Comparison of left and right radial approach for percutaneous coronary procedures

1. Department of Cardiology, Beijing Tiantan Hospital,
Capital Medical University, Beijing, China
Qiang Fu MD，Ph.D

2. The Temple of Heaven
New Tiantan Hospital

3. The feasibility and safety of TRI have been established.
- Easy hemostasis
- Less bleeding/neurological complications
TRI in China: 76%, but the choice of radial access
depends on the institutions.

4. Marked vascular tortuosity is more
common in right radial
approach（RRA）than that in
left radial approach
（LRA）and may lead to
coronary procedure failure.
TALENT study showed that LRA for coronary diagnostic
procedure is associated with lower fluoroscopy time and
radiation dose adsorbed by patients compared with the
RRA.

5. Recent studies indicated that incidence of microemboli was
higher in coronary procedures performed through RRA, and
LRA might reduce cerebrovascular complications compared
with RRA*. *Int J Cardiol. 2012 Oct 6. pii: S0167-5273(12)01130-8.
Until now, there is still no consensus on optimal radial
approach for coronary procedure. Left or right ?
Few data from randomized controlled trials in Asian
patients undergoing coronary angiography and
interventions are available.

6. Study I Comparison of transradial approach
for coronary angiography.
Study II Comparison of transradial approach
for primary PCI.

7. To determine whether LRA is a valid alternative
for coronary angiography compared with RRA in
Chinese populations.

8. Design:
Single-centre, prospective, randomized controlled
study.
Subjects:
Consecutive patients who underwent coronary
diagnostic procedures
Exclusion criteria:
Acute ST-elevation myocardial infarction,
Previous coronary artery bypass graft surgery,
Hemodynamic instability.

9. Primary end point
Coronary procedure success
Secondary end points
Total procedure time;
Fluoroscopy time;
Dose of radiation
cumulative air kerma: CAK,
CAK dose area product: CAK DAP;
Contrast volume.

10. Vascular complications
Radial occlusion,
Pseudoaneurysm,
Arteriovenous fistula,
Major bleeding at access-site.

11. Flow chart

12. Results
Coronary procedural success were 682 of 700 (97.4%) in
the LRA group and 680 of 488 (97.1%) in the RRA group.

13. Results
Baseline characteristics

14. Results
Procedural characteristics Table 3 Procedural characteristics in coronary angiography
RRA
(n=682)
LRA
(n=680)
P value
Total procedural time (min) 14.1±6.3 13.2±6.0 0.006
CAK (mGy) 320±205 302±173 0.09
CAK DAP (Gycm2) 28±20 26±17 0.13
Fluoroscopy time (min) 3.8±3.3 3.4±2.8 0.046
Contrast volume (ml) 63±14 62±17 0.29
Number of catheters 2.1±0.4 2.1±0.4 0.69
Data are expressed as the mean±SD or * median (25th percentile and 75th percentile)

15. Results
Vascular complications

17. To investigate the difference between left
and right radial approach in the setting of
primary PCI for STEMI.

18. Subjects:
All patients with STEMI were screened for
eligibility.
Inclusion criteria:
Patients undergoing primary PCI within 12
hours of symptom onset.
Exclusion criteria:
Cardiogenic shock.

19. Primary end point
Needle-to-balloon time, defined as the time from local
anesthesia infiltration to the first balloon inflation. If a manual
thrombectomy was conducted before balloon inflation, needle-to-balloon
time was also considered as the time from local anesthesia
infiltration to the beginning of thrombus aspiration.
Secondary end points
Fluoroscopy time;
Dose of radiation: CAK and CAK DAP;
Contrast volume;
In-hospital MACE: death, reinfarction, urgent
revascularization, stroke and new congestive heart failure

