Transradial Approach: Just Do It !

1. Transradial Approach: Just Do It !
TEJAS M. PATEL, MD, DM, FACC, FESC, FSCAI
PROFESSOR & HEAD
Department of Cardiovascular Sciences,
Smt. N.H.L. Municipal Medical College,
Sheth K.M. School of PG Studies & Research,
Sheth V. S. Hospital, Ahmedabad, India.
DIRECTOR
Department of Cardiovascular Sciences,
TCVS (Total Cardiovascular Solutions) Pvt. Ltd.
Ahmedabad, India.

2. Disclosure
Honorarium from Terumo US

3. Historical perspective

4. Mason Sones
Brachial cut-down

5. Melvin Judkins
Percutaneous femoral approach

6. Campeau
Transradial coronary angiogram

7. Kiemeneij
Transradial coronary intervention

8. UL LL

9. TRI TFI
Major Vascular Complications (n=1604) (n=5211)
Kiemeneij F et al. 1996 J Am Coll Cardiol 0 2%
Ziakas A et al. Am J Cardiol 1999 0 1.5%
Tift Mann et al. J Am Coll Cardiol 1999 0 4%
Choussat R et al. Eur Heart J 2000 0 4.5%
Hildic S et al. 2000 0 6%
Louvard Y et al. Catheter Cardiovasc Interv 2002 0 1.3%
Saito S et al. Catheter Cardiovasc Interv 2002 0 3%
Valsecchi O et al. Ital Heart J 2003 0 1.2%
Lefevre T (TCT 2003) 0 2.3%
Pooled data 0.0% 3.8%

10. SUCCESS
Transradial PCI In Setting Of AMI 96.6%
Tift Mann et al. J Am Coll Cardiol 1999 (n=68) 96%
Delarche N et al. Am J Geritar Cardiol 1999 (n=46) 100%
Kim MH et al. J Invasive Cardiol 2000 (n=30) 90%
Mathias et al. J Invasive Cardiol 2000 (n=14) 100%
Mulkutla SR et al. Catheter Cardiovasc Interv 2002 (n=41) 100%
Hamon M et al. Catheter Cardiovasc Interv 2002 (n=119) 100%
Louvard Y et al. Catheter Cardiovasc Interv 2002 (n=267) 98%
Ziakas A et al. Am J Cardiol 1999 (n=100) 90%
Saito S et al. Catheter Cardiovasc Interv 2002 (n=77) 96%
Valsecchi O et al. Ital Heart J 2003 (n=163) 97%

11. TRI TFI
Procedural Success Final TIMI 3 Flow
(n=665) (n=1726)
Tift Mann et al. J Am Coll Cardiol 1999 96 % 96 %
Ziakas A et al. Am J Cardiol 1999 99% 97%
Louvard Y et al. Catheter Cardiovasc interv 2002 98% 97%
Saito S et al. Catheter Cardiovasc Interv 2002 96 % 97 %
Valsecchi O et al. Ital Heart J 2003 97% 96%
Pooled data 97% 97%
p= ns in all studies

12. TRI TFI
Major Vascular Complications (n=945) (n=2802)
Tift Mann et al. J Am Coll Cardiol 1999 0 4%
Ziakas A et al. Am J Cardiol 1999 0 1.5%
Louvard Y et al. Catheter Cardiovasc Interv 2002 0 1.3%
Saito S et al. Catheter Cardiovasc Interv 2002 0 3%
Valsecchi O et. al Ital Heart J 2003 0 1.2%
Lefevre T (TCT 2003) 0 2.3%
Pooled data 0 1.8%

13. TRI: Impact of Gp IIb / IIIa Blockers
Absence of Major Vascular Complications
TRI TFI
Major vascular complications
(n=244) (n=1953)
Choussat R et al. Eur Heart J 2000 0 4.5%
ESPRIT trial J Am Coll Cardiol 2003 0.7% 6.6%
Pooled data 0.4% 6.5%

14. TRI In AMI: No Delay In Reperfusion
TRI TFI
PROCEDURAL TIME (minutes)
(n=945) (n=2802)
Ziakas A et al. Am J Cardiol 1999 43 19 50 28
Louvard Y et al. (Centre A) Catheter Cardiovasc Interv 2002 45 42 43 32
Louvard Y et al. (Centre B) Catheter Cardiovasc Interv 2002 67 25 68 21
Saito S et al. Catheter Cardiovasc Interv 2002 44 18 51 21
Valsecchi O et al. Ital Heart J 2003 62 23 61 22
Lefevre T (TCT 2003) 45 50 48 55
P=ns

