This document summarizes various studies comparing right and left radial approaches for cardiac catheterization. It begins by outlining several previous studies that found no differences in outcomes between right and left approaches. It then describes a new study comparing right versus left radial access in high-risk patients (elderly, female, hypertensive, short height) done by fellows under supervision. In this study, the left radial approach was associated with shorter fluoroscopy times and less contrast use, suggesting it may be preferable for difficult cases done by new operators.

1. John Coppola
NYU Langone Medical Center
New York
AIM RADIAL 2014

2. Basis for study
 R. Caputo 2000
 Catheterization in elderly right radial success
similar with age <70 vs. >70
 No association with failure and gender,
hypertension, diabetes BSA or smoking.
 Same procedure time, fluro time and contrast
CCI 2000; 51: 287-290

3. Arteria Lusoria
 Louvard 2001 11 patients of consesecutive
series of 3730 for incidence of 0.4%
CCI 2001;54:196-201

4. Innominate and subclavian
tortuosity
 Kwang 2341 patients right radial approach
found shorter height, hypertension female
gender older age predicted tortuosity
 Incidence 10 %
 Defined as need to use stiff guide wire to
control and engage the coronary
Am J Cardiol 2003;92:1220-1222

5. Left vs right
 Kawashima used Judkins catheters 205 right
vs. 232 left radial
 Left shorter procedure time
 Fluro time 3.7+/-5.9 vs 6.0 +/- 3.3
 Need to use guide wire to engage 20/205 vs
0/232
 All “experienced operators 4Fr system
CCI 2004;61:333-337

6. Radiation becomes issue
 Lange comparison operator exposure femoral
vs. radial
 Single operator >1500 radial experience
 Greater exposure to operator measured at
130cm from ground
 ? Scatter from pelvic bone and legs shielding
problems
CCI 2006;67:12-16

7. More confusion
 Sciahbasi 1540 patients 770 right vs. 770 left
 No difference in fluro time except in ELDERLY
and new operators
Am Heart J 2011;161:172-179

8. Radiation right vs Left
 Sciahbasi dosimetric substudy
 No difference fluro time
 Right vs left similar dose at thorax, thyroid,
shoulder only higher at LEFT WRIST again ?
shielding
Circ Cardiovasc Interv 2011;4:226-231

9. Time for a meta analysis
 Guo X meta analysis of 5,317 right vs. 4,970
left radial cases
 Conclusions left less failures to complete
lower fluro time

10. Right vs. Left
 Kwan ‘s group Beth Israel NY
 Patients similar clinical characteristics age
younger 64 average
 Same contrast fluro time difficult
 Single catheter success 78% right vs 18% left
Am J Cardiol 2011;109:195-197

11. New operators
 Dehghani et al from Toronto
 2100 patients only 17% female average age
64
 4.8% failure rate
 Biggest reason 51% could not enter
ascending aorta
 Predictors age short height prior bypass
JAMColl Cardiol Intv 2009;2:1057-64

12. Our Host
 Abdelaal Laval University reason for failure
of TRA PCI
 Female sex, prior bypass, shock predictors of
failure for TRA PCI
J Am Coll Cardiol Intv 2013;6:1129-1137

13. Why do it
 Most studies right vs. left took all comers
 We took group with expected difficulty Age> 70,
Female, Hypertension, height less than <162cm
(64”)
 Looked only at time to complete and radiation
based on selection of right vs. left with new
operators
 Fellows in training

14. Partial Data
 Single senior operator directing first year
fellows
 36 right radial 35 left radial
 Needed to meet 3 of 4 criteria

15. Patients
site right left
age 75 (70-79) 70 (62-75) p=0.02
sex Female 86% Female91% p=0.71
Height <64” 83% 100% p=0.025
Height cm 158.7 (151.3-163) 155 (152-160) p=0.13
hypertension 94% 89% p+0.43
PAD 14% 8.6 p=0.71

16. procedure
right left
Radial spasm 0% 2.9% p=0.49
Radial loop 11.1% 11.4% p=1.0
Subclavian tortuosity
13.9% 8.6% p=0.71
Access failure
5.6% 8.6% p=0.67
crossover
8.3% 8.6%

17. results
right left
Contrast ml 65 (50-79) 53 (45-63) p=0.02
Fluro time 5.9 (3.1-8.9) 3.7 (2.1-5.7) p=0.017
DAPuGy*m2 3698 (2182-5801) 3174 (1998-4561) p=0.15
Operator exposureuR 547(344-67) 473(240-936) p=0.39

18. conclusion
 In new operators selection of the left radial
approach in elderly hypertensive short
females may lead to quicker procedure times
with less fluro time and contrast use.