20. Results
Tables
Baseline characteristics
Table 1 Baseline characteristics of the study population
Right radial approach
(n=100)
Left radial approach
(n=100)
P value
Age (years) 59.6± 12.3 60.9± 10.9 0.41
Male 79 (79%) 82 (82%) 0.59
Height (cm) 167.9± 6.2 167.9± 7.4 0.98
Weight (Kg) 72.8± 10.8 71.1± 10.9 0.28
BMI (kg/m2) 25.9± 3.1 25.4± 2.8 0.22
Creatinine (μmmol/l) 71.8± 19.9 67.6± 14.8 0.10
Hypertension 64 (64 %) 55 (55%) 0.20
Diabetes mellitus 22 (22%) 31 (31%) 0.15
Dyslipidemia 16 (16 %) 10 (10%) 0.21
Current smoking 60 (60%) 56 (56%) 0.57
Anterior MI 52 (52%) 54 (54%) 0.78
Inferior MI 48 (48%) 46 (46%) 0.78
Killip class 0.29
Killip 1 72 (72%) 69 (69%)
Killip 2 26 (26%) 31 (41%)
Killip 3 2 (2%) 0 (0%)
Killip 4* 0 (0%) 0 (0%)

21. Results
Table 2 AngioPgrarpohicc anedd intuerrveantlio ncalh chaarracatecristtiecsr oif sstutdiyc psop ulation
Right radial approach
(n=94)
Left radial approach
(n=98)
P value
Infarct-related artery 0.84
Left anterior descending 51 (54%) 54 (55%)
Left circumflex 10 (11%) 8 (8%)
Right coronary artery 33 (35%) 36 (37%)
Initial TIMI Flow (0-1/2/3) 78/12/4 78/11/9 0.39
Guiding catheter 0.42
Judkins 82 (87%) 91 (93%)
Amplatz 4 (4%) 2 (2%)
XB back-up 8 (9%) 5 (5%)
Thrombus aspiration 26 (28%) 22 (23%) 0.41
GP IIb/IIIa inhibitors 73 (78%) 76 (78%) 0.99
Final TIMI 3 Flow 90 (96%) 95 (97%) 0.72
Contrast volume (ml) 128.8± 17.2 125.8± 19.6 0.31
Number of stents 1.1± 0.4 1.2± 0.4 0.22
Data are expressed as the mean±SD or number (%)

22. Results
Table 3 Procedural durations and radiation exposure of study population
Radiation exposure
Right radial approach
(n=94)
Left radial approach
(n=98)
P value
Needle-to-balloon time (minute) 18.0±6.5 16.0±4.8 0.02
Total CAK (mGy) 720± 359 715± 478 0.92
Total CAK DAP (Gycm2) 65.3± 49.1 51.9± 30.4 0.04
Fluoroscopy time (minute) 8.8±3.5 7.4±3.4 0.01

23. In-hospital MACE
Only one patient suffered a severe congestive heart
failure in right radial approach group. No patient
experienced death, reinfarction and stroke. No patient
required re-PCI or bypass surgery.

24. Similar to TELENT study, the LRA is associated with
shorter coronary procedure time and fluoroscopy time
compared with the RRA for Chinese populations in a
diagnostic coronary angiography.
Even in STEMI patients, primary PCI can be performed
via LRA with earlier blood flow restoration in infarct-related
artery and lower radiation exposure compared
with RRA.

25. Possible explanations of our findings:
1, The LRA has lower subclavian tortuosity and permits
more direct access to the ascending aorta, whereas the
RRA may be more difficult to access, owing to its
tortuosity and to the atherosclerosis of the right
common brachiocephalic trunk and subclavian artery

26. 2, The engagement of coronary ostia is easier through
the LRA. However, the catheter must be rotated to
afford the S-shaped geometry of subclavian-innominate-aorta
axis through the RRA.

27. On the basis of these advantages, procedure duration and
fluoroscopy time could be decreased in the LRA
compared to the RRA.
Therefore, in view of lower subclavian tortuosity, easier
catheter manipulation, and less radiation exposure via the
LRA, the LRA may be a better and more reasonable
choice, and it should be recommended in real-world
cardiac catheterization, especially in urgent cases that
need a faster coronary procedure.

28. Left radial approach may become a feasible and
attractive alternative to perform not only diagnostic
coronary angiography but also primary PCI for
STEMI patients.