Patients questionnaire contaied 36 items that, when scored, yields 8 domains (physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional, and mental health). All patients were pretreated with ASA and clopidogrel (90% > 12h) and received abciximab bolus prior the first balloon inflation. The results were that whether the patient was discharged the same day or overnight, there was no impact on any of the measurements up through 12 months.

2503-574/574. Unsuccessful Transradial Approach for Percutaneous Coronary Interventions: Predictors and Mechanisms of Radial Access Failure
Payam Dehghani, Tony Hong, Colin M. Suen, Waseem Sharieff, Atif Muhammad, Robert J. Chisholm, Michael J.B. Kutryk, Neil P. Fam, Asim N. -- Cheema, St. Michael's Hospital, Toronto, ON, Canada
Summary: The authors studied 2,100 patients -- all the patients undergoing transradial PCI at their center during 2002-2005 -- and attempted to determine the causes for those patients where the procedure could not be completed via the radial artery. A total of 98 patients (4.7%) experienced failure of the radial approach and were converted to femoral access -- all but four of these conversions were successful. Radial access for PCI in a diverse patient population was associated with a low rate of failure (<5%) and a low rate of vascular complications (<1%). The predominant reasons for radial failure were radial artery spasm, subclavian artery tortuosity, and an anatomy with unsuitable back-up for PCI. Advanced age, previous CABG and short stature were also independent predictors of radial failure.

2503-571/571. Cerebral Embolism is Related to Access Site at Coronary Angiography
Juliane Jurga, Jesper Nyman, Nondita Sarkar, Per Tornvall, Maria N. Mannila, Peter Svenarud, Jan van der Linden -- Dep of Cardiology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden, Dep of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Karolinska Institu, Stockholm, Sweden
Summary: Stroke is a rare but serious complication of coronary angiography. Its cause is not entirely explained, but might be related to the number of particulate emboli released by the catheter procedure. This small study attempted to measure if the number of emboli was related to the type of access site. The study randomized 50 patients to right femoral or right radial access. The number of particulate emboli passing the cerebral artery was measured using transcranial Doppler. The radial approach showed significantly more emboli passing the right middle cerebral artery than the femoral -- the left middle cerbral artery showed no differences between the approaches. Changing of catheters was also associated with an increase in emboli.

2503-572/572. Are Neurologic Complications Following Percutaneous Coronary Diagnostic or Interventions more Common in Transfemoral Versus Transradial Approach?
Helena Tizon-Marcos, Gerald Barbeau, Jacques Rouleau, Louis Roy, Onil Gleeton, Guy Proulx, J-Pierre Dery, Olivier Bertand, CM Nguyen, Bernard Noel, Josep Rodés-Cabau, Eric Larose, Stephane Rinfret, Robert De Larochellière -- Laval Hospital, Quebec, QC, Canada
Summary: In contrast to the above study, an analysis of 83,409 angiography or interventional procedures from April 1990-October 2007 in this single-center retrospective study showed that a cerebrovascular accident (CVA or stroke) was an uncommon complication of both coronary angiography and interventions -- it was observed in only 54 out of 83,409 patients (0.06%). However the transadial approach was associated with a lower incidence of per-procedural CVA than the transfemoral approach (0.049% vs 0.089%, p= 0.029).

About the Radial Access Center on Angioplasty.Org
To assist in educating the professional and patient population in the U.S. about the this technique, Angioplasty.Org has created the "Radial Access Center for Transradial Approach", a special section devoted to information and news about the transradial technique, for both patients and physicians. The Radial Center features interviews with leading practitioners of the radial technique, such as Drs. Jeffrey Popma, R. Lee Jobe, John Coppola, Shigeru Saito, Kirk Garratt and Howard Cohen.

For patients there is also a "Hospital Locator" that lists U.S. centers practicing radial angiography.


Reported by Burt Cohen, April 17, 2009