RADIAL ACCESS FOR ALL ACS PATIENTS

IVÁN J NÚÑEZ GIL, MD PhD FESC

Conflicts of Interest

Despite not having any relationship with industry or similar, I have a

conflict of interest …..

I AM

RADIALIST¡¡¡

History of Medicine

Nobel Prize: Physiology/Medicine 1956

Werner Forssmann

(1904-1979)

Andreas Gruentzig

(1939-1985) AHA, 1976

Sept´77, Zurich

History of Medicine

History of Coronariography

Radial access appeared very early in the interventional era

(1948, Radner first radial access).

The limitations of the material and equipment (Fr) required a change to

larger arterial vessels (FEMORAL).

Seldinger

Campeau, 1989 radial cath series

Kiemeneij & Laarman performed the first radial PCI, 1993

Due to the low rate of complications in the puncture site and the comfort

of the patient, begins a wave of enthusiasm.

Femoral Access: Classic

About 10 -20%

Hematoma

Retroperitoneal hematoma

Pseudoaneurysm

AV Fistulae

Arterial Infection

Complex access..

Femoral Complications

Radial Access

Very low risk of bleeding or pseudoaneurysm

No ischemic complications in case of occlusion if the palmar arc is permeable

Very low risk of arteriovenous fistula or nerve damage

Hemostasis is simpler

Save staff time and labor (sheath manipulation and groin monitorization)

Save on costs and complications of vascular closure devices

Radial Access Advantages

Ideal in selected patients as :

Obesity

Patients who can not lie after procedure Iliofemoral disease

Anticoagulated patients ACS patients: fibrinolysis, clopidogrel, 2b/3aInhibitors

Radial Access Advantages

Negative Allen´s risk(<10%) ??? spasm (mainly in very tiny arteries)

Difficult guide management (subclavian, brachiocephalic trunk curves….)

Respiratory induced guide deplacement

Femoral area is used anyway if IABP or temporary PM is needed

Radial Access Drawbacks

6F

7F

8F

†

9F

.070”

.078”

.088”

.098”

5F

.056”

Maximum diameter: Radial

Simultaneous compression of both arteries, radial and ulnar.

Ask the patient to open and close the hand three times

The palm acquires a pale colour

Then pressure is released from the ulnar artery

If there is adequate collateral circulation, normal color of the palm is recovered in less than 10 seconds

Allen´s Test

1 2

4

1

Needle: 21 G, guidewire: 0,018”

Radial Sheath 5-6 Fr Heparin30 U/kg Verapamile 2,5 - 5 mg/NTG

More complex puncture

Radial

Artery

Brachial Artery (distal)

Subclavian Artery

Brachial Artery

(proximal)

Tricks-Learning Curve

Immediate withdrawal of introducer (regardless of anticoagulation /

antiplatelet).

Grateful Post-procedure

Grateful Post-procedure

Pay attention! Complications

Comparative studies

Comparative studies

Prospective observational study (1999-2008, one centre), searching minimum number of cases for optimum clinical benefit

(control: ˃300 cases operators)

Learning Curve (PTCA)

Learning Curve (PTCA)

Learning Curve (PTCA)

To assess whether radial access was superior to femoral access in patients with ACS who undergo coronary angiography with possible intervention.

Multicenter randomized study 1:1 to Radial Vs. Femoral

˃7,000 patients.

Primary outcome: composite of death, myocardial infarction, stroke, or non-coronary artery bypass graft (non-CABG)-related major bleeding at 30 days.

Head to Head comparison !!

RIVAL Study

RIVAL Study

RIVAL Study

Head to Head comparison !!

RIFLE Study

Primary endpoint: 30d net adverse clinical events

(NACEs): composite of cardiac death, stroke,

myocardial infarction, target lesion revascularization,

& bleeding

J Am Coll Cardiol 2012 (In Press)

RIFLE Study

↓ Cardiac death

↓ bleeding (minor)CV

↓ anemization

Reduced hospital stay

Spain

Comparative studies

Comparative studies

MORTALITY MACE

More Comparative studies ¡¡¡

Long term Comparative studies

The femoral and radial accesses are two equally valid options.

Operator experience is the deciding factor for choosing one approach or

other. Radial learning curve steeper.

Conclusions

Bleeding complications are lower with transradial access. (at the expense

of failed accesses rate slightly higher -switch).

The hospitalization time was significantly lower with radial access, and the

total procedure time also.

Complex procedures (tortuosity, IABP, CTOs, etc..): Femoral required.

Radial access in patients with STEMI is associated with significant clinical

benefits, in terms of both lower morbidity and cardiac mortality. Thus, it

should become the recommended approach in these patients, provided

adequate operator and center expertise is present.