The document discusses anatomical variations of the radial artery that can cause failures in transradial interventions, techniques to manage arterial spasm and loops during the procedure, and evidence that the radial approach has better outcomes than femoral especially in STEMI patients while emphasizing the need for dedicated equipment and techniques to minimize complications.

1. From the wrist to the coronaries
Basics, Managing Loops, Tortuosity and Spasm
Martial HAMON, MD, FESC
CHU Caen, Cardiology
France

2. Disclosure Statement of Financial Interest
Affiliation/Financial Relationship
• Grant/Research Support:
GlaxoSmithKline, Lilly, The
Medicines Company.
• Consulting Fees/Honoraria:
Terumo, The Medicines Company,
Biotronik, Cordis, Medtronic.
www.angiosoft.net

3. Background
• The radial artery is increasingly used as a
preferred access route for PCI.
• Minimal vascular complications, immediate
ambulation, better post procedure comfort…
• Similar effectiveness in PCI and better outcomes in
STEMI patients
• A significant learning curve vs femoral procedures.
• Once the learning curve is passed, most TRl
procedure failures are due to anatomical variations

4. Are Radial Artery Anomalies a Major Cause of TRI Failure?
Multicentre prospective study from Dec 2005 to March 2007 in UK
Retrograde radial arteriography in all comers for a first radial procedure
Breakdown of anatomy and procedural outcome
Anatomical Findings No. of Patients % No. of P value
(n=1026) failure* (%)
Normal 871 84.9 8 (0.9) NA
Types of variations
High RA 80 7.8 4 (5.0) 0.415
bifurcation
RA loop 22 2.1 9 (40.1) <0.0001
RA tortuosity 25 2.4 6 (24.0) <0.001
UA anomaly 7 0.7 0 NA
Others 21 2.1 5 (23.8) <0.001
Total anomalies 155 15.1 24 (15.5) <0.0001
Lo TS and al. Heart 2009;95:410-415.

5. Normal Anatomy
BA
BA
RA
RA
UA
UA
Interosseous artery Interosseous & Median artery

6. Anatomical variations
In upper limb vessels

7. High take off of radial artery

8. Radio-ulnar anastomoses
Key message: asymmetric

9. Preventive Action+ + +
Complications
Forearm hematoma

10. Head and neck arteries: Right TRI
Over the wire exchange, deep breath to reach ascending aorta+++

11. From Brachiocephalic trunk
to Ascending Aorta
Deep breath to reach
ascending aorta

12. Complex PCI and Radial Approach
Anatomic variations of radial artery, spasm
Subclavian artery and brachiocephalic trunk
Access Ascending aorta
Guiding Cath. back-up (EBU++)
Dedicated Curves
Deep cannulation (5 F++)
Guiding… ES wires, buddy wires
Left main disease
Proximal tortuosity, calcification
Intervention Side branch, second wire, kissing
Length, diameter
 Caution in tortuous peripheral vasculature (Rota. or kissing )
Technical considerations Advanced TRI

13. Prevention of Arterial Spasm in TRI
The SPASM Study
1,219 consecutive patients randomized in 4 groups
Occurrence of radial Spasm (%)
22.2%
P<0.0001
13.3%
8.3% 7.9%
4.9%
Placebo Molsido. VerapamilVerapamil Verapamil
(n=198) 1 mg 2.5 mg 5 mg Molsido.
(n=203) (n=409) (n=203) (n=206)
Varenne O et al. Catheter Cardiovasc Interv. 2006;68:231-5

14. Minimizing radial artery injury
A randomized study 5F vs 6F
Dahm JB et al Cathet Cardiovasc Intervent 2002

15. Should Radial Access be the gold
standard in PCI?
Femoral: I C Future Recommendations ?
AHA/ACC/ESC
Radial: I A
I II III
Evidence &/or Conflicting Evidence Evidence &/or
Agreement Divergence of opinion Agreement
(Beneficial, Useful, Effective) (Usefulness, Efficacy) Not Useful/Effective
II a weight in favor Potentially Harmful
II b less well established
A. Multiple randomized trials or meta-analyses
B. Single randomized trial or non-randomized studies
C. Only consensus opinion of experts, case studies or standard of care
Hamon M, Nolan J. Heart 2009.

16. RIVAL
Primary and Secondary Outcomes
Radial Femoral
(n=3507) (n=3514) HR 95% CI P
% %
Primary Outcome
Death, MI, Stroke, 3.7 4.0 0.92 0.72-1.17 0.50
Non-CABG Major Bleed
Secondary Outcomes
Major Vascular Access
Site Complications 1.4 3.7 0.37 0.27-0.52 <0.0001

17. RIVAL
Outcomes stratified by STEMI vs. NSTEACS
% % Hazard Ratio(95% CI)
2N Radial Femoral Interaction
Primary Outcome p-value
NSTE/ACS 5063 3.8 3.5
STEMI 1958 3.1 5.2 0.025
Death, MI or stroke
NSTE/ACS 5063 3.4 2.7
STEMI 1958 2.7 4.6 0.011
Death
NSTE/ACS 5063 1.2 0.8
STEMI 1958 1.3 3.2 0.001
Non CABG Major Bleed
NSTE/ACS 5063 0.6 1.0
STEMI 0.56
1958 0.8 0.9
Major Vascular Complications
NSTE/ACS 5063 1.4 3.8
0.89
STEMI 1958 1.3 3.5
0.25 1.00 4.00
Radial better Femoral better

18. Proposed framework for learning steps
and competency levels

19. Summary-Conclusions
1. Expect anatomical variations
2. Over the wire exchange, never forced
3. Angiography if needed (anatomic variation)
4. Use dedicated material (needle, wires, sheaths..)
5. Spasm prevention & radial occlusion prevention
6. Minimize radial artery injury (5F, 6F, Sheathless
cath)
7. Consider alternative access in challenging cases
(Risk of stroke, radiation exposure)
8. Not a limitation in routine TRI