15. J Am Coll Cardiol. 2004; 44 (2): 349-56
Radial versus femoral approach for percutaneous
coronary diagnostic and interventional procedures;
Systematic overview and meta-analysis of
randomized trials
Agostoni P, Biondi-Zoccai GG, de Benedictis ML et al.
CONCLUSION:
The radial approach for coronary procedures appears as a
safe alternative to femoral access. Moreover, radial access
virtually eliminates local vascular complications

16. Am Heart J. 2009; 157(1):132-40
Radial versus femoral access for coronary
angiography or intervention and the impact on major
bleeding and ischemic events:
A systematic review and meta-analysis of randomized trials
Jolly SS, Amlani S, Hamon M et al.
CONCLUSION:
Radial access reduced major bleeding and
there was a corresponding trend for reduction
in ischemic events compared to femoral access

17. Catheter Cardiovasc Interv 2009;74: 408-415
Effectiveness of the transradial approach to reduce bleedings
in patients undergoing urgent coronary angioplasty with
GPIIb / IIIa inhibitors for acute coronary syndromes
Marco De Carlo, Gabriele Borelli, Roberto Gistri et al.
CONCLUSION:
The transradial approach dramatically reduces access site
bleedings, including TIMI major and minor bleedings, and
transfusion rate, while preserving procedural success and
clinical outcome. The transradial approach is an attractive
solution to reduce bleeding complications in patients
treated with GPIs

18. Catheter Cardiovasc Interv. 2010;75 (5): 695-9
Arterial access and door-to-balloon times for
primary percutaneous coronary intervention in patients
presenting with acute ST-elevation myocardial infarction
Weaver AN, Henderson RA, Gilchrist IC et al.
CONCLUSION:
Patients presenting with STEMI can undergo
successful PCI via radial artery approach without
compromise in D2B times as compared to femoral artery
approach

19. Catheter Cardiovasc Interv. 2010;75(7):991-5
Comparison of door-to-balloon times for primary PCI
using transradial versus transfemoral approach
Pancholy S, Patel T, Sanghvi K et al.
CONCLUSION:
Transradial approach to primary PCI provides similar
door-to-balloon times to transfemoral approach, and
significantly lowers access site related complications,
in patients presenting with STEMI

20. Impact of
bleeding & transfusion on
the procedural outcome

21. Heart 2008;94:1530-1532
EDITORIAL
Should radial artery access be the "gold standard" for PCI?
Martial Hamon1, James Nolan2
1 University Hospital of Caen, Caen, France
2 University Hospital of North Staffordshire, Stoke-on-Trent, UK

22. Heart 2008;94:1019-1025
Association of the arterial access site at angioplasty with
transfusion and mortality: the M.O.R.T.A.L study
(Mortality benefit of Reduced Transfusion after percutaneous coronary intervention via the Arm or Leg)
A J Chase, E B Fretz, W P Warburton et al.
Design, setting and patients:
By data linkage of three prospectively collated provincial registries, 38 872
procedures in 32 822 patients in British Columbia were analysed
The association between access site, transfusion & outcomes was assessed
Main outcome measures: 30-Day and 1-year mortality

23. CONCLUSION:
• The MORTAL study ,which looked at a registry
of 33,000 Canadian patients, showed 50% less
blood transfusions and accompanying
reductions in mortality for patient done radially
• By probit regression the absolute increase in risk
of death at 1 year associated with receiving a
transfusion was 6.78%

24. JACC 2009

25. JACC 2009

26. JACC 2009

27. J Am Coll Cardiol Intv, 2008; 1:379-386
Trends in the Prevalence and Outcomes of Radial and
Femoral Approaches to Percutaneous Coronary
Intervention
A Report From the National Cardiovascular Data Registry
Sunil V. Rao, Fang-Shu Ou, Tracy Y et al.
CONCLUSION:
Study looked at 593,094 U.S. patients
and found that radial patients experienced
58% less bleeding complications

28. RIVAL Study – ACC 2011
Lancet 2011;377:1409–20
Radial versus femoral access for coronary angiography and
intervention in patients with acute coronary syndromes (RIVAL):
a randomised, parallel group, multicentre trial
Jolly SS, Yusuf S, Cairns J et al.
CONCLUSION:
Radial access was associated with a
reduction in access-related complications
There was a trend towards survival benefit
in patients with STEMI

