Basics of Radial route angiography Dr Gaurav Choudhry

1. Percutaneous
coronary intervention
by Transradial
Approach –Newer and
Promising
Dr Gaurav Chaudhary
MD,DM Cardiology
Assistant Professsor
Department of
Cardiology

2. Road Map……..
 Why at all different site required (apart from Femoral )
 Basics of Radial Artery access
 Basics steps of Coronary angiography and angioplasty by
radial route (few examples )
 Evidence in support of Radial route intervention,Global trends
 Overall advantage of radial route percutaneous intervention
 Drawback and difficulty in radial route percutaneous intervention

3. Radial versus femoral
Radial Access
 Average diameter of
radial artery is 2.5 mm
 Access difficult
 Immediate Ambulation
 Complications minimal
( 1.4 %)
Femoral Access
 Average diameter of
femoral artery is 10
mm
 Access easy
 Delayed ambulation
 Significant
complications (3.7%)

4. Local Site Complications in
Femoral access are worrisome

5. Femoral Hematoma
Large Hematoma

6. Large Hematoma

7. Coronary intervention by Femoral
Approach
Complications can be fatal too !!!!!!!

8. Higher Femoral
Puncture can lead to
Retroperitoneal Bleed
which can prove Fatal

9. Lower Puncture leads to
Femoral Pseudo aneurysm

10. Retrospective review of 5,234 cath and PCI
Vascular complications by BMI: lower rate of vascular complications using TR
vs. TF approach for obese and non obese patients
5.3%
2.1%
4.00%
0.7%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
Non-obese Obese
Femoral Radial
P= 0.048 P= 0.040
Cox, N. Am J Cardiol 2004; 94
1174-1177
Risk of vascular complications associated with
femoral and radial access

11. Jolly SS et al.
Am Heart J
2009;157:132-40
Radial versus femoral
access for coronary
angiography or PCI:
A systematic review and
meta-analysis of randomized
trials (total of 4458 patients)

12. The Anatomy

14. Seldinger
Technique

15. Radial Artery is palpated and 21 gauge
needle is introduced

16. Basic steps
 Punture the Radial artery by 21 gauge needle
 Put 6 Fr sheath by seldinger technique
 Advance .035 inch guidewire via radial artery to axillary-
subclavian –Arch of aorta –Aortic sinus
 Advance catheter over the wire
 Hooking of coronary artery
 Angiogram obtained

18. Radial Band applied to achieve Hemostasis
and immediate ambulation

19. Patient becomes ambulatory just after the
diagnostic procedure

20. What is Evidence in
Favour of Radial
Approach …….

21. NSTE-ACS and STEMI
(n=7021)
Radial Access
(n=3507)
Femoral Access
(n=3514)
Primary Outcome: Death, MI, stroke
or non-CABG-related Major Bleeding at 30 days
Randomization
RIVAL Study Design
Key Inclusion:
• Intact dual circulation of hand required
• Interventionalist experienced with both (minimum 50 radial
procedures in last year)
Jolly SS et al. Lancet 2011.
Blinded Adjudication of Outcomes

22. Outcomes
Radial
(n=3507)
%
Femoral
(n=3514)
%
HR 95% CI P
Major Vascular
Access Site
Complications
1.4 3.7 0.37 0.27-0.52 <0.0001
Major Bleeding
TIMI Non-CABG
Major Bleeding
0.5 0.5 1.00 0.53-1.89 1.00
ACUITY Non-CABG
Major Bleeding
1.9 4.5 0.43 0.32-0.57 <0.0001
Jolly et al, Lancet 2011

23. RIVAL study
 7021 patients with ACS
undergoing PCI
 No difference in MACE
– death, MI, stroke
 Trend for less major
bleeding with radial
access, depending on
the bleeding definition
 Less vascular
complications with
radial access
 Special benefit for radial
in STEMI pts
Jolly et al, Lancet 2011
Primary endpoint - NACE
Non CABG major bleeding

24. Death, MI, Stroke or non-CABG major Bleed
Subgroups: Primary OutcomeR I V A L
0.25
1.00 4.00
Radial better Femoral better
Hazard Ratio (95% CI)
<75
≥75
Female
Male
<25
25-35
>35
≤70
70-142.5
>142.5
Lowest Tertile
Middle Tertile
Highest Tertile
NSTE-ACS
STEMI
Age
Gender
BMI
Radial PCI Volume by Operator
Radial PCI Volume by Centre
Diagnosis at presentation
Overall
0.786
0.356
0.637
0.536
0.021
0.025
Interaction
p-value
Jolly et al, Lancet 2011

25. Other Outcomes
Radial
(n=3507)
Femoral
(n=3514)
P
Access site Cross-over (%) 7.6 2.0 <0.0001
PCI Procedure duration (min) 35 34 0.62
Fluoroscopy time (min) 9.3 8.0 <0.0001
Persistent pain at access site
>2 weeks (%) 2.6 3.1 0.22
Patient prefers assigned
access site for next
procedure (%)
90 49 <0.0001
• No differences in PCI success rate

26. RIFLE-STEACS study (Radial Versus Femoral Randomized
Investigation in ST-Elevation Acute Coronary Syndrome)
• 1001 pts with ST elevation ACS randomized TRI vs
TFI at high volume centers
• NACE at 30 days (cardiac death, stroke, MI, TVR,
bleeding): 13.6% TRI VS. 21% TFI (P=0.003)
• Cardiac mortality : 5.2% TRI vs. 9.2% TFI (P=0.02)
• Bleeding: 7.8% TRI vs. 12.2% TFI (p=0.026)
• Shorter hospital stay with TRI
Romagnoli et al JACC, 2012

27. Meta-analysis of Radial vs. Femoral in STEMI pts
Mortality
Access site complications
Bleeding
Mamas et al Heart 2012

28. MATRIX TRIAL
Radial versus femoral access in patients
with acute coronary syndromes
undergoing invasive management: a
randomised multicentre trial
Marco Valgimigli et al , for the MATRIX Investigator
,March 2015 , The Lancet

29. Recent Data From Matrix Trial
Matrix trial 2015 ,The Lancet

30. Matrix trial 2015 ,The Lancet

31. Matrix trial 2015 ,The Lancet

32. Matrix trial 2015 ,The Lancet

33. Trend of Radial Intervention in
Europe , Asia ,us
 Overall 20 % procedures globally
 Upto 80 % of procedures in Europe
 Upto 35 % in India
 Upto 2-3 % in US

34. Thank you ……
Thank You