29. Ostensible Reasons
Blah…Blah…Blah
• Small artery
• RA spasm
• Difficult to use bulky devices
• Inadequate guide catheter backup
• Not so good for difficult coronary
anatomy
• Not safe for complex anatomy
• RA occlusion
• Radiation exposure

30. Experience
• From Jan - 1992 to Nov - 2001
• 25,450 Transfemoral procedures
• 6,360 coronary interventions through TFA
• From Dec - 2001 to June - 2011
• 35,202 Transradial procedures
• 9,152 coronary interventions through TRA
• 291 Peripheral intervention through TRA
• 98% procedures through TRA

31. Radial Artery Spasm

33. Working through
Calcified Radial Artery

35. Radial Artery
Perforation

37. Higher puncture of
Radial artery

38. Very low radial loop & High puncture

39. High Puncture

40. Lateral Puncture

41. Addressing the
loops

42. Simple loop

44. More
challenging
loop

46. Most
challenging
loop

47. “Downsize the Catheter”
Diagnostic 5F  4F

48. Intervention
through
Loop & Perforation

50. Intervention through
Loop & Spasm

52. Practice makes you perfect…

53. Acute angle crossed
using a PTCA
catheter

55. Catheter Knot
Reduction

57. Another example
Catheter Knot
Reduction

59. Axillo-Subclavian
Dissection

61. Working through Extreme
Subclavian Tortuosity
“use of pigtail catheter”

63. Working through
Subclavian Tortuosity
“use of PTCA catheter”

65. Another example
Balloon-assisted
guide catheter tracking
through a small RA

68. Working through
Arteria Lusoria

69. Effect of dilatation and distortion of aorta

70. Schematic diagram of different loops
produced due to distortion of aorta
• Normal
• Z–loop
• Roller-coaster loop
• Cobra loop

71. Arteria Lusoria

72. Arteria Lusoria
Anterior Posterior Oblique

73. Arteria Lusoria

74. Arteria Lusoria
‘Roller-coaster loop’

76. Arteria Lusoria - Cath Maneuver

77. Arteria Lusoria
‘Cobra loop’

79. Cobra loop
RCA stenting

81. Cobra loop
coronary
cannulation

85. Arteria lusoria with
Subclavian tortuosity

87. Practice makes you perfect…

88. Again…
Practice makes you
perfect…

89. Working through
Right Aortic Arch –
Right TRA

91. LIMA Cannulation using RRA

95. RCA
Air Embolization

98. LMCA Bifurcation Rota-Stent

100. LMCA intervention…
A real nightmare

101. RCA CTO

103. Unprotected LMCA Stenting
Extensive anterior wall MI-1 hour

105. Acute IWMI &
Cardiogenic Shock

109. Peripheral
Interventions

110. Our experience
Through TRA
Renal 107
Iliac 36
SFA 11
SMA 02
Subclavian 28
Vertebral & Basilar 66
ICA 41
Total 291

111. Published data by our group
 Patel T, Kuladhipati I, Shah S. et al.
Successful percutaneous endovascular management of acute post
traumatic superior mesenteric artery dissection using transradial
approach. J. Invasc. Cardiol. 2010; 22: 4: 61-64
 Patel T, Shah S, Pancholy S, Coppola J. et al.
Contralateral transradial approach for carotid artery stenting:
A feasibility study. Cathet Cardiovasc Interv 2010; 75: 2: 268-275
 Patel T, Shah S, Radadia R. et al.
Transradial approach for stenting of vertebro-basilar stenosis:
A feasibility study. Cathet Cardiovasc Interv 2009; 74: 925-931

112. Renal Artery
Stenting

114. Bilateral iliac
&
SFA Stenting

117. Superior
Mesenteric Artery
Stenting

119. Subclavian
Artery
Stenting

121. Vertebral Artery
Stenting
Ostial Lesion

123. Vertebral Artery
Stenting
Intra-cranial

125. Chronic Basilar
Artery
Occlusion

127. Left Carotid Stenting
through
Right Radial Route

129. What is the limitation ?

130. Anterior Tibial PTA

132. It is the limitation of hardware…

133. Thank You
www.transradialWORLD.org